Grace Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 2939 S. Peach Avenue, Fresno, California 93725
- CMS Provider Number
- 555352
- Inspections on file
- 31
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Grace Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and declining mobility was allowed to self-propel in a facility wheelchair without proper assessment, fitting, or supervision. Staff did not evaluate the safety or appropriateness of the wheelchair, nor did they update the care plan or refer for physical therapy despite documented functional decline. This led to the resident's legs becoming entangled in the wheelchair, resulting in fractures and hospitalization.
The facility failed to ensure the Director of Nursing (DON) maintained an active RN license, resulting in the DON working with an expired license. The Assistant Director of Nursing (ADON) knew of the inactive license but did not inform leadership, and the Administrator (ADM) was unaware. The facility's policy requires active licenses for nursing staff to ensure quality care, which was not adhered to, posing a risk to resident safety and care quality.
A nurse in a LTC facility was found to have misappropriated controlled medications, including alprazolam and tramadol, from several residents without administering or documenting their disposal. This affected residents with conditions such as anxiety and chronic pain, as they did not receive their prescribed medications. The discrepancies were discovered through inventory and record reviews, revealing forged signatures and altered dates. Interviews confirmed the nurse's responsibility, highlighting a failure in the facility's processes to prevent such incidents.
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. A resident's hydrocodone-acetaminophen tablets were unaccounted for upon discharge, and the facility's system for storing and destroying controlled drugs was inadequate. Additionally, the emergency kit usage and replenishment process was not properly documented, risking medication availability in emergencies.
Three residents in an LTC facility were administered controlled pain medications without proper clinical justification or monitoring. One resident's oxycodone was changed from as needed to routine after only two days, another resident received an additional routine hydrocodone-acetaminophen order despite limited use, and a third resident's tramadol order was increased without sufficient justification. The facility failed to document pain assessments, update care plans, or monitor for side effects.
A suspended LVN, under investigation for drug diversion, was allowed to work a 12-hour shift with residents, despite explicit instructions from the OA to remain off-duty. The DON, who permitted this, was later suspended for insubordination, as the facility's policy requires employees under investigation to have no resident contact.
Two licensed nurses in the facility failed to properly disinfect glucometers after performing blood glucose tests on residents. RN 3 used a non-approved disinfecting wipe, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time. Both nurses had not received competency-based training on glucometer use, leading to potential risks of spreading bloodborne diseases.
The facility failed to provide essential competency training to three nursing staff members, including training on glucometer use and medication administration. The DON bypassed the established orientation protocol, leading to untrained staff working with residents. The facility's assessment indicated that all residents required medication management, yet the necessary training was not provided.
The facility's QAPI program was found deficient as staff, including CNAs, an LN, and a Registered Nurse Supervisor, were unaware of the program and lacked a tool for measuring performance improvement. Despite a bulletin board display on reducing pressure ulcers, the DON could not specify the performance improvement measurement tool, indicating a failure in the program's implementation.
The facility did not perform reference checks for two newly hired nurses, an LVN and an LN, as required by their policy. The LVN's file lacked any reference checks, while the LN, a recent graduate, had personal references listed but not verified. The DSD admitted to not checking personal references, contrary to the facility's policy mandating background and reference checks for all applicants.
The facility failed to provide mandatory infection control training for two nurses, as their records lacked documentation of training on hand hygiene and PPE. The DSD confirmed the absence of training, and the IP admitted to not ensuring all staff received it, despite the facility's assessment stating such training is mandatory.
A facility failed to ensure a dietary cook was competent in food service, leading to incorrect portion sizes, unfortified diets, and improper food preparation. The cook served incorrect portions, did not fortify foods as required, and failed to follow pureed food recipes. Additionally, the cook did not check food temperatures before serving, and the kitchen ran out of the main dish, resulting in unrequested meal substitutions.
The facility failed to meet the nutritional needs of residents by serving incorrect portion sizes, not following fortified diet orders, and providing alternate meals without resident requests due to insufficient main dish preparation. These actions were contrary to the dietary orders and expectations set by the Registered Dietitian and Dietary Service Supervisor.
A long-term care facility failed to maintain effective infection control, as evidenced by a resident's wheelchair with dried fecal matter, used urinals improperly placed, a laundry room with pooled dirty water, and a nephrostomy catheter bag on the floor. Staff interviews confirmed these practices violated facility policies and posed infection risks.
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Additionally, a water leak from a washing machine in the laundry room led to pooled water, posing safety hazards. Despite staff awareness, these issues persisted due to inadequate maintenance follow-up and documentation.
Two residents in the facility lacked comprehensive care plans, leading to deficiencies in their care. One resident, with multiple health issues, did not have a care plan for the anticoagulant apixaban, while another resident on Enhanced Barrier Precaution due to skin issues lacked a care plan to guide staff. The absence of these care plans was confirmed by facility staff, highlighting a failure to adhere to policy requirements for developing individualized care plans.
The facility failed to adhere to professional standards for two residents. A resident's medication was left unattended, contrary to policy, risking improper administration. Another resident, with a condition requiring padded side rails, was observed without them, despite physician orders. Staff interviews confirmed awareness of policies, yet practices did not align, leading to these deficiencies.
The facility failed to properly label medications for 11 residents, as inhalers lacked expiration dates, potentially leading to the use of expired medications. Additionally, a medication cart was left unattended with keys on top, risking unauthorized access. These issues were confirmed by staff and violated the facility's policies on medication storage and labeling.
The facility failed to maintain sanitary food preparation practices for 54 residents due to the absence of an air gap in the kitchen's two-compartment prep sink. The Dietary Service Supervisor and Maintenance Supervisor were aware of the issue, which was noted in a previous survey. The Registered Dietitian highlighted the necessity of an air gap to prevent contamination, as required by facility policy and the FDA Food Code.
A resident with moderate cognitive deficit was not provided privacy during personal hygiene care, as a CNA left the door open and the privacy curtain was not fully drawn, exposing the resident to the hallway. The facility's policy on resident rights was not upheld, as confirmed by interviews with staff.
A resident with quadriplegia and no cognitive impairment was neglected when staff failed to provide supplies for his suprapubic catheter care, resulting in him being soiled with urine. Despite his independence and ability to manage his own care, the resident's requests for supplies were ignored by multiple staff members, leading to his distress and embarrassment.
A facility failed to notify the LTC-Ombudsman of a resident's emergency hospital transfer for a urinary tract infection. The resident had severe cognitive impairment and multiple medical conditions. Staff interviews revealed a lack of awareness about the notification requirement, which was confirmed by the DON. CMS guidelines mandate that such notices be sent to the Ombudsman.
A facility failed to meet required timelines for MDS assessments for a resident discharged to home. The MDSN did not complete or transmit the discharge MDS assessment, with the last assessment being a quarterly one. The DON and ADM acknowledged the MDSN's responsibility for timely completion and transmission of assessments, as per facility policy.
A facility failed to re-evaluate and document a resident's Level I PASARR, despite the resident having diagnoses of dementia, psychosis, depression, and anxiety. Staff interviews revealed confusion and lack of responsibility for PASARR assessments, with no designated person to complete them. The facility's policy required mental disorder screening upon admission, but this was not followed, resulting in the deficiency.
A resident with moderate cognitive impairment was using a bed rail without proper assessment, documentation, or informed consent. The facility failed to obtain a physician's order, create a care plan, conduct a safety evaluation, or secure informed consent for the use of the side rail, contrary to their policy. Staff interviews confirmed these omissions, which could potentially place the resident at risk.
A resident missed a dose of acetylsalicylic acid 325 mg due to the facility running out of the medication. The responsibility for re-ordering medications was with the nurses, and the facility's policy required reordering at least three days before the last dose. The Director of Nursing confirmed that the Associate Director of Nursing was sent to obtain the medication from a local pharmacy.
A resident's low air loss (LAL) mattress cover was found torn, potentially compromising its function and cleanliness. Staff interviews confirmed the importance of the LAL mattress for the resident's skin health, as the resident had a history of skin issues. The facility's policy required repair or replacement of worn components, which was not followed.
The facility was found non-compliant with regulations limiting resident room capacity to four. Eight rooms housed eight residents each, despite ensuring accessibility and privacy. Staff and residents reported no issues with care or space, but privacy curtains were noted as not always closing completely.
A facility failed to report an allegation of physical abuse within the required 24-hour timeframe. An LVN reported the allegation to the ADM, and the SSD was also aware, but the report to the CDPH was delayed. The resident involved had moderate cognitive impairment and reiterated the abuse claim during an interview.
Failure to Assess and Supervise Wheelchair Use Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who self-propelled in a wheelchair. Nursing staff were aware that the resident used a wheelchair equipped with foot pedals and self-propelled throughout the facility, but did not assess the safety or appropriateness of the wheelchair for the resident's physical size, abilities, or declining mobility. The resident was not evaluated or fitted for a personal wheelchair and instead used wheelchairs available for general use in the facility. Staff did not identify or address the resident's declining upper and lower extremity mobility as documented in the Minimum Data Set (MDS), nor did they refer the resident for a physical therapy assessment or update the care plan to address wheelchair use and safety. As a result of these failures, the resident experienced an unwitnessed, avoidable accident in which their legs became entangled in the wheelchair while self-propelling, leading to severe pain and a right lower leg injury. The resident was subsequently diagnosed with acute right tibial and proximal fibular fractures, requiring hospitalization and resulting in loss of mobility and increased isolation. Interviews with nursing staff and CNAs revealed that none were aware of a safety assessment for the resident's wheelchair use, and there was no documentation of a physical therapy referral, physician notification regarding the resident's functional decline, or a care plan component addressing wheelchair safety. Facility policy required that recommendations for assistive device use be based on comprehensive assessment and documented in the care plan, including evaluation of appropriateness for the resident's condition and personal fit. However, these policies were not followed, as confirmed by staff interviews and record reviews. The lack of assessment, supervision, and individualized equipment fitting directly contributed to the resident's accident and subsequent injury.
Failure to Maintain Active License for Director of Nursing
Penalty
Summary
The facility failed to designate a full-time Registered Nurse (RN) as the Director of Nursing (DON) for all 58 residents when the current DON's license expired. The Assistant Director of Nursing (ADON) was aware of the inactive license but did not notify leadership, allowing the DON to continue working with an expired license. The Administrator (ADM) was unaware of the situation and confirmed that the DON should not have been working without an active license. The Owner/Operator RN 1 also confirmed the DON worked during the month with an inactive license and highlighted the failure of the Director of Staff Development (DSD) to communicate the issue to leadership. The facility's policy requires nursing service personnel to have the necessary qualifications, including an active RN license, to ensure quality resident care. The DON's job description mandates maintaining an active RN license and being onsite full-time. The lack of an active license for the DON resulted in a potential risk of inadequate supervision and guidance for staff, which could affect resident safety and care quality. The facility's policy and job descriptions were not followed, leading to the deficiency.
Medication Misappropriation by Nurse in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, which are considered their property. A licensed nurse, identified as LVN 1, was found to have removed various controlled medications from the medication cart without administering them to the residents or properly documenting their disposal. This included medications such as alprazolam, tramadol, hydrocodone-acetaminophen, and oxycodone, which are used for treating anxiety, pain, and other conditions. The discrepancies were discovered through a review of the medication inventory count sheets and electronic medical records, revealing that the medications were neither given to the residents nor wasted according to facility policy. The report highlights specific instances involving multiple residents, each with their own medical conditions and needs for the medications. For example, Resident 67, who was severely cognitively impaired, did not receive their prescribed alprazolam for anxiety, as the medication was removed by LVN 1 without proper documentation. Similarly, Resident 59, also severely impaired, was deprived of their alprazolam, which was crucial for managing their anxiety disorder. Other residents, such as Resident 69 and Resident 71, who suffered from chronic pain, did not receive their tramadol, leading to potential untreated pain. Interviews with the Consultant Pharmacist, Assistant Director of Nursing, and Director of Nursing confirmed that LVN 1 was responsible for the missing medications, and there were indications of forged signatures and altered dates on the inventory sheets. The facility's processes were insufficient to prevent or detect this diversion of medications, which posed a risk to the residents' health and safety. The report does not mention any corrective actions or follow-up measures taken by the facility to address these deficiencies.
Inadequate Controlled Drug Management and Documentation
Penalty
Summary
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. Specifically, the facility could not account for 32 tablets of hydrocodone-acetaminophen 5-325 mg prescribed to a resident, who was admitted with a diagnosis including contracture of the right upper arm muscle. The resident was discharged without a record of the controlled drugs being transferred, and both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and the importance of maintaining accurate records to prevent medications from falling into the wrong hands. Additionally, the facility did not adhere to its policy and procedure for the destruction of controlled drugs. Controlled medications awaiting destruction were inadequately logged and stored, with the DON admitting to giving the key to the storage cabinet to nursing staff without a proper log of the medications stored. The Consultant Pharmacist (CP) confirmed that the facility's disposition log was inadequate for accurately tracking controlled drug medications, and the DON acknowledged the lack of a proper system to ensure controlled medications were not taken from the cabinet without authorization. The facility also failed to maintain an adequate system for the use and replenishment of the emergency kit (e-kit) containing controlled drugs. The DON was unable to provide e-kit usage records for several months, and the process for documenting and replacing used e-kits was not followed by nursing staff. The CP emphasized the importance of documenting every medication taken from the e-kit for billing, inventory tracking, and preventing drug diversion. The failure to replace the e-kit within the required timeframe could potentially impact the availability of necessary medications in emergency situations.
Inappropriate Medication Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that three residents were administered medications appropriately, leading to potential unnecessary drug use. Resident 55's oxycodone order was changed from as needed to routine without clinical justification, and there was no monitoring for side effects. Despite the resident not complaining of pain, the order was altered after only two days and five doses, without proper documentation or communication with the physician. The Medical Director did not recall authorizing this change, and the nursing staff did not update the care plan or document the rationale for the change. Resident 57's hydrocodone-acetaminophen order was similarly altered, with an additional routine order added without clinical justification. The resident, who was developmentally delayed, had only requested the medication three times as needed, yet a routine order was obtained. There was no documentation of a pain assessment or a diagnosis of chronic pain, and the Medical Director did not recall prescribing the routine order. The Assistant Director of Nursing acknowledged the inappropriateness of the routine order given the resident's limited use of the medication. Resident 59's tramadol order was increased from three times daily to four times daily without sufficient justification. The resident had only requested the medication four times as needed over a period of several weeks. The Assistant Director of Nursing admitted that the change was unwarranted based on the resident's usage. The Director of Nursing confirmed that the nursing staff did not follow proper procedures for documenting pain assessments or updating care plans, and there was no monitoring for side effects of the medications administered to the residents.
Suspended LVN Worked During Investigation
Penalty
Summary
The facility administration failed to prevent a Licensed Vocational Nurse (LVN) from working while suspended and under investigation for drug diversion. The LVN, suspected of diverting opioids and other medications, was suspended on September 25, 2024. Despite this, the Director of Nursing (DON) requested the LVN to return to work on September 28, 2024, to provide orientation to a newly hired LVN. This resulted in the suspended LVN working a 12-hour shift with approximately 30 residents, potentially compromising the integrity of the ongoing investigation. The Owner/Administrator (OA) had explicitly instructed the DON that the LVN should not be present in the facility during the suspension. The DON's decision to allow the LVN to work was against these instructions, leading to her suspension on October 7, 2024. The facility's policy mandates that any employee accused of resident abuse or theft is placed on leave with no resident contact until the investigation is complete. The DON's actions were considered insubordination, as there were other nurses available to provide the necessary orientation.
Improper Disinfection of Glucometers by Nursing Staff
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers by two licensed nurses, RN 3 and LN 22, after obtaining blood samples from residents. This oversight was identified through observations, interviews, and record reviews. Both nurses were responsible for administering medications and performing blood glucose fingerstick tests on residents. RN 3, who had been employed for three months, and LN 22, who had been employed for one week, had not received competency-based training on the use of glucometers. During observations, RN 3 used a disinfecting wipe that was not approved for killing bloodborne germs, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time as indicated on the product label. The Infection Prevention Nurse confirmed that the disinfecting wipes used by RN 3 were not suitable for eliminating bloodborne pathogens, and both nurses failed to follow the manufacturer's instructions for proper disinfection. The technical brief for the glucometer and the technical data bulletin for the germicidal wipes both emphasized the necessity of cleaning and disinfecting the glucometer after each use to prevent the transmission of bloodborne pathogens. The failure to properly disinfect the glucometers posed a risk of spreading bloodborne diseases to other residents undergoing blood glucose testing.
Deficiency in Staff Competency Training
Penalty
Summary
The facility failed to ensure that three nursing staff members, including a Licensed Vocational Nurse, a Licensed Nurse, and a Registered Nurse, received essential competency training. The Director of Staff Development (DSD) was responsible for overseeing the orientation of new nursing staff, which was supposed to include two classroom days before working on the floor. However, the Director of Nursing (DON) instructed one of the nurses to start working with residents after only one day of classroom orientation, bypassing the established protocol. This decision was made without consulting the DSD, as the DON needed a nurse on the floor immediately. Additionally, the facility did not provide competency-based training for the use of glucometers, which are essential for monitoring and treating diabetes, to the three nursing staff members. The DSD confirmed that there were no records of glucometer competencies for these staff members, despite the presence of residents requiring such monitoring. Furthermore, there were no records of medication administration competencies for these nurses, who were responsible for administering medications through various methods and routes. The facility's assessment indicated that all residents received medication management, and the training program was supposed to include medication administration and diabetic blood glucose testing.
Deficiency in QAPI Program Awareness and Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of awareness among staff members about the program and the absence of a tool for measuring performance improvement. During interviews, four staff members, including two Certified Nursing Assistants (CNAs), a Licensed Nurse (LN), and a Registered Nurse Supervisor, were unable to articulate knowledge of the facility's QAPI plan. The CNAs and LN were not aware of the program at all, while the Registered Nurse Supervisor knew the acronym but could not describe the plan or the performance improvement measurement tool. An observation of a facility bulletin board revealed a display related to QAPI, including an initiative to reduce pressure ulcers by 50% over the next quarter. However, during an interview, the Director of Nursing (DON) acknowledged that while the facility collects QAPI data on falls and pressure ulcers, they were unable to specify the performance improvement measurement tool used for pressure ulcers. This lack of awareness and understanding among staff members indicates a deficiency in the facility's implementation of its QAPI program, which is crucial for improving resident safety.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to conduct reference checks for two of the five sampled employees, specifically a Licensed Vocational Nurse (LVN) and a Licensed Nurse (LN), prior to their employment. During an interview, the Owner/Administrator expressed that it was expected for all candidates to have their previous employment and personal references checked. However, upon reviewing the personnel file of LVN 1, it was found that no reference checks were performed. The Director of Staff Development (DSD) acknowledged the absence of reference checks and admitted to not knowing where LVN 1's references were. Similarly, the personnel file of LN 22, who had just graduated from nursing school and had no prior nursing experience, showed that only personal references were listed, and these were not checked. The DSD confirmed that personal references for LN 22 were not verified, stating a preference for checking only employment references. The facility's policy and procedure document, dated March 2019, mandates background screening and reference checks for all applicants with direct access to residents, which was not adhered to in these cases.
Inadequate Infection Control Training for Nursing Staff
Penalty
Summary
The facility failed to implement an effective training program for infection control and prevention, specifically for two licensed nurses, a Licensed Vocational Nurse (LN 22) and a Registered Nurse (RN 3). During a review of their employee records, it was found that neither nurse had documented training on hand hygiene and personal protective equipment (PPE), which are critical components of infection control. The Director of Staff and Development (DSD) confirmed that the training was not completed as there were no signatures in the records to indicate otherwise. The Infection Preventionist (IP) acknowledged that hand hygiene and PPE training should be mandatory for all staff but admitted to not ensuring that all staff received this training. The facility's Facility Assessment, dated September 2, 2024, stated that staff training on infection control, including written standards, policies, and procedures, is part of their program. However, the lack of documented training for LN 22 and RN 3 indicates a failure to adhere to these standards, placing residents at risk for potential infection spread due to inadequate staff training.
Dietary Service Deficiencies in Portion Control and Food Preparation
Penalty
Summary
The facility failed to ensure that Dietary Cook (DC) 1 was competent in carrying out the functions of food and nutrition services safely and effectively. DC 1 served incorrect portion sizes for residents on large portion diets, providing one and a half servings of the main dish instead of the prescribed one serving. This was contrary to the facility's policy, which specified that large portions should include extra servings of vegetables, not the main dish. Additionally, DC 1 did not fortify foods for residents on fortified diets by failing to add the required extra butter to vegetables, which was necessary to meet the residents' higher nutrient demands. DC 1 also did not follow the pureed food recipe for residents on pureed diets, omitting the smooth Mexican tomato sauce that was supposed to enhance the flavor of the pureed foods. Furthermore, DC 1 neglected to check the temperature of pureed foods before serving, which is a critical step to ensure food safety and prevent foodborne illnesses. The facility's policy required all food temperatures to be checked prior to serving to ensure they were safe for consumption. Lastly, the kitchen ran out of the main dish, chile relleno casserole, and DC 1 had to serve an alternate meal, a beef, bean, and cheese burrito, to the last three residents. This was not in accordance with the facility's policy, which stated that alternates should only be provided upon resident request or if they did not like the main dish. The Dietary Service Supervisor (DSS) was responsible for ensuring that the kitchen staff were fully trained and that the menu was followed, but these deficiencies indicate a lack of proper oversight and training.
Nutritional Deficiencies in Meal Service
Penalty
Summary
The facility failed to ensure that the food served met the daily nutritional needs of several residents. Specifically, residents on large portion diets were served more than the required portion size of chile relleno casserole, which could lead to exceeding their recommended daily caloric intake. This was observed during a tray-line observation where the dietary staff served one and a half slices of the casserole instead of the prescribed one slice. The Registered Dietitian confirmed that the menu and portion sizes should have been followed to prevent potential weight gain or elevated lab levels. Additionally, the facility did not adhere to fortified diet orders for certain residents. During an observation, it was noted that the dietary staff failed to add extra butter to vegetables for residents on fortified diets, which was necessary to meet their additional caloric needs. The Dietary Service Supervisor acknowledged that the fortified diet order was not followed, and the expectation was to adhere to the menu and spreadsheet instructions. Furthermore, the facility ran out of the main dish, chile relleno casserole, and served alternate food to some residents without their request. This occurred because there was not enough of the main dish prepared, leading to the substitution of beef, bean, and cheese burritos. The Dietary Service Supervisor and Registered Dietitian both stated that it was not acceptable to provide alternate meals without resident requests, and the expectation was to have enough food to serve all residents according to the menu.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In one instance, Resident 4's wheelchair was found with dried fecal matter on the seat, which was not cleaned according to the facility's policies. Interviews with staff, including a Certified Nursing Assistant (CNA), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that such contamination could lead to the spread of infections like C-Diff and E-Coli. The facility's policy required that resident-care equipment be cleaned and disinfected, but this was not adhered to in this case. Another deficiency was observed in Resident 33's room, where two used urinal bottles were found on the bedside table next to drinking cups and personal hygiene supplies. One of the urinals had brown matter buildup, indicating it had not been cleaned or replaced as per the facility's guidelines. Staff interviews revealed that urinals should be changed weekly and not placed on bedside tables to prevent cross-contamination. The presence of dirty urinals next to personal items posed a significant infection control issue, as confirmed by the IP and DON. Additionally, the facility's laundry room had a leak causing dirty water to pool on the floor, which could lead to contamination of freshly washed linens. Laundry staff and the Assistant Director of Nursing (ADON) acknowledged the unsanitary conditions and the potential for mold or pathogen growth. Furthermore, Resident 214's nephrostomy catheter bag was found on the floor, which could lead to contamination and infection. Staff interviews confirmed that the catheter bag should not have been on the floor, as it posed an infection risk. The facility's policies on infection control were not followed, contributing to these deficiencies.
Deficiencies in Privacy and Safety Measures
Penalty
Summary
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Observations revealed that privacy curtains were either missing strings or had tangled strings, making them non-functional. Certified Nursing Assistants (CNAs) reported these issues to the Maintenance Supervisor (MS) and housekeeping, but the problems persisted due to a lack of parts for repairs. The MS confirmed the issues and stated that the facility had ordered new parts to address the problem. The Director of Nursing (DON) and the Administrator acknowledged the importance of maintaining privacy for residents, as it is a fundamental resident right. Additionally, the facility failed to address a water leak from one of the washing machines in the laundry room, leading to pooled water on the floor. This situation posed a safety hazard, with risks of slips, electrocution, and potential growth of mold and bacteria. Laundry staff and the Assistant Director of Nursing (ADON) were aware of the leak, which had been ongoing for about a year, but no repair request was documented in the maintenance log. The Maintenance Supervisor identified the source of the leak as a missing plug in the washing machine, and the DON emphasized the need for immediate action on such issues. The facility's policies and procedures for maintaining a homelike environment and ensuring safety were not effectively implemented. The maintenance department was responsible for keeping the building and equipment in safe and operable condition, but failed to address the reported issues in a timely manner. The lack of documentation and follow-up on maintenance requests contributed to the ongoing deficiencies, impacting the safety and comfort of residents and staff.
Deficiencies in Care Planning for Anticoagulant and Infection Control
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident 53, who was admitted with multiple diagnoses including End Stage Renal Disease, Acute Pulmonary Edema, Atrial Fibrillation, and Depression, did not have a care plan for the anticoagulant medication apixaban. This oversight was identified during a review of the resident's records, where it was noted that the care plan was missing despite the facility's policy requiring one for anticoagulant use. Interviews with the LVN, MDS, and DON confirmed the absence of the care plan, which is necessary to monitor for potential adverse reactions. Resident 51, who was admitted with heart failure, morbid obesity, and osteoarthritis, was placed on Enhanced Barrier Precaution (EBP) due to skin issues. However, there was no care plan in place to guide staff on how to manage the resident's needs under EBP. The Infection Preventionist, who was responsible for initiating such care plans, acknowledged the absence of the care plan during a review of the resident's clinical record. The DON and RNS also confirmed that the care plan was missing, emphasizing the importance of care plans in directing nursing staff on resident care. The facility's policy and procedure documents indicate that comprehensive care plans should be developed within seven days of completing a resident assessment. The lack of care plans for both residents 53 and 51 highlights a failure to adhere to these policies, potentially putting the residents at risk by not addressing their specific medical and care needs adequately.
Medication Safety and Bedrail Padding Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice for two residents, Resident 27 and Resident 44. For Resident 27, a medicine cup containing seven tablets was left unattended on the breakfast tray. This was observed during a visit, and the resident confirmed that the nurse left the medication for him to take after breakfast. The facility's policy and interviews with staff, including the LVN and DON, indicated that medications should not be left unattended at the bedside due to the risk of other residents accessing them or the resident not taking them. Despite this, the LVN responsible for Resident 27 admitted to leaving the medication at the bedside, believing it was safe for the resident to take after eating. For Resident 44, the facility failed to follow the physician's order for padded side rails. Observations on multiple occasions revealed that the resident's bedrails were raised without padding, despite having a condition that required such safety measures. Interviews with CNAs and the DON confirmed that the resident should have had padded side rails to prevent injury, especially given the resident's medical conditions, including epilepsy. The facility's policy emphasized the importance of implementing additional safety measures for residents at higher risk of injury, which was not adhered to in this case. The deficiencies in both cases were attributed to a lack of adherence to established policies and procedures. Staff interviews revealed a general understanding of the policies, yet the practices observed did not align with these standards. The failure to ensure medication safety for Resident 27 and the lack of padded side rails for Resident 44 highlighted lapses in the facility's compliance with professional standards of care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored safely and labeled according to accepted professional principles. Specifically, medications administered via inhalers for 11 residents were not labeled with expiration or use-by dates. During observations and interviews, it was confirmed by two Licensed Vocational Nurses (LVNs) that the inhalers lacked expiration dates, which was acknowledged as a potential issue by the Director of Nursing (DON) and the Skilled Nursing Pharmacy Consultant (SN PC). The facility's policy required medication labels to include expiration dates, but this was not adhered to, raising concerns about the potential administration of expired medications. Additionally, one of the medication carts was left unattended in a hallway with keys on top, posing a risk of unauthorized access to medications. This was observed and confirmed by an LVN, the Assistant Director of Nurses (ADON), and the Administrator (ADM), all of whom acknowledged that the keys should not have been left on the cart. The facility's policy stipulated that medications should be stored in locked compartments, accessible only to authorized personnel, but this protocol was not followed, creating a risk of medication misuse or diversion.
Lack of Air Gap in Kitchen Sink Risks Resident Safety
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices for 54 out of 62 residents due to the absence of an air gap in the two-compartment prep sink in the kitchen. During an observation and interview, the Dietary Service Supervisor (DSS) acknowledged that the sink lacked an air gap, which is essential for backflow prevention. The Maintenance Supervisor (MS) was also aware of this issue. The DSS admitted that the absence of an air gap was noted in a previous survey, and although attempts were made to install one, they were unsuccessful. The Registered Dietitian (RD) explained that an air gap is necessary to prevent gases or bacteria from entering the prep sink area through the pipeline, which could contaminate food and potentially cause illness among residents. The facility's policy and procedure, as well as the FDA Food Code, require backflow prevention through an air gap to prevent contamination. Despite this requirement, the facility did not have the necessary air gap installed, posing a risk of food-borne illness to the residents.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) did not provide adequate privacy during personal hygiene care. During an observation, it was noted that the door to the resident's room was open, and the resident's buttocks were exposed and visible from the hallway. The privacy curtain was not fully drawn, leaving the resident exposed to visitors, staff, and other residents. The CNA acknowledged that the privacy curtain was stuck and admitted to not ensuring the door was closed to provide the necessary privacy. The resident involved had been admitted with diagnoses including unspecified dementia and psychosis, with a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the CNA should have ensured the resident was covered and the door was closed, especially since the privacy curtain was not functioning properly. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Resident Neglect Due to Lack of Catheter Supplies
Penalty
Summary
The facility failed to ensure that Resident 19 was free from neglect when he did not receive the necessary supplies to conduct his suprapubic catheter care. Resident 19, who was diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and depression, was admitted to the facility with the ability to change his own suprapubic catheter with staff supervision. Despite being independent and having no cognitive impairment, as indicated by a BIMS score of 15, Resident 19 was left soiled with urine after requesting supplies from three staff members, none of whom provided the necessary items. Interviews with various staff members, including an LVN, CNA, RN, ADON, and DSD, confirmed that Resident 19 was independent and capable of managing his own catheter care. The staff acknowledged that they neglected to provide the supplies when requested, which led to Resident 19 being upset and embarrassed due to his soiled condition. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and ensuring they are free from neglect, which was not upheld in this instance.
Failure to Notify LTC-Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman office of a resident's transfer to the hospital. This deficiency was identified during a review of the records for a resident who was transferred to an acute care facility for treatment of a urinary tract infection. The resident, who had severe cognitive impairment, was admitted to the facility with diagnoses including hydronephrosis, infection due to nephrostomy, and diabetes mellitus. Despite the transfer, the facility did not send a copy of the transfer notification to the local LTC-Ombudsman office, leaving them unaware of the resident's emergency transfer. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the LTC-Ombudsman of hospital transfers. A Licensed Vocational Nurse and the Director of Staff Development both stated they were unaware of this requirement. The Director of Nursing acknowledged that the LTC-Ombudsman should have been notified, as they are there to assist residents in case issues arise. A professional reference from CMS clarified that notices for emergency transfers must be sent to the Ombudsman, highlighting the facility's failure to comply with this requirement.
Failure to Transmit MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to meet the required timelines for encoding, completion, and transmission of Minimum Data Set (MDS) assessments for a resident, identified as Resident 58. The Minimum Data Set Nurse (MDSN) did not complete or transmit the discharge MDS assessment for Resident 58, who was discharged to home. During an interview and record review, it was revealed that the last assessment for Resident 58 was a quarterly assessment dated April 11, 2024, and no discharge assessment was completed or transmitted when the resident was discharged on May 1, 2024. The MDSN admitted to not having reviewed the MDS schedules and was unaware of the missing discharge assessment until the review. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the MDSN was responsible for ensuring all MDS assessments were completed and transmitted in a timely manner. The facility's policy and procedure on MDS Completion and Submission Timeframes indicated that assessments should be conducted and submitted in accordance with federal and state guidelines. The failure to complete and transmit the discharge assessment for Resident 58 resulted in the potential harm of the resident's needs upon discharge going unmet.
Failure to Re-evaluate and Document PASARR for Resident
Penalty
Summary
The facility failed to re-evaluate and document the current condition for Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is a federal requirement to ensure residents with mental disorders or intellectual disabilities are not inappropriately placed in a nursing home. The resident in question was admitted with diagnoses including unspecified dementia, psychosis, depression, and anxiety. Despite these diagnoses and the prescription of psychotropic medications, the resident's PASARR Level I indicated no diagnosis of mental disorder, highlighting a discrepancy in the documentation. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASARR assessments. The Business Office Manager, who was new and part-time, was unfamiliar with the PASARR process, and the Assistant Director of Nursing was unsure who was responsible for completing the assessments. The Director of Nursing acknowledged the absence of a designated person for PASARR completion, and the Administrator expressed the need for staff training on PASARR assessments. The facility's policy required screening for mental disorders upon admission, but this was not effectively implemented, leading to the deficiency.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for one resident, identified as Resident 59, who had moderate cognitive impairment. The resident was observed using the right side rail on multiple occasions to reposition himself and place his urinal. Despite this, there was no documented physician's order, care plan, safety evaluation, or informed consent for the use of the side rail. Interviews with staff, including CNAs and an LVN, confirmed that the necessary procedures and documentation were not completed prior to the use of the side rail. The facility's policy on bed safety and bed rails, dated August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these steps were not followed for Resident 59, as confirmed by the MDS Coordinator and the Director of Nursing. The lack of proper assessment and documentation had the potential to place the resident at risk for decreased freedom of movement, entrapment, and/or injury.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide acetylsalicylic acid 325 mg to a resident who had an order for this medication to prevent blood clots. This deficiency was identified when the medication was found to be missing during an observation and interview with a Licensed Vocational Nurse (LVN) in front of the resident's room. The LVN confirmed that the medication was not available, and the Director of Nursing (DON) indicated that the Associate Director of Nursing (ADON) was sent to a local pharmacy to obtain the medication. Interviews with the Skilled Nursing Pharmacy Consultant (SN PC) and the ADON revealed that the responsibility for re-ordering medications lies with the facility's nurses. The SN PC stated that nurses should reorder medications before they run out, and the ADON confirmed that either the ADON or RN supervisor is responsible for ordering over-the-counter medications. The ADON also stated that a full bottle of medication should always be available before the supply runs out. A review of the resident's Medication Administration Record (MAR) confirmed the order for acetylsalicylic acid 325 mg daily, and the facility's policy indicated that medications should be reordered at least three days before the last dose is administered.
Failure to Maintain LAL Mattress Cover
Penalty
Summary
The facility failed to maintain a low air loss (LAL) mattress cover sheet in good condition for one of the residents, leading to a potential malfunction of the mattress. The LAL mattress, which is designed to prevent skin breakdown by distributing the patient's body weight, had a tear where the resident rested his head. This issue was identified during an observation and interview with a certified nursing assistant (CNA), who noted the wear and tear on the mattress cover and acknowledged the importance of the LAL mattress for the resident due to past skin problems. Interviews with various staff members, including CNAs, a licensed vocational nurse (LVN), the infection preventionist (IP), the director of nursing (DON), and the director of staff development (DSD), confirmed that the LAL mattress cover should not have been torn. They emphasized that a torn cover could affect the mattress's functionality and cleanliness, potentially leading to skin breakdown for the resident. The facility's policy on bed safety also indicated that any worn or malfunctioning bed system components should be repaired or replaced, which was not adhered to in this case.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey conducted from September 9 to September 13, 2024, it was observed that eight rooms each housed more than four residents, specifically accommodating eight residents per room. This arrangement was made to cater to the residents' particular care needs and comfort. Despite the non-compliance, the facility ensured that wheelchairs and toilet facilities were accessible, and a reasonable amount of privacy and adequate storage space were provided. The staff reported no issues with providing care, and residents did not express concerns about personal space. Interviews with residents and staff revealed that the residents felt they had privacy when needed, and the staff did not encounter difficulties in delivering care. A resident expressed satisfaction with the shared room arrangement, and a CNA confirmed that each resident had personal storage space. An LVN noted that while the rooms were spacious enough for care, privacy curtains did not always close completely. An EVS staff member stated that there was ample room for cleaning. Despite these observations, the facility's room arrangements did not meet the regulatory requirements, leading to the deficiency noted in the report.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in accordance with its Abuse Prevention Program policy. A Licensed Vocational Nurse (LVN) overheard a resident alleging on the phone that staff were hitting her and reported this to the Administrator (ADM) on 5/14/24. Despite this, the facility did not notify the appropriate agencies of the abuse allegation within the required 24-hour timeframe. The Social Service Director (SSD) was also aware of the allegation and informed the ADM on the same day. However, the ADM acknowledged that the report should have been made to the California Department of Public Health (CDPH) by 5/15/24, but it was not done within the stipulated time. The resident involved had a moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. During an interview on 5/16/24, the resident reiterated that staff were hitting her. The facility's policy on abuse prevention, which mandates timely and thorough investigations and reporting of abuse allegations, was not followed. The ADM confirmed that the facility follows an All Facilities Letter (AFL) guideline requiring abuse allegations to be reported within 24 hours, which was not adhered to in this case.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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