Granada Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynwood, California.
- Location
- 3565 E Imperial Hwy, Lynwood, California 90262
- CMS Provider Number
- 555348
- Inspections on file
- 25
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Granada Post Acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and hearing difficulties consistently refused to wear hearing aids, yet the care plan was not updated to reflect this refusal or to document alternative interventions. Staff acknowledged the ongoing refusal and communicated by speaking directly into the resident's ear, but the facility did not revise the care plan as required by policy.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care in these areas.
A resident with osteopenia, fractures, and contractures who was fully dependent on staff did not have a comprehensive, person-centered care plan. The care plan lacked specific details about the location of the osteopenia and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not sufficiently individualized to guide care.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect data transmission to CMS. One resident's MDS did not reflect dental issues, another's did not indicate the absence of natural teeth, and a third's was inaccurately coded regarding oral status. The MDS Nurse acknowledged these inaccuracies, which could result in unmet care needs.
A facility failed to submit an accurate Level I PASRR for a resident with psychosis, depression, and anxiety disorder. The initial PASRR, completed by the hospital, did not reflect these SMIs, leading to a determination that the resident did not require a Level II PASRR Mental Health Evaluation. The Social Services Director acknowledged the oversight and the need for a new assessment, as per facility policy.
The facility failed to implement care plans for two residents, one with epilepsy and another requiring oxygen therapy. Resident 288's care plan required padded siderails to prevent injury during seizures, but observations showed no padding was applied. Resident 191, dependent on supplemental oxygen, lacked a care plan for oxygen administration, and no oxygen sign was posted outside the room. Interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for comprehensive care planning.
A LTC facility failed to implement proper interventions for pressure ulcer prevention for four residents. Incorrect settings on low-air-loss mattresses (LALM) were observed for three residents, with one resident not receiving a LALM as ordered. The facility's policy for air mattresses was not followed, leading to potential risks for pressure ulcer development or worsening.
A resident with epilepsy was observed multiple times in bed without the required padding on siderails, as specified in their care plan. Despite the facility's policy and the resident's high risk for injury, the necessary safety measures were not implemented, placing the resident at risk.
A facility failed to post an oxygen signage for a resident receiving oxygen therapy, as observed during a survey. The resident, with a history of acute respiratory failure and other health issues, was receiving supplemental oxygen via nasal cannula. A nurse and the DON acknowledged the absence of the sign, which was required by the facility's policy for safety.
A resident with Parkinson's, diabetes, and seizure disorders received medications late and incorrectly, resulting in an 18.75% medication error rate. An LVN administered six medications over an hour late and applied Lidocaine cream to the wrong knee. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed.
A resident on a pureed diet was not provided with a menu or offered alternative meal options, despite expressing dissatisfaction with the meals and consuming less than 50% of them. The resident, who communicated through a digital device, reported the meals were inedible and lacked variety. Staff failed to offer alternatives, citing the pureed diet as a reason, and there was confusion over which department was responsible for providing menus. Facility policies requiring substitute food items and menu postings were not followed, impacting the resident's nutritional status and quality of life.
A facility failed to ensure staff were knowledgeable about handling unlabeled resident clothes and did not complete a belonging list upon a resident's readmission. Interviews revealed discrepancies in staff understanding of the process for managing unlabeled clothes, with some staff placing them in a donation box and others keeping them in the laundry room. Additionally, an inventory list was not created upon the resident's readmission, contrary to facility policy, potentially violating the resident's right to a safe and homelike environment.
A resident with polyneuropathy and joint replacement surgery experienced a fall, but the facility failed to conduct an IDT meeting or update the care plan with safety interventions. Despite the resident's cognitive intactness and partial assistance needs, the care plan lacked measures to prevent future falls, such as providing a reacher, which was only added nine days later. The DON confirmed the absence of documentation for an IDT meeting and the delay in care plan revision.
The facility failed to implement infection control measures by improperly cohorting residents and not posting necessary signage for contact isolation and Enhanced Barrier Precautions (EBP). A resident with MRSA was placed in a room with two others without contact precautions, and staff did not wear PPE when entering the room. Additionally, signage for EBP was missing for two residents, leading to potential risks of infection transmission.
A resident's transfer to a GACH Rehab was delayed due to the facility's failure to send complete documentation, including essential PT notes. The resident, with conditions like hemiplegia and muscle weakness, required further therapy, but the incomplete referral led to the case being closed by the rehab center. Interviews revealed that the facility's Social Services could not confirm the transmission of the missing documents, resulting in the resident not being accepted for transfer.
Failure to Update Care Plan for Resident's Refusal of Hearing Aids
Penalty
Summary
The facility failed to timely develop a comprehensive care plan addressing a resident's ongoing refusal to wear hearing aids. The resident, who had diagnoses including congestive heart failure and moderate cognitive impairment, was documented as having difficulty hearing and required substantial assistance with activities of daily living. Despite the care plan indicating the use of hearing aids to help the resident hear effectively, multiple staff interviews and observations confirmed that the resident consistently refused to wear the hearing aids. Staff, including a CNA, Social Services Director, and LVN, acknowledged the resident's refusal and reported communicating by speaking directly into the resident's ear, but the care plan was not updated to reflect this ongoing issue. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, including documentation of services not provided due to resident refusal. However, the care plan did not address the resident's persistent refusal to use hearing aids, nor did it outline alternative interventions or document the resident's exercise of their right to refuse. This omission was confirmed by staff interviews and record reviews, indicating a failure to meet the facility's own policy and regulatory requirements for care planning.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as needed.
Failure to Develop Comprehensive, Person-Centered Care Plan for Resident with Osteopenia
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with osteopenia, as well as other conditions including fracture, contracture, and disorders of bone density and structure in the right shoulder. The resident was totally dependent on staff for all activities of daily living and did not have the capacity to make decisions, according to the History and Physical. However, the Minimum Data Set indicated the resident was able to understand and be understood by others. The care plan in place for osteopenia included general interventions such as handling the resident gently and observing for joint pain and stiffness, but it did not specify the location of the osteopenia or provide detailed, measurable objectives and timetables tailored to the resident's specific needs. During an interview, the DON acknowledged that the care plan lacked specificity regarding the location of the osteopenia and stated that care plans are intended to guide resident care and should be more individualized. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's physical, psychosocial, and functional needs, but this was not implemented for the resident in question.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion and documentation of the Minimum Data Set (MDS) assessments for three residents, leading to the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Resident 23's MDS, dated March 6, 2025, did not reflect the resident's dental concerns, despite observations of poor dentition and broken teeth. The MDS Nurse (MDSN) acknowledged the inaccuracy, noting that the MDS should have indicated the resident's dental issues to ensure appropriate care planning. Resident 24's MDS was also inaccurately coded, failing to reflect the resident's lack of natural teeth. During an observation, Resident 24 was seen without upper and lower teeth and consuming soft or pureed foods. The MDSN confirmed the incorrect coding of the oral/dental assessment, which could potentially result in unmet care needs and services for the resident. Similarly, Resident 19's MDS did not accurately represent the resident's oral/dental status, as the resident had no natural teeth and was on a pureed diet. The MDSN was aware of this discrepancy and acknowledged the incorrect coding. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, and the information should reflect the resident's status, which was not adhered to in these cases.
Inaccurate PASRR Assessment for Resident with SMI
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was submitted for a resident, which is a tool used to identify possible serious mental illness (SMI) and determine if specialized services are required. The resident in question was admitted with diagnoses of psychosis, depression, and anxiety disorder, yet the Level I PASRR assessment did not reflect these SMI diagnoses. Consequently, the PASRR determination letter indicated that the resident did not require a Level II PASRR Mental Health Evaluation, as the Level I assessment inaccurately showed no SMIs. The Social Services Director (SSD) acknowledged that the Level I PASRR was initially completed by the hospital before the resident's admission to the facility. Upon review, the SSD noted that the Level I PASRR did not accurately reflect the resident's SMIs and admitted that a new and accurate Level I PASRR should have been completed and submitted. The facility's policy requires that all residents have a Level I PASRR completed to ensure they receive necessary services for their SMI in the appropriate setting, which was not adhered to in this case.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to implement a care plan for Resident 288, who was admitted with a diagnosis of epilepsy and severe cognitive impairment. The care plan, dated 3/6/2025, required padding on the siderails of the resident's bed to prevent injury during seizures. However, observations on multiple occasions revealed that the siderails were not padded, placing the resident at risk for physical harm. Interviews with the Registered Nurse Supervisor confirmed the absence of padding and acknowledged the risk of injury if a seizure occurred. For Resident 191, the facility did not develop or implement a care plan for oxygen administration, despite the resident's dependence on supplemental oxygen due to conditions such as acute respiratory failure and congestive heart failure. Observations showed that there was no oxygen sign posted outside the resident's room, and the care plan lacked specific interventions for oxygen therapy. Interviews with the Licensed Vocational Nurse and the MDS Nurse revealed that the oxygen care plan was not initiated upon readmission, leaving the resident's oxygen therapy unmonitored and without clear guidelines for staff. The facility's policies and procedures require comprehensive, person-centered care plans and additional safety measures for residents at higher risk of injury. However, the lack of adherence to these policies resulted in deficiencies in care planning and implementation for both residents, potentially compromising their safety and well-being.
Improper Use of Low-Air-Loss Mattresses in LTC Facility
Penalty
Summary
The facility failed to ensure proper interventions for preventing the development or worsening of pressure ulcers for four residents. For Residents 288, 74, and 191, the settings on their low-air-loss mattresses (LALM) were incorrect. Resident 288's mattress was set at 350 lbs, despite a physician order for a 150-lb setting, and the resident's weight was 154 lbs. Similarly, Resident 74's mattress was set at 280 lbs and later at 250 lbs, while the resident's weight was 140 lbs, and the physician order required a 150-lb setting. Resident 191's LALM was labeled with another resident's name and incorrect weight settings, leading to potential confusion and improper therapeutic support. Resident 23 did not receive a LALM as ordered by the physician, despite being at risk for developing pressure ulcers. Observations over multiple days confirmed that Resident 23 was lying in bed without the prescribed LALM. The Treatment Nurse acknowledged the absence of the LALM but could not provide a reason for this oversight. The facility's policy and procedure for air mattresses were not followed, as the mattresses were not set according to the residents' weights, and the labeling was incorrect. The Treatment Nurse and Quality Assurance Nurse confirmed these discrepancies, acknowledging that the incorrect settings and labeling could lead to the development or worsening of pressure ulcers. The Director of Nursing also stated that the LALM should be set according to the resident's weight to prevent skin breakdown.
Failure to Pad Siderails for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure the safety of Resident 288 by not padding the siderails of the resident's bed, as required by the care plan. Resident 288, who was admitted with a diagnosis of epilepsy, was observed on multiple occasions lying in bed with metal siderails that lacked the necessary padding. The resident's care plan, dated 3/6/2025, specifically indicated that padding should be applied to the siderails to prevent injury in the event of a seizure. Despite this, observations on 3/24/2025 and 3/25/2025 confirmed the absence of padding on the siderails. Interviews with RN 1 corroborated the oversight, as the nurse acknowledged the requirement for padding due to the resident's seizure disorder. During a concurrent observation and interview on 3/26/2025, RN 1 confirmed that Resident 288 was at risk for injury without the padding, especially if a seizure occurred. The facility's policy on Bed Safety and Bed Rails, revised in 8/2022, also indicated that additional safety measures should be implemented for residents with a higher risk of injury, which was not adhered to in this case.
Failure to Post Oxygen Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to place an oxygen signage at the room door entrance for a resident receiving oxygen therapy, which was observed during a survey. The resident was receiving supplemental oxygen via nasal cannula at three liters per minute, but there was no sign indicating oxygen was in use outside the room. The resident had a history of acute respiratory failure with hypoxia, dependence on supplemental oxygen, pneumonia, congestive heart failure, and diabetes mellitus. The resident's cognitive abilities were severely impaired, and they were dependent on assistance for daily activities. During an interview, a Licensed Vocational Nurse acknowledged the absence of the oxygen sign and stated that it should have been posted for safety reasons. The Director of Nursing also confirmed that oxygen signage should have been placed on the doorway. The facility's policy and procedure for oxygen administration required an 'Oxygen in Use' sign to be placed on the outside of the room entrance door, which was not followed in this instance.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 18.75%. This was due to the actions of an LVN who did not administer medications to a resident in a timely manner as per the physician's orders. The resident, who had a history of Parkinson's Disease, type 2 diabetes mellitus, and convulsions, received six medications more than one hour after the scheduled administration time. Additionally, the LVN applied Lidocaine cream to the resident's right knee instead of the left knee as prescribed. The resident's medical records indicated that the medications were crucial for managing conditions such as Parkinson's disease, diabetes, and seizure disorders. The medications included benztropine, carbidopa-levodopa, docusate sodium, empagliflozin, Lidocaine cream, and primidone. The LVN acknowledged that the medications were administered late and that the Lidocaine cream was applied incorrectly, which could lead to adverse effects and symptoms that the medications were intended to treat. Interviews with the LVN and the Director of Nursing confirmed that the medications should have been administered within a specific time frame, which was not adhered to in this instance. The facility's policy required medications to be administered within one hour of their prescribed time, a guideline that was not followed, leading to the identified deficiency.
Failure to Provide Menu and Alternative Meal Options
Penalty
Summary
The facility failed to provide a daily menu and offer alternative menu options for a resident, identified as Resident 3, who was on a pureed diet. Resident 3, who was admitted with diagnoses including muscle wasting, dysphagia, and severe protein-calorie malnutrition, was cognitively intact and communicated through a digital device. Despite being on a pureed diet, Resident 3 reported that the meals were inedible and lacked variety, leading to dissatisfaction and reduced food intake. The resident had not received a menu since admission and was not offered alternative meal options despite expressing dissatisfaction and consuming less than 50% of the meals. Observations and interviews revealed that Resident 3's meals were not varied, and the resident was not provided with a menu to choose alternative options. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) involved did not offer alternative meals, citing the resident's pureed diet as a reason. The LVN acknowledged that without a menu, Resident 3 could not see what was available and was unable to request preferred meals. The Dietary Services Supervisor and Director of Nursing (DON) had conflicting views on which department was responsible for providing menus, leading to a lack of clarity and failure to meet the resident's dietary needs. The facility's policies indicated that residents should be offered substitute food items for dislikes and that menus should be posted in accessible areas. However, these policies were not followed, resulting in Resident 3 not receiving a menu or alternative meal options. The failure to adhere to these policies and provide appropriate dietary care had the potential to impact Resident 3's nutritional status and quality of life, as the resident was consuming less than the recommended amount of food.
Failure to Protect Resident's Property and Ensure Staff Knowledge
Penalty
Summary
The facility failed to ensure staff were knowledgeable about the process for handling unlabeled resident clothes found in the laundry area and did not complete a resident belonging list upon readmission for one of the residents. This deficiency was identified during interviews and record reviews. A Licensed Vocational Nurse stated that dirty clothes during room transfers should be given to the laundry and returned to the resident once clean. However, a Laundry Services staff member indicated that unlabeled clothes were placed in the facility's donation box, while another staff member stated they should be kept in the laundry room. The Director of Nursing confirmed that unlabeled clothes should be kept in a designated area and compared to residents' belongings lists if clothes are reported missing. The report also highlighted that upon readmission, an inventory list of the resident's belongings was not created, as confirmed by the Medical Records review. The facility's policy and procedure on theft and loss, as well as the role of the nursing assistant during admission, require an inventory of all resident property, including clothing and valuables. The failure to adhere to these procedures had the potential to violate the resident's right to a safe and homelike environment, as it did not adequately protect the resident's property from loss or theft.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement its policies and procedures regarding comprehensive care planning and fall prevention for a resident who experienced a fall. After the resident's fall, the facility did not conduct an Interdisciplinary Team (IDT) meeting with the resident and their family representative to discuss and revise the care plan. The care plan was not updated to include safety interventions or measures to prevent future falls, despite the resident's fall being unwitnessed and resulting in a hospital transfer. The resident, who was cognitively intact and required partial assistance with activities of daily living, had a history of polyneuropathy and joint replacement surgery. The facility's policies required that care plans be reviewed and revised periodically and after changes in a resident's condition. However, the care plan did not include interventions such as providing a reacher to help the resident reach items, which was only added nine days after the fall. The Director of Nursing acknowledged the lack of documentation for an IDT meeting and the delay in updating the care plan.
Infection Control Deficiencies in Cohorting and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control measures for five out of seven residents by not ensuring proper cohorting and signage for contact isolation and Enhanced Barrier Precautions (EBP). Residents 1 and 3 were cohorted with Resident 2, who had orders for contact isolation due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. Despite Resident 2's need for contact precautions, Residents 1 and 3, who did not have such orders, were placed in the same room, contrary to the facility's policy. Additionally, the facility did not post clear signage to inform staff and visitors about the EBP required for Residents 6 and 7. Observations revealed that PPE supply drawers were present outside Resident 6's room without appropriate signage, and a PPE cart was observed across Resident 7's bed without EBP signage. Licensed Vocational Nurses (LVNs) and a Certified Nurse Assistant (CNA) acknowledged the absence of necessary signage, which is crucial for communicating the type of precautions and PPE required. Furthermore, staff failed to wear personal protective equipment (PPE) when entering a contact isolation room. A Physical Therapy Assistant (PTA) entered the room shared by Residents 1, 2, and 3 without donning PPE, despite a Contact Precaution sign on the door. The Infection Prevention Nurse (IPN) and Director of Nursing (DON) confirmed that staff should always wear PPE in such rooms, as the entire room is considered infected. The facility's policy indicated that residents with active infections should be placed in a private room or cohorted with residents with the same microorganism, which was not followed in this case.
Incomplete Documentation Delays Resident Transfer to Rehab
Penalty
Summary
The facility failed to ensure that all necessary documents were sent to the General Acute Care Hospital (GACH) Rehabilitation Center for a resident's evaluation and transfer. The resident, who was admitted with conditions such as hemiplegia, hemiparesis, muscle weakness, and gait disorders, required a transfer to the GACH Rehab for further physical therapy. However, the referral sent by the facility's Social Services (SS) was incomplete, lacking essential Physical Therapy (PT) notes. Despite attempts to send the missing documents, the SS could not provide confirmation of their transmission, leading to the GACH Rehab closing the resident's case due to incomplete documentation. Interviews with the SS and the Admissions Director (AD) at GACH Rehab revealed that the facility's failure to provide complete documentation resulted in the resident not being accepted for transfer. The AD confirmed that the missing PT notes were crucial for determining the resident's eligibility for admission. The facility's policy on discharge planning emphasized the importance of incorporating all relevant resident information to avoid delays, which was not adhered to in this case. This oversight delayed the resident's transfer and access to necessary therapies, impacting their potential for maintaining optimal physical, mental, and psychosocial well-being.
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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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