Granite Hills Healthcare & Wellness Centre, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 1340 E Madison Ave, El Cajon, California 92021
- CMS Provider Number
- 555878
- Inspections on file
- 55
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Granite Hills Healthcare & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident with left-sided hemiplegia and dementia had a fall risk care plan that included general fall precautions but did not address the need to keep personal items on the unaffected side for safe access. On one occasion, a CNA left for a lunch break without notifying the covering CNA, and the resident’s bedside table was positioned on the affected side, making items difficult to reach. After the roommate activated the call light, staff found the resident on the floor between beds with a forehead injury and later learned the resident had fallen while reaching for the remote on the bedside table. Hospital evaluation revealed a sutured forehead laceration and a femoral neck fracture.
A resident with dementia was involved in an altercation with a roommate, resulting in a bruise under the eye. The facility failed to report the injury within 24 hours, delaying the abuse investigation. The resident's family reported the injury, and staff speculated it might have occurred during an attempt to open a gate. The DON acknowledged the failure to report the incident to authorities as required by policy.
The facility failed to maintain safe food practices, with peeling paint in the kitchen ceiling posing a contamination risk, and staff entering the kitchen without proper hair coverings. The issues were reported but not addressed, and staff admitted to knowing the requirements for hair restraints.
The facility failed to maintain a homelike environment in four rooms within a secured unit. Observations revealed issues such as calcified sinks, broken furniture, exposed wires, and mold, which were acknowledged by the Director of Maintenance and the DON as not meeting the facility's policy for a clean and comfortable environment.
The facility failed to maintain a safe environment in six resident rooms, with hazards such as protruding wires and loose toilet seats. Additionally, a resident with a history of weakness was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring two-person assistance. These deficiencies posed a risk of injury to residents.
The facility's QAPI plan failed to identify deficient practices, including the lack of staff education on managing residents with PTSD and unaddressed environmental hazards. During interviews, the DON confirmed no PTSD-related education was provided, and the ADM admitted to being unaware of the environmental hazards and the existence of a safety committee.
A resident with Parkinson's disease and cataracts was inaccurately assessed in the MDS as having adequate vision, despite expressing blindness and difficulty seeing. The MDS Nurse admitted the error, which led to CMS being uninformed of the resident's impaired vision. The DON expected accurate MDS assessments, but the facility failed to follow the MDS Resident Assessment Instrument guidelines.
A resident with Parkinson's disease and cataracts experienced weight loss due to unaddressed visual impairment, as the facility failed to follow through on a referral to an ophthalmologist. Despite the resident's repeated complaints about his inability to see, there was no documented evidence of a consultation with an eye specialist, and the facility's policy on referrals was not effectively implemented.
A resident with Parkinson's and impaired vision experienced significant weight loss due to the facility's failure to investigate the root cause of his nutritional issues. Despite the resident's complaints about his inability to see food, the facility did not explore his vision problems or implement effective interventions. The resident's food consumption was inaccurately documented, and the care plan was not properly executed, leading to further weight loss.
The facility failed to identify and address PTSD triggers for two residents, leading to a deficiency in trauma-informed care. One resident, with PTSD and other mental health diagnoses, reported staff were unaware of his triggers, which were not documented in his care plan. Another resident, with PTSD from past abuse, experienced physical symptoms when triggered, but staff were unaware of her condition. The facility's policy requires identifying and mitigating triggers, but this was not implemented, potentially causing psychosocial harm.
A facility failed to monitor a resident's behaviors and side effects of a psychotropic medication prescribed for Tourette's Disorder and dementia. The resident exhibited self-harm behavior, and there was no evidence of behavior tracking or side effect monitoring in the MAR. Interviews with staff highlighted the importance of such monitoring, but the facility's policy was not adhered to, placing the resident at risk.
A facility failed to secure treatment and medication carts in the East Station area, leaving them unlocked and unattended. The treatment cart contained prescription creams, ointments, scissors, and wound dressing materials, while the medication cart held over-the-counter and prescription medications. LN 1 admitted to forgetting to lock the medication cart, and both the DSD and DON confirmed that carts should be locked when not in use to prevent unauthorized access.
The facility failed to accurately document food intake for a resident with Parkinson's disease, leading to discrepancies in monitoring weight loss. Additionally, care documentation for a resident with cerebral infarction was inaccurate due to a CNA using another's login credentials, highlighting issues with password sharing and record accuracy.
A facility failed to create a person-centered care plan for a resident with cognitive impairment and combative behavior during ADLs. Despite staff observations and interviews indicating the resident's tendency to hit during care and his responsiveness to Spanish, no care plan was developed to manage these behaviors, contrary to the facility's policy.
The facility failed to implement its fall prevention program for two residents with a history of falls. One resident had unwitnessed falls and lacked a functioning call light, while another had falls with an inaccessible call light and closed bedroom door. Staff were unaware of the fall risks, and no IDT meetings or care plan revisions were conducted as required by the facility's policy.
A resident's representative experienced a delay in receiving requested medical records due to the facility's failure to follow its policy of providing records within two working days. The Medical Record Department did not maintain a log of requests and delayed the process by not promptly seeking corporate approval. The Director of Nursing acknowledged the lapse in following the established procedure.
A facility failed to follow discharge protocols for a resident with End Stage Renal Disease. Despite a bed hold agreement, the resident was discharged without a 30-day notice or appeal information. The DON cited unmet needs and non-compliance as reasons for discharge, but the resident was ready for discharge from the hospital before the bed hold expired. The resident was distressed about not returning to his home and retrieving belongings.
A resident with cirrhosis and hepatic encephalopathy did not receive lactulose as prescribed, as the MAR lacked documentation of administration on specific dates. Interviews confirmed the absence of required initials, indicating potential non-administration, which could impact the resident's health.
A facility failed to implement an individualized care plan for a resident with paranoid schizophrenia and bipolar disorder, leading to a risk of elopement. The resident was observed unattended on the patio and had previously eloped by climbing over a fence. Despite a physician's order for a wanderguard, the system was not functional, and the resident was only monitored one-on-one during the PM/NOC shift. The facility's policy required immediate interventions, but the care plan did not adequately address the risk, as acknowledged by the DON.
The facility failed to ensure cooks followed recipes, impacting residents' nutritional status and satisfaction. Residents complained about the food quality, describing it as bad and insufficient. Observations showed improper chicken preparation and inadequate portion sizes for deli meat sandwiches, with the food service director acknowledging these issues.
A resident with a history of suicidal behavior swallowed a metal fork after being left unattended during mealtime, despite a care plan requiring close supervision. The resident had previously been observed breaking utensils and required one-to-one assistance during meals. The CNA left the resident alone briefly, leading to the incident, and the facility lacked a policy on mealtime supervision.
A resident with End Stage Renal Failure had a blood draw from his fistula, contrary to his care plan. The procedure was not documented in the medical record, and the phlebotomist did not indicate the blood draw location. The ADON confirmed that proper documentation was not followed.
Failure to Individualize Fall Prevention for Hemiplegic Resident Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized care planning for a resident with left-sided hemiplegia and hemiparesis. The resident’s care plan, dated 12/8/2025, identified a risk for falls related to impaired mobility and a history of CVA and included interventions such as nonskid socks, clutter-free environment, adequate lighting, low bed, call light within reach, and reorientation as needed due to dementia. However, the care plan did not address the resident’s specific physical limitation by directing staff to place personal items and belongings on the resident’s right (unaffected) side for safe and easy access. The facility’s fall management policy stated that the facility would maintain an environment free of accident hazards and provide adequate supervision and assistive devices to prevent avoidable accidents. On the day of the incident, the resident’s roommate activated the call light, and staff later found the resident on the floor between the B-bed and C-bed in a three-bed room. The bedside table was observed tilted and pushed against the B-bed, and the resident had a bump and superficial scrape on the right forehead with a moderate amount of blood. The resident reported reaching for the remote control on the bedside table, feeling weak, and then falling to the floor. The DON stated that the facility’s investigation determined the bedside table had been placed on the resident’s affected side, making it difficult for the resident to reach needed items. CNA 1 acknowledged knowing the resident had left-sided weakness and that the bedside table should have been on the right side, but could not recall the table’s position before leaving for a 30‑minute lunch break and did not inform the covering CNA of her absence. The resident was transferred to the hospital, where a superficial forehead laceration was sutured and a femoral neck fracture was diagnosed.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within 24 hours for a resident, which delayed the abuse investigation and placed residents at risk for abuse. The resident, who was admitted with diagnoses including muscle weakness and dementia, was involved in an altercation with a roommate. A licensed nurse observed the altercation but was unsure if there was physical contact. Later, a certified nursing assistant noticed a dark purple bruise under the resident's left eye, which was believed to have been caused by the altercation, although the incident was not witnessed. The Assistant Director of Nursing was informed by the resident's family about the bruise and a cut on the resident's arm, and it was suggested that the injuries might have occurred when the resident attempted to open a gate. The Director of Nursing was also informed by the family that the resident claimed to have been punched. Despite these reports, the injury was not reported to the state licensing agency, and the Director of Nursing acknowledged that the incident should have been reported immediately to the appropriate authorities. The facility's policy requires that unexplained injuries be promptly investigated and reported, which was not adhered to in this case.
Failure to Maintain Safe Food Practices
Penalty
Summary
The facility failed to adhere to safe food practices, as evidenced by two main issues. Firstly, the ceiling above the kitchen tray line area was observed to have peeling and bubbling paint, with pieces hanging downwards, which posed a risk of contamination to resident food and kitchen equipment. The Certified Dietary Manager (CDM) had reported the issue multiple times to the maintenance department, but the repairs were never completed. The Director of Maintenance, who started working at the facility in July 2024, was unaware of the ceiling issues until the day of the survey. The Registered Dietician (RD) and the Director of Nursing (DON) both acknowledged the importance of repairing the ceiling to prevent contamination. Secondly, two staff members were observed entering the kitchen without proper hair coverings. Kitchen Aide 1 (KA 1) and Dishwasher 1 (DW) both entered the kitchen wearing baseball hats without hair nets, and DW also had an uncovered beard. Both staff members admitted to knowing the requirement for hair and beard coverings to prevent cross-contamination. The CDM confirmed that sanitation and hairnet training had been provided to the staff, and the RD and DON emphasized the necessity of hair restraints to prevent contamination of food and equipment.
Failure to Maintain Homelike Environment in Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment for residents in four rooms within a secured unit, as observed during a survey. In one room, the sink was centrally located and covered with lime green calcification, which the Director of Maintenance (DM) acknowledged as unsanitary and in need of replacement. Another room had broken plastic cord covers, missing dresser knobs, and a leaning dresser, making it difficult for residents to use their furniture. The DM confirmed these issues and noted the room did not appear neat or homelike. In a third room, both beds lacked dresser knobs, a cable wire was protruding from the wall, and the thermostat was exposed, which the DM described as non-functional and unappealing. In the fourth room, a resident expressed dissatisfaction with mold around the sink, which she believed was affecting her health. The DM noted the poor condition of the sink area and agreed it was not homelike. The Director of Nursing (DON) also acknowledged that missing dresser handles did not contribute to a homelike environment. The facility's policy emphasizes providing a clean, comfortable, and homelike environment, which was not upheld in these instances.
Environmental Hazards and Inadequate Supervision in Resident Transfers
Penalty
Summary
The facility failed to maintain a safe environment for residents in six of the fifteen rooms reviewed for accidents. Observations revealed various hazards, including a protruding cable wire, splintered plastic cord covers, a hole in a bathroom door, a protruding screw head on a dresser, a loose toilet seat, peeling paint, and a long cable cord. These hazards were identified during observations and interviews with the Director of Maintenance (DM), who admitted to being unaware of these issues and acknowledged their potential to cause harm to residents. The facility's policy required immediate notification of unsafe situations, but these hazards were not addressed promptly. Additionally, the facility failed to provide adequate assistance during the transfer of a resident using a mechanical lifting device. Resident 29, who had a history of complete and partial weakness following a stroke, was transferred by a single Certified Nursing Assistant (CNA) instead of the required two-person assistance. The CNA admitted to performing the transfer alone due to the unavailability of other staff, despite having received training on the necessity of two-person assistance for safety. Interviews with other CNAs and the Director of Staff Development confirmed that the facility's policy required two-person assistance for mechanical lifts, although this was not explicitly stated in the policy. The facility's failure to address environmental hazards and provide adequate supervision during resident transfers posed a risk of injury to residents. The Director of Nursing (DON) acknowledged the expectation for resident rooms to be safe and free of hazards and confirmed the requirement for two-person assistance during mechanical lifts. Despite these expectations, the facility's policies and practices did not ensure compliance, leading to potential harm to residents.
QAPI Plan Fails to Address PTSD Education and Environmental Hazards
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) plan, developed by the Quality Assessment and Assurance (QAA) committee, failed to identify deficient practices prior to their recertification survey. Specifically, the facility did not provide education to staff regarding the management of residents with post-traumatic stress disorder (PTSD) and the associated triggers. Additionally, the facility did not identify and correct environmental hazards that could have caused injury. During a joint interview with the Administrator (ADM) and the Director of Nursing (DON), it was revealed that no education was provided to staff about PTSD, and the ADM acknowledged awareness of maintenance issues but had not identified the environmental hazards found during the survey. The ADM was also unaware of the existence of a safety committee within the facility.
Inaccurate Vision Assessment and MDS Reporting
Penalty
Summary
The facility failed to accurately assess, document, and transmit Minimum Data Set (MDS) information regarding a vision assessment for a resident with impaired vision. The resident, who was readmitted with diagnoses including Parkinson's disease, expressed difficulty seeing and stated he was blind. Despite this, the most recent quarterly MDS inaccurately listed the resident's vision as adequate. The care plan indicated impaired vision related to cataracts, and an eye doctor consultation confirmed bilateral cataracts. However, there was no documentation of a follow-up ophthalmology appointment. The MDS Nurse acknowledged the inaccuracy in the vision assessment, stating that the incorrect coding led to CMS being unaware of the resident's impaired vision. The Director of Nursing expected MDS assessments to be accurate to provide CMS with a clear picture of each resident's status. The MDS Resident Assessment Instrument outlines steps for assessing vision, which include consulting direct care staff and the resident about visual abilities, but these steps were not effectively followed, resulting in the deficiency.
Failure to Address Resident's Visual Impairment
Penalty
Summary
The facility failed to address a resident's visual impairment in a timely manner, leading to a deficiency in quality of care. Resident 3, who was readmitted with Parkinson's disease and cataracts, experienced weight loss due to his inability to see his food. Despite a care plan intervention to arrange a consultation with an eye practitioner, there was no documented evidence that Resident 3 was referred to or seen by an ophthalmologist. Observations and interviews revealed that Resident 3 repeatedly expressed his inability to see, which was not adequately addressed by the staff. The facility's records showed that Resident 3 had cataracts diagnosed in both eyes, and a referral to an ophthalmologist was noted but not followed through. The Social Services Director confirmed the lack of follow-up, and the Director of Nursing acknowledged that the resident's vision care was not addressed in a timely manner. The facility's policy on referrals to outside services was not effectively implemented, as there was no specific policy for vision care, contributing to the oversight in addressing Resident 3's needs.
Failure to Address Resident's Vision and Nutrition Needs
Penalty
Summary
The facility failed to investigate and analyze the root cause of weight loss for a resident diagnosed with Parkinson's disease and impaired vision due to cataracts. The resident was observed with untouched meal trays and expressed difficulty in eating because of his inability to see the food. Despite the resident's complaints about his vision, the facility did not explore or investigate the issue during the Interdisciplinary Team (IDT) meeting, nor was there any documented evidence of a recent vision exam. The resident's weight had decreased from 170.5 pounds to 156.5 pounds over six months, indicating a 13.7% weight loss. The facility's records inaccurately documented the resident's food consumption, showing 75-100% intake when observations indicated no food was consumed. The care plan included interventions such as providing finger foods and nutritional supplements like Ensure, but these were not effectively implemented, as evidenced by the non-finger food items on the resident's breakfast tray. The Registered Dietician (RD) acknowledged the oversight in addressing the resident's vision issues and the lack of discussion on using soda as an incentive for eating. The Director of Nursing (DON) expected the IDT to collaborate and address the root cause of the resident's weight loss, which included the unaddressed visual impairment. The facility's policy on evaluating nutritional status emphasized assessing and analyzing factors affecting residents' nutritional needs, which was not adequately followed in this case.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address triggers related to PTSD for two residents, leading to a deficiency in providing trauma-informed care. Resident 27, who was admitted with diagnoses including PTSD, anxiety disorder, and schizoaffective disorder, expressed that staff were not aware of how to handle his PTSD. Interviews with staff, including a licensed nurse and the Assistant Director of Nursing, revealed a lack of awareness and documentation of Resident 27's PTSD triggers in his care plan. The Social Service Director noted that Resident 27 did not like people behind him or screaming, but these triggers were not documented or addressed in his care plan. Similarly, Resident 35, who was readmitted with a PTSD diagnosis, reported that her PTSD stemmed from past abuse and that she experienced physical symptoms when triggered. Interviews with a CNA and a licensed nurse indicated that they were unaware of Resident 35's PTSD diagnosis and triggers. The Director of Nursing emphasized the importance of knowing a resident's PTSD diagnosis and triggers to prevent re-traumatization and manage emotional needs, but this was not reflected in Resident 35's care plan. The facility's policy on trauma-informed care requires the identification and mitigation of triggers to prevent re-traumatization. However, the failure to implement this policy for Residents 27 and 35 resulted in a deficiency, as staff were not informed or trained to handle the residents' PTSD triggers, potentially leading to severe psychosocial harm and affecting their quality of life.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to monitor the behaviors and side effects of a psychotropic medication for a resident diagnosed with Tourette's Disorder and dementia. The resident, who had a BIMS score indicating cognitive impairment, was observed with an open wound between the upper lip and nose, which was attributed to self-harm behavior related to Tourette's Disorder. The resident was prescribed risperidone to manage symptoms such as tics and skin picking, but there was no evidence in the Medication Administration Record (MAR) that these behaviors were being tracked or that the resident was being monitored for side effects of the medication. Interviews with the Licensed Nurse and the Director of Nursing revealed that the facility recognized the importance of monitoring the resident's behaviors and potential side effects of the psychotropic medication to assess its effectiveness and ensure the resident's safety. However, the facility's policy on Behavior/Psychoactive Drug Management, which required specific behavior monitoring and side effect observation, was not followed. This oversight placed the resident at risk for receiving unnecessary medication and experiencing unrecognized adverse reactions.
Failure to Secure Treatment and Medication Carts
Penalty
Summary
The facility failed to secure one of three treatment carts and one of three medication carts in the East Station area, as observed during a survey. On the morning of January 30, 2025, a treatment cart was found unlocked and unattended near the nurse's station, containing prescription creams, ointments, scissors, and wound dressing materials. Similarly, a medication cart was also found unlocked and unattended, containing over-the-counter and prescription medications. No staff were present in the area at the time of these observations. Licensed Nurse 1 (LN 1) admitted to forgetting to lock the medication cart, acknowledging that this oversight could allow residents, staff, and visitors unauthorized access to medications, potentially causing harm. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that treatment and medication carts should be locked when not in use to prevent unauthorized access and potential harm. The facility's policy, dated April 2008, specifies that only licensed nurses, pharmacy personnel, and those lawfully authorized should have access to medications.
Inaccurate Documentation of Resident Care and Food Intake
Penalty
Summary
The facility failed to accurately document food intake percentages for a resident with Parkinson's disease, who was experiencing weight loss. Observations revealed that the resident did not consume his meals, yet the documentation inaccurately recorded a 75-100% consumption for both breakfast and lunch. The Registered Dietician (RD) expressed reliance on accurate documentation to monitor residents' nutritional intake, especially for those with weight loss. The Director of Nursing (DON) emphasized the importance of precise documentation to prevent further weight loss, aligning with the facility's policy on recording food intake. Additionally, the facility failed to accurately document care provided to a resident with cerebral infarction and functional quadriplegia. The resident's chart inaccurately indicated a shower was given, while a Certified Nursing Assistant (CNA) reported providing a bed bath. The CNA used another staff member's login credentials to document the care, which was against the facility's policy. The Director of Staff Development (DSD) and the DON both highlighted the importance of accurate documentation and the risks associated with password sharing, which could lead to inaccurate records.
Failure to Develop Person-Centered Care Plan for Combative Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for Resident 84, who was admitted with diagnoses including cerebral infarction and anxiety disorder. The resident was cognitively impaired, as indicated by a BIMS score of 3. Observations and interviews with CNAs revealed that Resident 84 exhibited combative behavior during ADLs, such as attempting to hit staff during shaving and nail care. Despite these behaviors, there was no care plan in place to address or manage these combative tendencies. Interviews with staff, including CNAs and a Licensed Nurse, highlighted that Resident 84 was confused but responded to Spanish, which could be used to calm him during care. The Director of Nursing acknowledged the importance of having an individualized care plan for Resident 84, especially given his confusion, combative behavior, and language needs. However, a review of the resident's records confirmed the absence of such a care plan, which was contrary to the facility's policy on comprehensive person-centered care planning.
Failure to Implement Fall Prevention Program for Residents
Penalty
Summary
The facility failed to implement its fall prevention program for two residents who experienced repeated falls. Resident 2, with a history of falling and mobility issues, had unwitnessed falls on two occasions. During an observation, it was noted that Resident 2 had a cut on the forehead and lacked a functioning call light, which is crucial for fall risk residents. The Certified Nursing Assistant (CNA) assigned to Resident 2 was unaware of the specific details of the falls and acknowledged the absence of a call light. The Interim Director of Nursing (IDON) confirmed that Interdisciplinary Team (IDT) meetings were not conducted after the falls to determine the root cause and revise the care plan, as required by the facility's Fall Management Program. Resident 3, also with a history of falling and severe cognitive impairment, had unwitnessed falls on two separate occasions. Observations revealed that Resident 3's call light was out of reach, and the bedroom door was closed, limiting supervision. The CNA assigned to Resident 3 did not recognize the resident as a fall risk, and the supervising nurse was unaware of the recent fall. The IDON stated that there were no identifying markers for fall risk residents and emphasized the importance of accessible call lights. The facility's policy indicated that high-risk residents should be identified and monitored more frequently, but no new interventions were documented in Resident 3's care plan after the falls.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to honor the rights of a resident's representative to access medical records in a timely manner. The Medical Record Department (MRD) was unable to provide evidence that the representative of a resident received the requested medical records promptly. The resident, who was admitted with a diagnosis of hemiplegia, had their representative request a copy of the medical record on June 25, 2024. However, the MRD did not complete the request form and email the corporation for approval until July 23, 2024. The corporation responded on July 30, 2024, and the representative finally received the records around August 2, 2024, which was well beyond the facility's policy of providing records within two working days. During an unannounced onsite visit on October 2, 2024, for a complaint investigation, the MRD admitted to not maintaining a log of requests for medical records and was unsure of the timeline for providing hard copies. The Director of Nursing (DON) confirmed that the facility's policy and procedure for requesting medical records, which mandates providing records within two working days, was not followed. The facility's policy, dated October 1, 2015, requires documentation of requests and timely responses, which was not adhered to in this case.
Failure to Follow Discharge Protocols
Penalty
Summary
The facility failed to follow appropriate discharge protocols for a resident diagnosed with End Stage Renal Disease. The resident was admitted to the facility and had a bed hold agreement that allowed for a seven-day hold if transferred to a hospital. Despite this agreement, the facility discharged the resident after the seven-day period without providing a 30-day notice or information on how to appeal the discharge, as required by their policy. The facility's Director of Nursing (DON) stated that the resident was discharged because the facility could not meet his needs, citing non-compliance with medications and diet. The resident was ready for discharge from the hospital on the fifth day of the bed hold, but the facility refused to readmit him, stating he had been discharged. The resident expressed distress over not being able to return to what he considered his home and was concerned about retrieving his belongings. The facility's failure to document a proper discharge process, including the lack of a 30-day notice and appeal information, was a significant oversight in their discharge protocol.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a medication as ordered by the physician to a resident diagnosed with cirrhosis of the liver and hepatic encephalopathy. The resident was prescribed lactulose, a medication used to prevent and treat hepatic encephalopathy, to be taken 30 grams by mouth three times a day. However, a review of the Medication Administration Record (MAR) for August and September 2024 revealed that the licensed nurse did not record the administration of the morning and midday doses on specific dates, indicating that the medication may not have been given. Interviews with licensed nurses and the Director of Nursing (DON) confirmed that the MAR lacked the necessary initials or signatures to verify that the medication was administered. The facility's guidelines require that the individual administering the medication record it directly after administration. The DON acknowledged that the MAR indicated the medication was not given, and depending on the medication, a missed dose could significantly impact the resident's health.
Failure to Implement Individualized Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with a history of elopement, which put the resident at risk for further elopements and injury. The resident, diagnosed with paranoid schizophrenia and bipolar disorder, was observed unattended on the patio of the secured unit. The resident had previously eloped by walking out the back door and climbing over a fence. Despite having a physician's order for a wanderguard to prevent unassisted ambulation off the unit, the system was not functional, and no alarm would activate if the resident attempted to leave. Additionally, the resident was placed on one-on-one monitoring only during the PM/NOC shift, with hourly checks during the day, which were insufficient to prevent elopement. Interviews with staff revealed that the resident frequently ambulated throughout the secured unit and liked to sit outside on the patio daily. The facility's policy required the IDT to develop a care plan considering individual risk factors and to implement immediate interventions upon a resident's return from elopement. However, the facility's wanderguard system was not operational, and the resident's care plan did not adequately address the risk of elopement, as acknowledged by the Director of Nurses. The facility had contacted a company to assess and potentially raise the height of the fence, but this action was not part of an immediate intervention plan.
Deficient Meal Preparation and Portion Control
Penalty
Summary
The facility failed to ensure that cooks followed recipes when preparing meals, which had the potential to impact the residents' nutritional status and satisfaction with the food served. During interviews conducted with nine alert and oriented residents, five expressed dissatisfaction with the food, describing it as bad, bland, and insufficient, with one resident mentioning weight loss due to the poor quality of meals. Observations revealed that raw chicken was improperly prepared by a diet assistant, who planned to cook it too early, potentially affecting its palatability by making it tough and dry. Additionally, the facility's food service director acknowledged issues with portion sizes during a previous meal service, where residents received inadequate portions of deli meat sandwiches. The spreadsheet for the meal indicated that one ounce of meat and cheese, along with accompaniments, should be provided, but the director admitted that only one slice of meat and cheese was served, and could not recall if the accompaniments were included. A sample weighing of the deli meat confirmed that the portions were below the specified amount, highlighting a failure to ensure proper portion sizes and adherence to recipes.
Failure to Supervise Resident with Suicidal History Leads to Incident
Penalty
Summary
The facility failed to provide a safe environment for a resident with a known history of suicidal behavior, resulting in the resident swallowing part of a metal fork. The resident, who had previously been admitted to the facility's secured unit, had a documented history of suicidal ideation and had previously swallowed foreign objects. Despite the care plan indicating the need for close monitoring during mealtime, the resident was left unattended, leading to the incident. The resident's care plan, initiated shortly after admission, included interventions for close monitoring during meals due to the resident's behavior of self-harm. The interdisciplinary team and nursing staff had documented the need for one-to-one supervision during meals, especially after observing the resident breaking utensils. However, on the day of the incident, the assigned CNA left the resident alone to fetch a blanket, during which time the resident swallowed a fork. Interviews with facility staff revealed that the CNA was aware of the supervision requirements but left the resident unattended, believing it would be safe to do so briefly. The facility did not have a policy available regarding safe environment or supervision during mealtime, which contributed to the oversight and subsequent incident. The resident was transferred to the hospital for the removal of the swallowed fork.
Incomplete and Inaccurate Clinical Record for Blood Draw
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate for a resident who had a blood draw performed. The resident, who had End Stage Renal Failure and was undergoing renal dialysis, reported that a phlebotomist drew blood from his fistula, despite his care plan indicating that blood should not be drawn from the arm with the graft. The medical record did not document the blood draw, although a lab result was recorded, indicating that the procedure had occurred. The phlebotomist also did not indicate the blood draw location on the Test Request Form. During a joint interview and record review, the Assistant Director of Nursing confirmed that the licensed nurse should have documented the blood draw, including the site and how the resident tolerated the procedure. The phlebotomist should have also indicated the site of the blood draw. The facility's policy on Laboratory Services did not address documentation requirements after the procedure was completed.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
