Green Acres Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 8101 E Hill Drive, Rosemead, California 91770
- CMS Provider Number
- 555755
- Inspections on file
- 36
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Green Acres Healthcare Center during CMS and state inspections, most recent first.
The facility failed to monitor and document refrigerator temperatures in the temporary food storage room, risking foodborne illness for residents. Temperature logs for one refrigerator and the freezer were left blank for several days, contrary to the facility's policy requiring daily checks. The Dietary Service Supervisor was unsure if the designated staff had performed the required checks.
A facility failed to obtain informed consent for psychotropic medications for a resident with dementia and schizophrenia, and did not ensure POLST forms for three residents were properly completed and signed. The omissions in documentation could lead to delays in care during emergencies, as POLST forms serve as physician orders. The facility's policies for informed consent and POLST completion were not followed, violating residents' rights to be informed and make decisions about their care.
The facility failed to maintain resident dignity and effective communication, as seen in two cases. A resident with a suprapubic catheter was observed without a urinary bag cover, violating privacy. Another resident, hard of hearing and speaking a foreign language, faced communication barriers due to inadequate tools and methods, leading to frustration and unmet needs. Staff acknowledged these issues, which contravened facility policies on resident rights and dignity.
The facility failed to ensure Advance Directives (AD) were offered and documented for two residents, one with bipolar disorder and schizophrenia, and another with pneumonia and schizophrenia. Despite intact cognition, neither resident had an AD or POLST in their records. Staff interviews revealed confusion about responsibility for ADs, and the medical records director admitted oversight, contrary to facility policy requiring inquiry and assistance with ADs upon admission.
The facility failed to develop comprehensive care plans for two residents, one with aggressive behavior and another with communication barriers. Despite incidents of aggression and communication difficulties, the facility did not create adequate care plans, leading to unmet needs and compromised resident rights.
A resident with hearing difficulties and language barriers did not receive necessary assistive devices or an audiology consult, despite a physician's order. Staff were aware of the resident's communication challenges but did not provide effective solutions, leading to impaired communication and delayed care. The facility's policy on accommodating communication deficits was not followed.
A resident with a suprapubic catheter was at risk for UTIs due to improper catheter care. The drainage bag was observed hanging higher than the bladder, and the tubing was wrapped around the resident's leg, both of which could cause urine backflow. Staff acknowledged these practices were inappropriate, and the facility's policies emphasize proper positioning to prevent infections.
A facility failed to refer a resident with schizophrenia for a psychiatric consultation despite documented aggressive behavior and a care plan intervention. The resident's aggressive actions were noted in assessments, but the facility overlooked the necessary referral, contrary to its behavioral health services policy.
A facility failed to maintain a medication error rate below 5%, reaching 13.79% during a medication pass. An LVN crushed and mixed four medications for a resident with bipolar disorder and schizophrenia, contrary to best practices. The DON confirmed that medications should be administered separately unless preferred otherwise. The facility's policy lacked specific guidance on administering crushed medications.
The facility failed to properly store medications by placing Hydrogen Peroxide Topical Solution, an external medication, on the same shelf as oral medications. This was observed during an inspection with an LVN, who confirmed the improper storage. The DON acknowledged the risk of misidentification and accidental ingestion due to similar container appearances. The facility's policy requires separate storage for oral and external medications.
A resident with a suprapubic catheter on Enhanced Barrier Precautions received high-contact care from an LVN and a CNA who failed to wear isolation gowns and perform hand hygiene, contrary to the facility's Infection Prevention and Control Program. The resident had a history of urinary issues and cognitive impairment, necessitating strict adherence to PPE protocols to prevent infection spread.
The facility was found to have three rooms each accommodating five residents, exceeding the regulatory limit of four residents per room. Despite a waiver request and no reported concerns from residents or staff about space, the setup did not comply with regulations. Interviews confirmed residents had intact cognitive skills and required assistance with daily activities, but the room arrangement still constituted a deficiency.
The facility failed to meet the required room size of 100 sq. ft. for four single resident rooms, with Rooms 4 and 5 measuring 76 sq. ft. and Rooms 16 and 17 measuring 99.75 sq. ft. Despite this, observations and interviews indicated that the room sizes did not affect the care provided. A resident with schizophrenia, hypertension, and anxiety disorder reported having enough space, and staff confirmed sufficient space for care delivery.
The facility failed to provide direct exit access for four resident rooms, requiring residents to pass through other rooms to reach an exit corridor. Although the residents were ambulatory and reported no issues, this arrangement potentially compromised their safety in emergencies. Interviews with staff and a resident confirmed the current setup, and a room variance indicated no adverse effects on residents' health and safety.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures in the temporary food storage room, which placed residents at risk for foodborne illness. During a follow-up kitchen tour, it was observed that the temperature logs for one of the refrigerators and the freezer were not filled out for several days. Specifically, the log for Refrigerator 2 was blank from the afternoon of February 4th to February 6th, and the logs for Refrigerator 3 and the freezer were blank for the same period. The Dietary Service Supervisor (DSS) indicated that the responsibility for checking and logging the temperatures of the refrigerators and freezers fell to the cooks on both the AM and PM shifts. However, the DSS was unsure if the cooks had checked the logs, and acknowledged that the logs should not have been missed. The facility's policy requires daily temperature checks and documentation at the first opening and at closing in the evening, but this procedure was not followed, leading to the deficiency.
Failure to Obtain Informed Consent and Complete POLST Forms
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding informed consent for medications and life-sustaining treatment orders. Resident 37, who was diagnosed with dementia, psychotic disorder, and schizophrenia, was prescribed Quetiapine and Divalproex Sodium without obtaining informed consent from the resident's representative or power of attorney. The facility's policy required the prescriber's signature on the informed consent within 24 hours of admission, but this was not completed, leaving the resident's representative unaware of the medication's risks, benefits, and alternatives. Additionally, the facility did not ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 12, 69, and 14 were properly completed and signed by the responsible parties. Resident 12, with a moderately impaired cognitive status, had a POLST indicating DNR status, but it lacked the responsible party's signature, rendering it invalid. Similarly, Resident 69's POLST was missing the responsible party's signature, and Resident 14's POLST was prepared without obtaining the resident's signature. These omissions could lead to delays in care during emergencies, as the POLST forms serve as physician orders for medical professionals. The facility's policies and procedures for informed consent and POLST completion were not followed, resulting in incomplete documentation and potential delays in care. The Director of Nurses and other staff acknowledged the deficiencies, noting the importance of having valid POLST forms and informed consent to ensure residents and their representatives are aware of treatment options and preferences. The lack of proper documentation violated residents' rights to be informed and make decisions about their care, potentially affecting their quality of life and health outcomes.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 3 and Resident 226. Resident 3, who had a suprapubic catheter, was observed without a urinary catheter bag cover, which is a violation of privacy and dignity. The staff, including a CNA and an LVN, acknowledged the absence of the cover and recognized it as a breach of the resident's rights. The facility's policy mandates that urinary catheter bags should be covered to maintain resident dignity. Resident 226, who was hard of hearing and spoke a foreign language, experienced significant communication barriers with the staff. The resident expressed frustration and sadness due to the inability to communicate effectively, as the staff did not provide adequate means of communication such as a communication board or appropriate translation services. Interviews with various staff members, including CNAs and LVNs, revealed that the facility did not have effective communication tools in place, and the staff often resorted to ineffective methods like body language or phone translation, which were not suitable given the resident's hearing impairment. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and ensuring effective communication. However, the lack of proper assessment and implementation of communication strategies for Resident 226, along with the failure to maintain privacy for Resident 3, demonstrate a disregard for these policies. The Director of Nursing acknowledged the deficiencies and the impact on resident rights, highlighting the need for comprehensive care plans and effective communication methods.
Failure to Implement Advance Directive Policy
Penalty
Summary
The facility failed to implement its policy and procedure on Advance Directives (AD) by not ensuring that the AD was offered, explained, and signed for two residents. Resident 14, admitted with diagnoses including bipolar disorder and schizophrenia, had intact cognition according to the Minimum Data Set (MDS) but did not have an AD in their medical records or the facility's database. There was no documentation indicating that the facility offered an AD during Resident 14's admission. Similarly, Resident 39, who was readmitted with pneumonia and schizophrenia, also lacked an AD or a Physician's Orders for Life-Sustaining Treatment (POLST) in their records. Although initially noted as lacking decision-making capacity, the MDS indicated intact cognition. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring ADs and POLSTs were in place, with the medical records director admitting oversight. The facility's policy requires the social services director or designee to inquire about ADs upon admission and assist in establishing them if needed, which was not followed in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in care. Resident 9, who was diagnosed with schizophrenia and had intact cognition, exhibited aggressive behavior towards staff and other residents. Despite multiple incidents of aggression and attempts to take personal belongings from other residents, the facility did not create a care plan to address these behaviors. Interviews with staff revealed that although Change of Condition assessments were initiated, no interdisciplinary team meeting or care plan was developed to ensure the safety and dignity of all residents. Resident 226, who was admitted with Type 2 Diabetes Mellitus, dementia, and hearing difficulties, faced communication barriers due to a language difference and hearing impairment. The resident expressed frustration over the inability to communicate effectively with staff, which was exacerbated by the lack of a communication board or other aids. Staff interviews confirmed that communication methods were inadequate, and there was no documented evidence of translation services or communication aids being provided. The facility's failure to assess and address these communication needs resulted in unmet care needs and compromised resident rights. The facility's policy required the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. However, the facility did not adhere to this policy for either resident, resulting in deficiencies that affected the residents' physical, mental, and psychosocial well-being. The Director of Nursing acknowledged the lapses in care planning and communication, emphasizing the importance of effective communication and comprehensive care planning to uphold resident rights and ensure their well-being.
Failure to Provide Hearing Assistive Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper assistive devices to maintain hearing abilities, resulting in a delay of services for the resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, unspecified dementia, and abnormalities of gait and mobility, was observed having difficulty hearing and communicating with staff. Despite a physician's order for an audiology consult as needed for hearing problems, the facility did not arrange for this referral, leading to the resident's inability to hear adequately during interactions with staff. Interviews with staff revealed that they were aware of the resident's hearing difficulties and language barriers, yet no effective communication methods or assistive devices were provided. The Social Service Director stated that no hearing disability was reported upon admission, and the Director of Nursing acknowledged the failure to assess and address the resident's communication needs. The facility's policy on accommodating communication deficits was not followed, as the resident's needs for adaptive devices and modifications were not evaluated or addressed, impairing the resident's ability to communicate effectively and maintain dignity.
Improper Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter. On two separate occasions, the resident's catheter drainage bag was improperly positioned, which could lead to backflow of urine and potential UTIs. On the first occasion, the drainage bag was observed hanging on the wheelchair's armrest, higher than the resident's bladder, contrary to the facility's policy that requires the bag to be positioned lower than the bladder. On another occasion, the resident's catheter tubing was found wrapped around their leg, which could impede urine flow and cause backflow. Both the Registered Nurse and Licensed Vocational Nurse acknowledged that these practices were inappropriate and could lead to UTIs. The facility's Infection Preventionist and Director of Nurses confirmed that the drainage bag should always be below the bladder and the tubing should not be wrapped around the leg to prevent backflow and potential infections. The resident involved had a history of urinary tract infections and was diagnosed with conditions such as benign prostatic hyperplasia and obstructive and reflux uropathy, which necessitated the use of a suprapubic catheter. The facility's policies on suprapubic catheter care and infection prevention emphasize the importance of proper catheter positioning to prevent infections, but these were not adhered to in the resident's care.
Failure to Provide Psychiatric Referral for Aggressive Resident
Penalty
Summary
The facility failed to implement its policy and procedure on behavioral health services by not providing a referral for a psychiatric consultation for a resident exhibiting aggressive behavior. The resident, who was diagnosed with schizophrenia, was readmitted to the facility and had intact cognition according to the Minimum Data Set. Despite the creation of a care plan on January 28, 2025, which included an intervention for a psychiatric consultation, the facility overlooked this intervention and did not refer the resident to a psychiatrist. The resident's aggressive behavior was documented in Change of Condition assessments on January 16 and January 28, 2025, indicating attempts to attack staff and residents and taking personal belongings from another resident. Interviews with Licensed Vocational Nurses and the Director of Nursing confirmed the oversight in referring the resident for psychiatric evaluation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that residents should receive necessary behavioral services to maintain their highest practicable well-being, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass, resulting in a 13.79% error rate. This was observed during a medication administration for one of the residents, who was diagnosed with bipolar disorder and schizophrenia, and had severely impaired cognition. The resident was prescribed several medications, including Depakote Sprinkles, Docusate Sodium, Multivitamin-Minerals, and Sodium Chloride. During the medication administration, an LVN prepared and crushed four oral medications, mixing them in a single container with applesauce. The surveyor intervened before the medications were administered. The LVN acknowledged the mistake, stating that the resident would not know what medication they were taking if mixed together. The DON later confirmed that medications should ideally be administered separately unless the resident prefers otherwise. The facility's medication administration policy lacked specific instructions on administering crushed medications.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper and safe storage of medications and biologicals. During an inspection of the East Wing medication storage room, a bottle of Hydrogen Peroxide Topical Solution, which is an external medication, was found stored on the same shelf as oral medications, such as stool softeners and vitamins. This observation was made in the presence of an LVN, who acknowledged that external medications should not be stored with oral medications to prevent medication errors. The Director of Nursing (DON) confirmed that oral and external medications should be stored separately to avoid the risk of misidentification and accidental ingestion, especially if the containers are similar in appearance. The DON was unaware of who placed the external medication on the shelf with oral medications. A review of the facility's medication storage policy, effective since April 2008, indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the case of a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, it was noted that a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) provided high-contact care to the resident without wearing the required isolation gowns as part of their Personal Protective Equipment (PPE). Additionally, both staff members did not perform hand hygiene after completing the care and proceeded to the nurses' station, which was against the facility's policy. The resident involved had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary tract infections, and was cognitively impaired, requiring assistance with daily activities. The care plan for the resident included Enhanced Barrier Precautions due to the use of a suprapubic catheter, which required staff to use gloves, gowns, and masks during direct care and to perform hand hygiene before and after care. Despite these clear directives, the staff failed to comply with the necessary precautions. Interviews with the involved staff and facility leadership confirmed awareness of the requirements for PPE and hand hygiene. The LVN admitted to forgetting to wear a gown and perform hand hygiene, while the CNA could not provide a reason for the oversight. The Infection Preventionist and Director of Nurses reiterated the importance of following the EBP policy to prevent the spread of infections, highlighting the potential risk posed by the staff's non-compliance with established protocols.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three rooms (Rooms 6, 15, and 26) each accommodated five residents, exceeding the maximum of four residents per room. This deficiency was identified through observation, interviews, and record reviews. The rooms in question had varying square footage, with Room 6 at 332.5 sq. ft, Room 15 at 441 sq. ft, and Room 26 at 496 sq. ft. Despite the facility's submission of a room waiver request, which claimed no adverse effects on residents' health, safety, or welfare, the setup did not align with the regulatory standards. Interviews with residents and staff revealed that the residents did not express concerns about the room space or sharing with others. Residents 67, 36, and 20, who were interviewed, all had intact cognitive skills and required varying levels of assistance with daily activities. They reported having enough room to perform their activities and did not mind sharing their rooms. Staff members, including a CNA and an LVN, also indicated that they had sufficient space to provide care and had not received complaints from residents regarding room space. However, the facility's arrangement still constituted a regulatory deficiency due to the number of residents per room exceeding the allowed limit.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that four single resident rooms met the required minimum size of 100 square feet per resident. Specifically, Rooms 4 and 5 measured 76 square feet each, while Rooms 16 and 17 measured 99.75 square feet each. This deficiency was identified through a review of the facility's Client Accommodation Analysis and a waiver request submitted by the Administrator. The report indicates that the room sizes did not meet the Centers for Medicare & Medicaid Services (CMS) requirements, potentially affecting the quality of care, health, and safety of the residents due to inadequate space for care, mobility, and privacy. Despite the deficiency, observations and interviews conducted on February 7, 2025, revealed that the room sizes did not negatively impact the care and services provided to the residents. Residents and staff reported having sufficient space for care delivery and daily activities. Resident 8, who has a history of schizophrenia, hypertension, and anxiety disorder, stated she had enough space in her room and did not experience any issues with her care. Similarly, a CNA and an LVN confirmed that they had enough space to perform their duties in the single rooms and had not received any complaints from residents.
Deficiency in Direct Exit Access for Resident Rooms
Penalty
Summary
The facility failed to ensure that four resident bedrooms (Rooms 4, 5, 16, and 17) had direct access to an exit corridor without passing through another resident's bedroom. This deficiency was identified during a facility tour, where it was observed that residents in these rooms had to pass through adjacent rooms to reach the nearest exit corridor. This practice potentially compromised the privacy, health, and safety of the residents, particularly in emergency situations where direct access to an exit is crucial. Despite the lack of direct access, the residents in these rooms were ambulatory and did not express any concerns about their room locations. Interviews with a resident and staff members, including a CNA and an LVN, indicated that the residents were able to move in and out of their rooms without issues. Additionally, a room variance received during the survey period suggested that the residents' needs were accommodated without adverse effects on their health, safety, and welfare. However, the facility's arrangement still posed a potential risk due to the lack of direct exit access.
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.
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