Guardian Rehabilitation Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 533 S. Fairfax Ave, Los Angeles, California 90036
- CMS Provider Number
- 056008
- Inspections on file
- 34
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Guardian Rehabilitation Hospital during CMS and state inspections, most recent first.
A CNA repeatedly used a personal cell phone during work hours to record and post TikTok videos taken inside a resident’s room, activity/dining areas, and facility hallways, with a cognitively impaired, fully dependent resident visible in the background. The CNA admitted knowing that facility policy prohibited personal cell phone use in resident care areas and banned taking resident photos or videos without consent, yet did not obtain permission from the resident or responsible party. The resident later reported not having signed consent or given permission to appear on social media. The DSD and DON confirmed that no written consents existed, that photos/videos are allowed only for medical purposes, and that taking and posting such images without authorization violates abuse-prevention, privacy/PHI, and cellular phone policies.
A resident admitted with a Leaf Sensor device did not receive comprehensive care as required by their care plan and physician orders. Staff were not adequately trained on the device, did not assess or document skin integrity or pain under the sensor, and failed to follow manufacturer guidelines for monitoring. The absence of proper assessment and documentation led to a deficiency in meeting the resident's individualized care needs.
A resident with multiple medical conditions was admitted with a Leaf Sensor device, but staff failed to assess or document skin integrity and pain at the device site as required by care plans, physician orders, and facility policy. Staff lacked training on the device, did not follow manufacturer guidelines, and did not document reinforcement or monitoring of the sensor, resulting in a failure to meet professional standards of care.
A resident with dementia and a history of falls was injured during wheelchair transport due to the facility's failure to implement care plans. The CNA did not provide instructions or reassurance, and chose a route with steep ramps instead of a safer flat route. The resident made a sudden movement, causing a fall and a clavicle fracture. Staff did not follow existing care plans or develop a plan for safe wheelchair transport.
The facility failed to provide appropriate care for two residents, leading to potential health risks. A resident did not have a left knee splint applied correctly, and the RNA order allowed for wearing knee splints longer than the safe duration determined by physical therapy. Another resident did not receive active range of motion exercises as ordered, which could lead to a decline in strength and function. These deficiencies were observed during RNA treatment sessions and confirmed through staff interviews.
The facility failed to complete annual competency checks for six Restorative Nursing Aides (RNAs) on the application and removal of splints and braces. An observation revealed an RNA incorrectly applied a knee splint on a resident, which was later corrected by a Physical Therapist. The Director of Staff Development confirmed the absence of these evaluations in the competency checklists, despite facility policies requiring them to ensure resident safety.
The facility failed to maintain six pieces of electrical rehabilitation therapy equipment, including bicycles and parallel bars, as per manufacturer recommendations. The equipment was not regularly checked for electrical safety or power cord damage, and maintenance was only performed if issues were reported. The lack of a maintenance policy and documentation put residents at risk of injury during therapy sessions.
A resident with severe cognitive impairment and mobility issues fell in their room due to inadequate supervision and assistance with transfers. Despite being identified as high risk for falls, the resident was found on the floor with the call light out of reach. The facility's failure to implement necessary fall prevention measures resulted in the resident being transferred to a hospital for evaluation.
A resident with COPD was receiving oxygen therapy without a physician's order and with unlabeled equipment, contrary to facility policy. The resident's nasal cannula and humidifier were not labeled, and there was no physician's order for the oxygen therapy, which is necessary for proper care. The DON confirmed that the standing order for oxygen was missed upon admission.
A resident with severe cognitive impairments and limited mobility had incomplete documentation regarding the use of knee splints. The facility failed to record the duration the splints were worn, as required by the physician's order. Observations and interviews revealed that the resident sometimes tolerated the splints for less than the prescribed time, but this was not documented, leading to inaccurate medical records.
The facility failed to meet the minimum space requirements for two resident rooms, with room 102 and room 125 falling short of the required square footage for multiple resident bedrooms. Despite this, staff and residents reported no issues with space affecting care or comfort. The facility requested a room variance, stating the rooms were adequate for residents' needs.
A facility failed to accurately assess a resident's fall history and range of motion (ROM) limitations. The resident, admitted with a history of falls and fractures, was inaccurately documented in the MDS as having no recent falls or ROM impairments. Interviews with the MDS coordinator and DON confirmed these discrepancies, highlighting the importance of accurate assessments to prevent injury risks.
A resident with severe cognitive impairment and a history of falls was left unsupervised, contrary to the IDT plan requiring a sitter from 3 PM to 7 AM. The assigned CNA left the room without notifying other staff, and the facility lacked a specific policy for sitters, contributing to the oversight.
A resident with a complex medical history experienced a change in condition, including chest congestion and a productive cough, which was not promptly assessed by the LVN or communicated to the RN. The RN failed to perform a thorough assessment or notify a doctor, resulting in a delay of over seven hours in providing necessary medical services. The resident was later found unresponsive and transferred to a hospital, where they were diagnosed with septic shock and severe dehydration, ultimately leading to their death.
A resident with multiple sclerosis and dementia resisted care and became combative during ADL assistance. A CNA continued to assist the resident despite the combativeness, as no additional help was available. The DON stated that staff should stop care if a resident becomes resistive to prevent injury. The facility's policy emphasizes treating residents with dignity, which was not followed in this case.
A resident with multiple sclerosis and dementia exhibited skin discolorations and combativeness during care, but staff failed to notify the physician or document the change of condition using the SBAR tool. The CNA delayed reporting the incident, and there was uncertainty among staff about whether proper procedures were followed.
The facility failed to document a grievance reported by a resident's family member, who found the resident in a wheelchair with no undergarments and pants below the knee. Despite notifying the head nurse, the grievance was not documented because the family member refused to discuss the issue further with the Director of Staff Development. The Director of Nursing acknowledged that a grievance report should have been completed.
A resident with severe cognitive impairment experienced nausea and vomiting after being administered cephalexin, which was not documented in the allergy profile. This led to the resident receiving the medication again and experiencing the same adverse effects. The DON and the resident's physician acknowledged the oversight.
Unauthorized Resident Video Recording and Social Media Posting by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident’s rights to dignity, privacy, and confidentiality when a CNA recorded and posted videos including the resident without consent. The resident had diagnoses including dysphagia, COPD, and heart failure, and assessments showed severely impaired cognitive skills, lack of decision-making capacity, and total dependence on staff for ADLs. The resident’s care plan documented cognitive loss, short- and long-term memory impairment, poor recall, and psychosocial impairment related to psychosis and other conditions, with interventions directing staff to provide pleasant, reassuring interactions, approach the resident calmly and unhurriedly, and provide emotional support. A complaint was submitted to the District Office alleging that the CNA posted a video of the resident on social media, with two videos attached. In an interview, the resident reported that a staff member took a video of himself while the resident was in the background and that this video was posted on TikTok without the resident’s knowledge or signed consent. The resident stated he did not give permission to be posted on social media. In interviews, the CNA admitted that since November 2025 he had been taking videos and posting them on his TikTok account during work hours, including videos taken inside the resident’s room on two specific dates where the resident could be seen lying in bed in the background. The CNA acknowledged he was aware staff were not allowed to use personal cell phones during work hours or take photos or videos inside residents’ rooms, and that he did not obtain permission or consent from the resident. The DSD and DON confirmed that facility policies prohibit personal cell phone use in resident care areas, prohibit taking photos or videos of residents without written consent, and limit resident photos/videos to medical purposes only. They also confirmed there were no written consents on file for the videos taken of the resident and that taking such videos without authorization and consent is considered a type of abuse under facility policy.
Failure to Implement Comprehensive Care Plan for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed all of a resident's assessed needs upon admission with a medical device, specifically a Leaf Sensor. The resident was admitted and readmitted with multiple diagnoses, including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for moderate assistance with activities of daily living. The Braden Scale assessment showed a mild risk for pressure ulcers, and the resident was admitted with a Leaf Sensor on the mid-chest, with a physician's order to reinforce the sensor with Tegaderm if it became dislodged. Despite the care plan identifying the presence of the Leaf Sensor and the associated risk for infection and skin breakdown, staff interviews and record reviews revealed that key interventions were not implemented. Certified Nursing Assistants and nursing staff were not adequately informed or trained on the care and purpose of the Leaf Sensor. There was no documentation or evidence that the resident's skin integrity was assessed under the device, nor were pain assessments conducted as required by the care plan. Staff also did not document any reinforcement of the Tegaderm, and the monitoring device associated with the Leaf Sensor was not present in the facility during the resident's stay. The Director of Nursing and Administrator confirmed that there was no specific policy or procedure for the Leaf Sensor device, and that staff relied on general manufacturer guidelines. However, these guidelines required periodic inspection of the skin under the sensor for irritation or infection, which was not performed or documented. The lack of assessment and documentation regarding the resident's skin integrity and pain at the sensor site constituted a failure to follow the comprehensive care plan and physician orders, resulting in a deficiency.
Failure to Assess and Monitor Skin Integrity for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to follow professional standards of practice in the management, assessment, and monitoring of a resident who was admitted with a Leaf Sensor medical device. The resident, who had multiple diagnoses including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea, was admitted with a Leaf Sensor attached to the mid-chest. The care plan identified the risk of skin breakdown and infection at the sensor site, with specific interventions such as providing good skin care, assessing skin integrity, assessing for pain, and reinforcing the sensor with Tegaderm if dislodged. However, there was no documentation that these interventions were carried out, particularly regarding assessment of skin integrity and pain at the sensor site. Interviews with facility staff revealed a lack of knowledge and training regarding the Leaf Sensor device. The Certified Nursing Assistant reported not being informed about the care required for the sensor, and the Treatment Nurse admitted to never fully assessing the skin underneath the device or being educated on its use. The Director of Nursing confirmed that there was no specific policy for the device and that the manufacturer's guidelines were not fully implemented, as the sensor was never removed or the skin underneath assessed during the resident's stay. Additionally, the monitoring component of the device was not present in the facility, and there was no documentation of reinforcement or assessment as required by the care plan and physician's orders. The facility's policies required licensed nurses to document meaningful and informative notes reflecting care, treatment, and assessments, including skin and pain assessments. The manufacturer's guidelines for the Leaf Sensor also specified the need for periodic inspection of the skin around the sensor for signs of irritation or infection. Despite these requirements, the facility did not document or perform the necessary assessments, placing the resident at risk for skin-related complications associated with the device.
Failure to Implement Care Plans Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, resulting in a fall and injury. The resident, who had a history of falls and was at high risk for further falls, was being transported in a wheelchair by a CNA. The CNA did not provide any instructions or reassurance to the resident during the transport, despite the resident's known episodes of confusion, forgetfulness, and poor safety awareness. The CNA chose a route with multiple steep ramps, which was closer to the street parking for convenience, rather than a safer flat route through the garage. During the transport, the resident became nervous and made a sudden movement while being wheeled up a ramp, causing the wheelchair to tilt and the resident to fall. The CNA attempted to catch the resident but was unsuccessful, resulting in the resident sustaining a right clavicle fracture and severe pain. The facility's staff, including the LVN and CNA involved, did not follow the resident's existing care plans for dementia and fall risk, which required explaining procedures, providing reassurance, and ensuring safety during transport. The facility's failure to implement the resident's care plans and to develop an appropriate care plan for wheelchair transport contributed to the incident. The staff did not assess the resident's comfort with wheelchair use, did not provide necessary instructions to prevent sudden movements, and did not use a safer route or request additional assistance for the transport. These oversights led to the resident's fall and subsequent injury, highlighting deficiencies in the facility's care and safety protocols for residents with dementia.
Failure to Provide Appropriate ROM and Mobility Care
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for two residents, leading to potential health risks. For Resident 49, the facility did not correctly apply a left knee splint during a Restorative Nursing Aide (RNA) treatment session, as observed on January 28, 2025. The splint was placed too low on the leg, not covering the knee as required, which could exacerbate contractures. Additionally, the RNA order for Resident 49 was incorrect, allowing for the wearing of knee splints for four to six hours, despite physical therapy determining a maximum safe duration of three hours to prevent skin irritation and other adverse effects. Resident 49's medical history includes severe sepsis, muscle wasting, and generalized osteoarthritis, with severe cognitive impairments and functional limitations in the lower extremities. The resident's care plan and physician's orders emphasized the importance of correctly applying splints and adhering to the recommended duration to prevent further decline in ROM. However, the facility's failure to follow these directives was evident during observations and interviews with staff, including the Director of Nursing and Physical Therapist. For Resident 54, the facility did not provide active range of motion (AROM) exercises for both upper and lower extremities as ordered by a physician. Instead, passive range of motion (PROM) exercises were performed, which are not suitable for residents capable of AROM. Resident 54, who has hemiplegia and osteoarthritis, expressed a desire to continue exercises for arms and legs, but the RNA session only included walking and a leg exercise stepper. The failure to perform AROM exercises could lead to a decline in strength and function, contrary to the care plan's goals. Interviews with staff, including the Director of Staff Development and Physical Therapist, confirmed the importance of following AROM orders to maintain the resident's strength and prevent contractures.
Deficient Competency Checks for Restorative Nursing Aides
Penalty
Summary
The facility failed to ensure that annual competencies were completed for six sampled Restorative Nursing Aides (RNAs) who are responsible for tasks such as applying and removing splints and braces. This deficiency was identified through observation, interviews, and record reviews. Specifically, the competency evaluations for RNAs did not include a skills performance check for the application and removal of splints and braces, which are crucial for maintaining residents' range of motion and preventing contractures. During an observation, an RNA incorrectly applied a knee splint on a resident, placing it too low on the leg, which was later corrected by a Physical Therapist. The Director of Staff Development confirmed that the annual competency checklists for RNAs did not include evaluations for splint and brace application, despite the facility's policy requiring such competencies to ensure resident safety. The facility's policy on splint application emphasizes the importance of correct application to prevent contractures and maintain range of motion. The lack of proper competency checks could potentially lead to improper application of splints and braces, as evidenced by the incorrect placement observed during the survey.
Failure to Maintain Electrical Rehabilitation Equipment
Penalty
Summary
The facility failed to maintain six pieces of electrical rehabilitation therapy equipment, which are essential for restoring residents to their highest possible level of physical, mental, and psychosocial well-being. The equipment included upper and lower extremity bicycles, automatic parallel bars, an exercise leg stepper, an adjustable work table, and an adjustable therapy mat. The user manuals for these devices recommended regular maintenance checks, including electrical safety inspections and routine checks for power cord damage. However, the facility did not perform these checks, as confirmed by the Physical Therapist and the Maintenance Director, who stated that maintenance was only performed if issues were reported by therapists. The Administrator and Director of Nursing acknowledged the importance of maintaining the rehabilitation equipment to ensure resident safety and effective therapy. Despite this, the facility lacked a policy for the maintenance of electrical equipment in the rehabilitation department and did not have a user manual for the adjustable work table. The absence of maintenance logs or documentation further highlighted the facility's failure to adhere to the manufacturer's maintenance recommendations, potentially putting residents at risk of injury during therapy sessions.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent accident risks and hazards for a resident, identified as Resident 77, who was admitted with significant medical conditions including hemiplegia, hemiparesis, and severe cognitive impairment. The resident required substantial assistance with daily activities such as toileting hygiene, walking, and transferring between bed and wheelchair. Despite being assessed as a high risk for falls, the resident experienced multiple falls within the facility, including an unwitnessed fall on 1/23/2025. On 1/27/2025, Resident 77 was found sitting on the floor in their room, with the wheelchair nearby and the call light out of reach on the bed. The resident was unable to recall how they ended up on the floor and was not in pain or visibly injured. The Registered Nurse Supervisor confirmed that the resident had fallen from the wheelchair and acknowledged that the resident required assistance with transfers to prevent such incidents. The resident was subsequently assessed by a Nurse Practitioner and transferred to a General Acute Care Hospital for further evaluation. The facility's policy on fall risk and prevention of injury was not adequately followed, as the resident was not provided with the necessary supervision and assistance to prevent falls. The Director of Nursing acknowledged the resident's high risk for falls and the need for frequent monitoring and supervision. Despite the care plan interventions, the lack of adequate supervision and assistance led to the resident's fall, highlighting a deficiency in the facility's implementation of fall prevention measures.
Deficiency in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had properly labeled equipment and a physician's order for the therapy. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), cerebral infarction, and nicotine dependence, was observed receiving oxygen via nasal cannula with a pre-filled humidifier that was not labeled. The Licensed Vocational Nurse confirmed the lack of labeling, which is required to ensure proper tracking and maintenance of the equipment. Further review revealed that there was no physician's order for the resident's oxygen therapy, which is necessary for residents with COPD to ensure appropriate care parameters are followed. The Director of Nursing acknowledged that the standing order for oxygen was missed upon the resident's admission, and the lack of a physician's order meant that nurses could not administer the required oxygen. The facility's policies require a physician's order for oxygen administration and proper labeling of equipment, which were not adhered to in this case.
Incomplete Documentation of Knee Splint Usage for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate documentation for Resident 49, specifically regarding the tolerance of knee splints. Resident 49, who was admitted with severe sepsis, muscle wasting, and generalized osteoarthritis, had a care plan that included the use of knee splints to prevent contractures. The physician's order required the splints to be worn for four to six hours daily, as tolerated. However, the RNA flowsheet for January 2025 did not document the duration for which the knee splints were worn from January 1 to January 27, 2025. During an observation on January 28, 2025, RNA 1 was unable to find the knee splints and did not apply them to Resident 49. RNA 1 later acknowledged that on January 27, 2025, Resident 49 tolerated the splints for only two hours, but this was not documented. RNA 1 admitted that there were other days when the resident could only tolerate the splints for two hours, but these instances were not recorded, leading to incomplete documentation. Interviews with the Physical Therapist and the Director of Staff Development confirmed that the RNA documentation was incomplete and did not reflect the actual duration the splints were worn. The Director of Nursing emphasized the importance of following RNA orders and maintaining accurate documentation to reflect the resident's condition during RNA treatment. The facility's policy on documentation principles required that health records be current, accurate, and descriptive, which was not adhered to in this case.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to ensure that two of the sampled resident rooms met the minimum space requirements of 80 square feet per resident in multiple resident bedrooms. Specifically, room 102, which housed two residents, measured 158.35 square feet, and room 125, which housed three residents, measured 229.54 square feet. These measurements fell short of the required 160 square feet for a two-bedroom and 240 square feet for a three-bedroom. Despite this, the facility submitted a letter to the Department requesting a room variance, stating that the rooms had adequate space for the residents and would not adversely affect their health and safety or impede their well-being. During observations and interviews, nursing staff and residents expressed that the space in these rooms did not interfere with care or comfort. Licensed Vocational Nurse 1 and Certified Nursing Assistant 1 both reported that the space was not an issue and did not hinder their ability to provide care. Residents in the rooms also stated they had no complaints about the space, and staff were able to assist them without difficulty. Despite these observations, the facility's failure to meet the minimum space requirements was noted as a deficiency.
Inaccurate Resident Assessment of Fall History and ROM
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident, which did not reflect the resident's history of falls and functional limitations in range of motion (ROM). The resident was admitted with a history of repeated falls and a displaced comminuted fracture of the right femur, and was later readmitted with a periprosthetic fracture around the internal prosthetic right hip joint. Despite these conditions, the Minimum Data Set (MDS) inaccurately indicated that the resident had no falls in the last month and no fractures related to falls in the last six months prior to admission. Additionally, the MDS incorrectly noted no impairment in the lower extremity ROM. Interviews with the MDS coordinator and the Director of Nursing (DON) confirmed the discrepancies in the resident's MDS assessment. Both acknowledged that the fall history and functional limitation in ROM were inaccurately documented. The MDS coordinator and the DON emphasized the importance of accurate assessments to prevent potential risks of injury or falls. The facility's job description for the Resident Assessment/Care Plan Coordinator (MDS) outlines the responsibility for ensuring accurate resident assessments in accordance with current regulations.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of falls, as per the Interdisciplinary Team (IDT) plan, which required a sitter from 3 PM to 7 AM. The resident, who had severe cognitive impairment and was at high risk for falls, was observed alone in their room without a staff member present. This occurred when the assigned Certified Nursing Assistant (CNA) left the room to dispose of trash without notifying another staff member to take over supervision. The CNA acknowledged the need for continuous supervision and admitted to not informing other staff members of their temporary absence. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the CNA should have communicated their need to leave the room and ensured another staff member was present. The DON also noted that the fall care plan was not updated to reflect the IDT's decision for a sitter, which was crucial for staff awareness and intervention implementation. The facility lacked a specific policy for sitters or one-to-one supervision, which contributed to the oversight in maintaining the resident's safety.
Delayed Response to Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to promptly assess and address a change in condition for a resident who exhibited symptoms of chest congestion and a productive cough. The resident, who had a complex medical history including a heart transplant, immunodeficiency, and quadriplegia, was not immediately assessed by the Licensed Vocational Nurse (LVN) when the change in condition was reported by a Certified Nursing Assistant (CNA). The LVN did not check the resident's vital signs or inform the Registered Nurse (RN) on duty about the change in condition in a timely manner. The RN also failed to perform a thorough assessment of the resident's condition, including checking vital signs and performing chest auscultation, after being informed by the LVN. Furthermore, the RN did not notify a medical doctor or nurse practitioner about the resident's condition, which included a productive cough and chest congestion. This lack of immediate action and communication resulted in a significant delay in providing necessary medical services to the resident. As a result of these deficiencies, there was a delay of over seven hours in addressing the resident's medical needs. The resident was eventually found unresponsive and was transferred to a general acute care hospital, where they were diagnosed with septic shock, severe dehydration, and other complications. The resident passed away two days after the transfer, highlighting the critical impact of the facility's failure to promptly assess and respond to the resident's change in condition.
Failure to Respect Resident's Dignity During Care
Penalty
Summary
The facility failed to provide care that promoted or enhanced the dignity and respect of a resident, identified as Resident 1, who was admitted with multiple sclerosis, right hand contracture, and dementia. The resident had fluctuating capacity to understand and make decisions, as noted in their history and physical assessment. Despite having intact cognition for daily decision-making, Resident 1 required maximal assistance from staff for activities of daily living (ADLs). On a specific occasion, Resident 1 resisted care and became combative during ADL assistance, specifically when being changed and cleaned. During an interview, a Certified Nursing Assistant (CNA1) reported that they continued to assist Resident 1 despite the resident's combativeness, as they could not find additional help at the time. The Director of Nursing (DON) later stated that staff should stop providing care if a resident becomes resistive and combative to prevent injury. The facility's policy emphasizes treating residents with consideration, respect, and dignity, which was not adhered to in this instance, potentially causing psychosocial harm to Resident 1.
Failure to Notify Physician and Document Change of Condition
Penalty
Summary
The facility staff failed to ensure proper physician notification and documentation of a change of condition for a resident. The resident, who was admitted with diagnoses including multiple sclerosis, right hand contracture, and dementia, exhibited multiple scattered skin discolorations on the upper extremities and had an episode of resisting care with combativeness during activities of daily living. Despite these changes, there was no documentation of a change of condition using the SBAR tool, nor was the physician notified as required by the facility's policy. Interviews with staff revealed that a Certified Nursing Assistant (CNA) did not report the resident's refusal of care and combativeness immediately, as he went on a lunch break. The Registered Nurse (RN) and Licensed Vocational Nurse (LVN) were only informed after the CNA returned, and there was uncertainty about whether the physician was notified or if a change of condition was documented. The Treatment Nurse confirmed that no skin discolorations were documented prior to the resident's transfer to a general acute hospital, and the Director of Nursing emphasized the importance of immediate reporting and documentation for any new skin issues or behavioral changes.
Failure to Document Grievance
Penalty
Summary
The facility failed to ensure documentation of grievances was completed for one of three sampled residents. Resident 1 was admitted with diagnoses including cerebral infarction, difficulty in walking, and abnormal posture. The Minimum Data Set indicated that Resident 1 had severely impaired cognitive skills and required moderate assistance for activities of daily living. Despite these needs, a grievance reported by Resident 1's family member on 4/17/2024 was not documented. The family member found Resident 1 in a wheelchair with no undergarments and pants below the knee and reported this to the head nurse. The Registered Nurse notified the Director of Nursing and the Director of Staff Development about the concern, but no grievance report was completed because the family member refused to discuss the issue further with the Director of Staff Development. The Director of Nursing acknowledged the importance of documenting grievances to investigate and resolve issues but admitted that a grievance report should have been completed in this case. The facility's policy and procedures, reviewed on 1/9/2024, state that the resident has the right to have grievances promptly addressed. The failure to document the grievance violated Resident 1's family's right to have their concern addressed, as per the facility's grievance policy.
Failure to Document Medication Intolerance
Penalty
Summary
The facility failed to document a medication intolerance for cephalexin in the medication allergy profile of a resident, leading to the resident receiving the medication again and experiencing adverse effects. The resident, who had severe cognitive impairment and required moderate assistance for activities of daily living, was initially prescribed cephalexin for a urinary tract infection. After the first dose, the resident experienced nausea and vomiting, but this intolerance was not documented in the allergy profile. Consequently, the resident was prescribed and administered cephalexin again, resulting in another episode of nausea and vomiting. The Director of Nursing acknowledged the oversight and stated that if the allergy had been documented, the medication would not have been administered a second time. The resident's physician was also unaware of the initial adverse reaction and stated that he would not have prescribed cephalexin again if the allergy had been documented. The facility's policies on medication administration and orders emphasize the importance of documenting allergies and verifying orders, but these protocols were not followed in this case.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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