Hanford Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanford, California.
- Location
- 1007 West Lacey Blvd, Hanford, California 93230
- CMS Provider Number
- 056288
- Inspections on file
- 26
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hanford Post Acute during CMS and state inspections, most recent first.
Three residents receiving oxygen therapy were found to have deficiencies in the maintenance of their oxygen concentrators: one was operating without a filter, while two others had filters covered in dust and lint. The IP and DON confirmed that these conditions did not meet facility policy or manufacturer requirements, and that licensed nurses were responsible for ensuring proper cleaning and assembly of the equipment.
A resident with multiple respiratory and cardiac conditions was given 4.5L/min of oxygen via nasal cannula instead of the physician-ordered 2L/min. Staff interviews and record reviews confirmed there was no documentation or physician order to justify the increased oxygen flow, and facility policy requiring adherence to physician orders was not followed.
A resident with a history of constipation, who was cognitively intact and dependent on staff for ADLs, repeatedly refused continence care and brief changes over several days. Staff did not adequately monitor or document bowel movements, assess for abdominal distention, or notify the physician in a timely manner. No bowel protocol or alternative interventions were implemented. This resulted in the resident developing a severe fecal impaction, requiring hospital transfer, and ultimately led to septic shock and death.
Two residents with cognitive impairment and poor safety awareness experienced multiple falls due to the facility's failure to provide adequate supervision and implement effective, individualized fall prevention interventions. Despite repeated unwitnessed falls and injuries, staff relied on ineffective measures such as reminders and environmental adjustments, and did not consistently update care plans or provide one-on-one monitoring, resulting in repeated injuries and, for one resident, a fatal outcome.
A resident with multiple medical and cognitive impairments was identified as a fall risk but did not have a comprehensive fall prevention care plan or effective interventions implemented upon admission. The resident experienced multiple falls before any fall risk interventions were added to the care plan, and staff did not document or provide adequate supervision as required by facility policy.
A resident with dementia and mobility issues experienced multiple unwitnessed falls due to inadequate supervision and ineffective fall prevention interventions, despite staff awareness of the resident's high fall risk. The resident sustained repeated injuries, including lacerations and a subdural hematoma, ultimately resulting in hospitalization and death. Staff interviews confirmed that necessary one-on-one monitoring and supervision were not provided, and existing interventions did not address the causes of the falls.
A facility failed to use QAPI data effectively to develop a fall prevention program, resulting in a resident experiencing multiple unwitnessed falls, repeated injuries requiring emergency care, and ultimately a fatal subdural hematoma.
The facility failed to implement comprehensive care plans for five residents, leading to deficiencies in care. A resident's care plan did not address the use of a transfer pole for safe transfers, while another's lacked toenail assessment despite complaints of pain. Two residents' care plans failed to include oxygen therapy services, resulting in noncompliance with prescribed treatments. Additionally, a resident's preference for a high bed position was not care planned, posing a risk of injury. These deficiencies reflect a lack of individualized care plans that address residents' needs and physician orders.
Two residents in an LTC facility did not have their care plans updated to reflect their current needs. One resident, with multiple health conditions, was non-compliant with prescribed oxygen therapy, and the care plan was not revised to address this. Another resident, with severe cognitive impairment, did not have her need for prescription glasses included in her care plan, impacting her ability to perform daily activities. The facility's policies require care plans to be updated as conditions change, but this was not done in these cases.
A resident with Alzheimer's, Type 2 Diabetes, and diabetic neuropathy experienced long, painful toenails due to the facility's failure to provide appropriate care. Despite the resident's complaints, staff did not assess or document the condition, nor was a podiatry consult requested. Facility policies required diabetic residents to receive toenail care from a podiatrist, but this was not followed, leading to potential complications.
The facility failed to conduct periodic reconciliation of controlled medications, as observed during an interview with the ADON and DON. The controlled medication log sheets lacked reconciliation, and the Pharmacy Consultant confirmed it was not part of the current policy. This oversight led to inadequate record-keeping and potential risks of medication diversion.
A Pharmacy Consultant failed to report irregularities in a resident's drug regimen review. The resident, with iron deficiency anemia and kidney failure, had consistently low hemoglobin levels without a documented goal, and was given 500 mg of Vitamin C daily without monitoring, risking toxicity. The DON and ADON confirmed the absence of necessary documentation and monitoring.
A resident with iron deficiency anemia and acute kidney failure received Procrit without a target Hgb goal or iron lab monitoring, and Ascorbic Acid without Vitamin C level checks. The facility's failure to monitor these parameters posed potential health risks, as confirmed by the DON and pharmacy consultant.
Two residents were prescribed psychotropic medications without proper documentation or non-pharmacological interventions. One resident was given Aripiprazole for hallucinations and delusions without evidence of such behaviors, and another had Olanzapine changed from PRN to routine without a psychosis assessment. There was ineffective monitoring and no gradual dose reduction attempts, increasing the risk of adverse reactions.
The facility's medication error rate was 11.11%, exceeding the acceptable threshold. Errors included a resident's blood glucose being checked post-meal, another resident receiving Olmesartan despite low blood pressure, and a third resident being given a medication not ordered by the physician. These actions were against the facility's medication administration policy.
The facility failed to monitor room temperatures in medication storage areas, risking medication efficacy. Discontinued medications were not removed from carts, posing a risk of errors. Inhalers lacked open date labels, risking expired medication use. A resident's medication lacked updated administration directions, risking incorrect dosage. Staff acknowledged these issues, highlighting the need for adherence to policies.
The facility failed to maintain food service safety standards, affecting 90 residents. Observations revealed unsanitary conditions, including a towel and gloves on the floor, a dirty stove, and food residue in the resident refrigerator. Additionally, cracked tiles in front of the ice machine posed a safety and infection risk. These deficiencies increased the risk of cross-contamination and foodborne illness.
A facility failed to ensure complete POLST forms for three residents, leading to potential non-compliance with their end-of-life care preferences. The forms lacked essential information such as physician contact details and signatures, which are necessary for the POLST to be valid. This deficiency could result in staff performing CPR on residents with DNR orders, as the incomplete forms do not clearly communicate the residents' wishes.
The facility failed to maintain effective infection control practices, as observed with several residents. A resident's urinary catheter bag was found on the floor, contrary to policy, posing a risk of infection. Additionally, oxygen nasal cannulas for two residents were improperly stored, increasing the risk of cross-contamination. Staff interviews confirmed these practices were against facility guidelines.
A facility failed to notify the state LTC Ombudsman of a resident's transfer to a GACH, as required by policy. The resident, with conditions including muscle weakness and end-stage renal disease, was transferred due to shortness of breath. Interviews with the DON and SSD confirmed the omission, highlighting a lapse in following the facility's transfer or discharge procedures.
A resident was not provided with written information about the facility's bed hold policy upon transfer to the hospital. Interviews revealed that notifications were made only via phone, contrary to the facility's policy requiring written notice at admission and at the time of transfer. This oversight violated the resident's right to be informed of the bed hold policy.
A resident with COPD did not receive continuous oxygen therapy as ordered, and the oxygen tubing was not labeled for replacement, leading to potential bacterial contamination. The resident reported tiredness and difficulty breathing, and staff confirmed the oversight in administering the prescribed therapy.
Two residents in the facility were found with call lights clipped to privacy curtains, out of reach, contrary to their care plans. One resident had severe cognitive impairment and mobility issues, while the other required maximum assistance with personal care. Staff interviews confirmed that call lights should be within reach to ensure residents can request help.
The facility was found to have four resident rooms with less than the required 80 square feet of space per resident. Rooms 106, 108, 110, and 119 each housed four residents, with space per resident ranging from 73.7 to 79.5 square feet. Despite this deficiency, the rooms met the residents' needs for privacy, storage, and accessibility, and a waiver for the space requirement was recommended to continue.
A resident with GERD did not receive their prescribed omeprazole for seven consecutive days due to a failure by the nursing staff to administer the medication and document the reasons for the omission. The LVN did not notify the physician about the missed doses, and the facility's policies requiring documentation and timely administration of medications were not followed.
Failure to Maintain Clean and Properly Assembled Oxygen Concentrators
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three of six sampled residents who were receiving oxygen therapy. One resident's oxygen concentrator was found to be operating without a filter installed, as observed during a room inspection. The Infection Preventionist (IP) and Director of Nursing (DON) both confirmed that the concentrator should not be used without a filter, and that it is the responsibility of licensed nurses to ensure the cleanliness and proper assembly of such equipment. Facility policy and the manufacturer's manual both require that the filter be present and cleaned regularly. Additionally, two other residents were observed using oxygen concentrators with filters that were covered in dust and lint. The IP stated that the filters should be cleaned at least once a week and as needed, and that using dirty equipment is not acceptable. The DON also confirmed that the expectation is for licensed nurses to clean the concentrators twice a week and as needed, in accordance with facility policy and job descriptions that require maintaining a clean and sanitary environment. Record reviews for all three residents showed that they had medical conditions such as COPD, congestive heart failure, and generalized muscle weakness, and were receiving oxygen therapy as ordered by their physicians. The observations and interviews revealed that the required maintenance and cleaning of oxygen concentrators were not being performed as per facility policy, job descriptions, and manufacturer instructions, resulting in the identified deficiencies.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, hypertension, dyspnea, and asthma was administered supplemental oxygen at a rate of 4.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This was observed during a routine check, and the Infection Preventionist confirmed that the oxygen setting was not in accordance with the physician's order. The physician order summary and progress notes did not indicate any clinical justification or documentation for increasing the oxygen flow above the prescribed amount. Interviews with facility staff, including the Infection Preventionist, Minimum Data Set Nurse, and Director of Nursing, confirmed that the oxygen administration did not follow professional standards or facility policy, which require verification and adherence to physician orders for medication administration, including oxygen. The facility's policy and job descriptions also specify that licensed nurses are responsible for reviewing and following physician orders, but this was not done in this instance.
Failure to Monitor and Intervene for Constipation Leading to Fatal Fecal Impaction
Penalty
Summary
A facility failed to ensure that a resident with a known history of constipation received necessary treatment and care in accordance with facility policies, procedures, and professional standards of practice. The resident, who was cognitively intact and dependent on staff for activities of daily living, repeatedly refused continence care and brief changes over several days. Despite these refusals and the resident's infrequent bowel movements, nursing staff did not adequately monitor or document bowel movements, assess for abdominal distention, or notify the physician in a timely manner about the ongoing refusals and lack of bowel movements. The facility also did not implement a bowel protocol or alternative interventions to prevent complications from constipation and impaction. Multiple staff interviews revealed that neither licensed nurses nor CNAs could confirm whether the resident had regular bowel movements, as the resident often refused care and staff did not perform or document necessary assessments. Although the resident was on a PRN stool softener, it was not administered because staff could not confirm the need due to lack of documentation and assessment. The physician was reportedly informed verbally of the refusals but did not provide new orders, and there was no documentation of these communications or of any interdisciplinary team meetings or care conferences to address the ongoing refusals and risks. The facility's own policy required detailed documentation and physician notification in cases of treatment refusal, but these steps were not consistently followed. As a result of these failures, the resident developed a severe fecal impaction, presenting with altered mental status and hypotension, and was transferred to an acute care hospital. There, a large amount of hardened stool was removed, but the resident deteriorated rapidly, developed septic shock, and died later that day. The deficiency was directly linked to the lack of monitoring, assessment, documentation, and timely intervention in response to the resident's ongoing refusals and known risk factors for constipation and impaction.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for two residents with known cognitive impairments, poor safety awareness, and histories of impulsive behaviors and multiple falls. For one resident, staff were aware of his moderate cognitive impairment, unsteady gait, and repeated incidents of getting out of bed without assistance, yet did not provide the necessary supervision or one-on-one monitoring. Despite multiple unwitnessed falls occurring in his room, interventions remained limited to reminders to use the call light and environmental adjustments, which staff acknowledged were ineffective due to the resident's inability to remember or comply. This resident experienced several unwitnessed falls resulting in injuries, including lacerations requiring emergency care and ultimately a fatal subdural hematoma following repeated falls. Another resident, also with moderate cognitive impairment and a history of brain injury, muscle weakness, and poor balance, was assessed as a fall risk but did not have a fall prevention care plan or interventions in place prior to his first fall. The resident exhibited impulsive behaviors, such as standing up suddenly and attempting to ambulate without assistance, leading to eight falls within a 30-day period. Staff interviews confirmed that the resident required constant supervision to prevent falls, but interventions were limited to periodic checks and environmental cues, which did not prevent further incidents. Documentation showed that care plans and interventions were not consistently updated or implemented in response to the resident's escalating fall risk and repeated incidents. Facility policies reviewed indicated that individualized, resident-centered fall prevention plans should be developed and revised as needed, and that residents identified as high risk should not be left unsupervised while out of bed. However, the facility did not follow these protocols, as evidenced by the lack of effective supervision and failure to implement or update care plans in response to ongoing falls. Staff and administration acknowledged that the interventions in place were insufficient to address the residents' needs and prevent avoidable accidents, resulting in repeated injuries and, in one case, death.
Failure to Develop and Implement Timely Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the fall risk of a resident who had multiple medical conditions, including a history of skull fracture, muscle weakness, gait and mobility abnormalities, diabetes, cognitive communication deficit, and several neurological disorders. Upon admission, the resident was assessed as having moderately impaired cognition and was identified as a fall risk, with behaviors such as standing up without staff supervision. Despite these assessments, no fall risk care plan or effective interventions were put in place prior to the resident's first fall. The resident experienced eight falls over a period of less than a month, with incidents occurring in various locations such as the bed, wheelchair, dining room, and near the nurses' station. Staff interviews revealed that the resident was confused, impulsive, and unable to safely stand without assistance, yet continued to attempt to do so. Although the resident was placed on frequent checks, these interventions were not documented in the care plan, and more intensive supervision, such as 1:1 monitoring, was not implemented. Staff acknowledged that the resident's need for supervision and specific fall prevention strategies were not addressed in the care plan until after several falls had already occurred. Record reviews and staff interviews confirmed that the care plan lacked fall prevention interventions until well after the resident's risk had been established and multiple falls had taken place. The facility's own policies required the development of a comprehensive, person-centered care plan with measurable objectives and timely interventions based on resident assessments. However, the care plan for this resident was not initiated on admission, and the necessary interventions to address the resident's high fall risk and supervision needs were not included or implemented in a timely manner.
Failure to Implement Effective Fall Prevention and Supervision
Penalty
Summary
The facility administrator failed to provide consistent administrative oversight and resources to ensure that a resident at high risk for falls received adequate supervision and individualized care planning. Despite being aware of multiple falls experienced by the resident, the administrator did not ensure that the Interdisciplinary Team implemented effective fall prevention interventions. The resident, who had diagnoses including dementia, gait abnormalities, and osteoarthritis, was assessed as moderately cognitively impaired and at high risk for falls. Staff interviews confirmed that the resident was confused, did not follow commands, attempted to get out of bed without assistance, and required supervision and continuous monitoring, which were not provided. The resident experienced a series of unwitnessed falls in his room over several months, each time being found on the floor next to his bed. Interventions such as keeping the call light within reach and encouraging its use were in place, but staff acknowledged these measures did not address the underlying causes of the falls, as the incidents occurred when the resident was unsupervised. The resident sustained injuries from these falls, including lacerations above the left eye that required emergency department visits for sutures. The resident was also on blood-thinning medication, increasing the risk of serious injury from falls. Following additional falls, the resident suffered a subdural hematoma and other head injuries, ultimately leading to hospitalization and death. The facility's policy required that fall prevention plans be reviewed and revised as appropriate, especially if a resident continued to fall. However, the administrator acknowledged that not enough fall interventions were implemented to keep the resident safe, and the necessary supervision and monitoring were not provided, resulting in repeated injuries and the resident's eventual death.
Failure to Use QAPI Data for Fall Prevention Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program, specifically by not utilizing resident fall data to establish a comprehensive safety plan for fall prevention. Despite tracking the number of falls and using the data to incentivize staff with rewards such as pizza parties for fall-free periods, the administrator was unable to articulate how this data was used to ensure an effective fall prevention program. The QAPI committee's activities did not translate into actionable strategies to address repeated falls, as required by the facility's own QAPI policy and job descriptions. As a result of these deficiencies, a resident experienced multiple unwitnessed falls over several months, leading to repeated injuries, including lacerations that required emergency department visits and sutures. The resident ultimately suffered a subdural hematoma following a fall, which contributed to their death. The facility's failure to analyze and act upon fall data as part of its QAPI process directly resulted in ongoing harm to the resident.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to deficiencies in their care. Resident 51's care plan did not address the use of a transfer pole, an assistive device necessary for safe transfers due to the resident's muscle weakness and mobility issues. Despite being identified as a fall risk and requiring the transfer pole, the care plan lacked specific instructions, potentially compromising the resident's safety during transfers. Resident 75's care plan failed to address toenail assessment and condition, despite the resident's complaints of pain and discomfort due to long, thick, and curled toenails. The resident, who has Alzheimer's Disease and Type 2 Diabetes with Diabetic Neuropathy, did not receive appropriate toenail treatment and monitoring, as the condition was not identified in daily assessments or documented in the medical record. Similarly, Resident 342's care plan did not include oxygen therapy services or address noncompliance with these services, resulting in the resident not receiving continuous oxygen therapy as prescribed for their COPD. Resident 343's care plan did not address noncompliance with maintaining a low bed position, despite the resident's history of seizures and risk of injury from falls. The resident preferred the bed in a high position, which was not care planned to ensure safety. Lastly, Resident 84's care plan did not include oxygen therapy services, leading to the resident's nasal cannula being found on the floor, contrary to the physician's order for continuous oxygen therapy. These deficiencies highlight the facility's failure to provide individualized care plans that reflect the residents' conditions, needs, and physician orders.
Failure to Revise Care Plans for Oxygen and Vision Needs
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for two residents, leading to deficiencies in their care. Resident 31, who was diagnosed with conditions such as metabolic encephalopathy, pulmonary edema, and heart failure, was observed not using his prescribed oxygen therapy. Despite having a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, the resident was non-compliant, and the care plan was not updated to address this non-compliance. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged that the care plan should have been revised to reflect the resident's current condition and interventions needed to manage the non-compliance. Resident 67, who had severe cognitive impairment and was diagnosed with muscle weakness, dementia, and diabetes mellitus, was found without her prescription glasses, which were placed out of reach. The resident's care plan did not include the need for glasses, despite a vision report recommending new reading glasses to improve vision and quality of life. The Minimum Data Set (MDS) Coordinator admitted that the care plan should have been updated to ensure the resident's need for glasses was addressed, as it was crucial for maintaining her functional independence and reducing fall risk. The facility's policies and procedures require that care plans be comprehensive, person-centered, and revised as residents' conditions change. However, in these cases, the care plans were not updated to reflect the residents' current needs, leading to potential risks for the residents. The facility's failure to revise the care plans in a timely manner resulted in Resident 31 not receiving oxygen as prescribed and Resident 67 not having access to her glasses, which could impact her ability to perform daily activities.
Failure to Provide Appropriate Toenail Care for Resident
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 75, who was admitted with diagnoses including Alzheimer's Disease, Type 2 Diabetes, and diabetic neuropathy. Despite Resident 75's complaints of long, painful toenails, no Certified Nursing Assistant (CNA), Licensed Vocational Nurse (LVN), or provider assessed his toenails. Observations revealed that Resident 75's toenails were long, yellow, hard, thick, curled, and separated from the nail bed, which could lead to further complications. Interviews with facility staff, including CNAs, LVNs, the Infection Preventionist (IP), and the Director of Nursing (DON), indicated that there was a breakdown in communication and documentation regarding Resident 75's toenail condition. CNAs were expected to report any resident complaints or changes in condition, including toenail issues, to the licensed nurse, who would then document and address these concerns. However, this process was not followed, and Resident 75's toenail issues were not documented or care planned, nor was a podiatry consult requested. The facility's policies and procedures required that residents with diabetes receive toenail care from a podiatrist, and any toenail concerns should be reported to the Social Services Director (SSD) for referral. Despite these policies, Resident 75's toenail condition was not identified or documented in the medical record, and no podiatry services were consulted. This oversight resulted in Resident 75 experiencing pain and discomfort, with the potential for further complications due to the lack of appropriate toenail care.
Failure to Conduct Periodic Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not conducting periodic reconciliation of controlled medications for residents with standing and as-needed orders. During an observation and interview, it was found that the controlled medication log sheets stored in a locked cabinet lacked periodic reconciliation. The Assistant Director of Nursing (ADON) was unsure if there was a process in place for this reconciliation. The Director of Nursing (DON) confirmed that periodic reconciliation was not being conducted, acknowledging its importance in preventing medication diversion and ensuring residents receive proper treatment. Further interviews revealed that the Pharmacy Consultant (PC) stated that periodic reconciliation was not included in the facility's policy and procedure, although it was deemed important to prevent diversion. A review of the facility's policy and procedure from 2001 indicated that controlled substance inventory should be monitored and reconciled to identify loss or potential diversion. The consultant pharmacist or designee was supposed to routinely monitor controlled substance storage records, but this was not being implemented, leading to inadequate record-keeping and potential risks of medication diversion.
Pharmacy Consultant Fails to Report Drug Regimen Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities in the drug regimen review for a resident with iron deficiency anemia and kidney failure. The resident's hemoglobin (Hgb) levels were consistently low, ranging from 8.1 to 8.3 gm/dL over five months, without a documented Hgb goal. This oversight meant there was no clear target to assess the effectiveness of the anemia treatment, which included Procrit injections. The Director of Nursing (DON) confirmed the absence of a Hgb goal in the resident's medical record, emphasizing its importance for evaluating treatment efficacy. Additionally, the resident, who had kidney failure, was administered 500 mg of Ascorbic Acid (Vitamin C) daily without monitoring Vitamin C blood levels. This lack of monitoring posed a risk of Vitamin C toxicity, as excessive Vitamin C can lead to oxalate buildup, potentially causing kidney stones and other complications. The Assistant Director of Nursing (ADON) was unable to provide documentation for iron and Vitamin C labs, indicating they had not been conducted. The PC acknowledged that typically, a lower dose of Vitamin C is recommended for residents with chronic kidney disease to avoid such risks.
Inadequate Monitoring of Drug Regimen and Lab Tests
Penalty
Summary
The facility failed to adequately monitor and manage the drug regimen of a resident, leading to potential health risks. The resident, diagnosed with iron deficiency anemia and acute kidney failure, received Procrit to treat low hemoglobin (Hgb) levels. However, the facility did not establish a target Hgb goal, nor did they conduct necessary iron lab monitoring. The resident's Hgb levels remained consistently low over several months, and the Director of Nursing (DON) acknowledged the absence of a documented Hgb goal, which is crucial for assessing the effectiveness of the treatment. The pharmacy consultant also emphasized the importance of having a goal for Hgb levels to determine the need for alternative interventions. Additionally, the resident was administered Ascorbic Acid (Vitamin C) without appropriate monitoring of Vitamin C blood levels. The DON and Assistant Director of Nursing (ADON) confirmed that no documentation for iron and Vitamin C labs was available, indicating that these tests had not been conducted. The pharmacy consultant noted that for residents with chronic kidney disease, a lower dose of Vitamin C is typically recommended. The lack of monitoring for Vitamin C levels posed a risk of toxicity due to unmonitored dosing.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 43 and Resident 67, were free from unnecessary psychotropic medications. Resident 43 was prescribed Aripiprazole for behaviors of auditory hallucinations and delusions, despite no documentation of such behaviors. Additionally, there was ineffective monitoring for behaviors of sadness, as evidenced by the lack of a target goal for behavior care planning, and no non-pharmacological interventions were implemented for Bupropion. Observations and interviews revealed that there was no documentation of hallucinations and delusions, and the care plan did not specify the types of distress to monitor. Resident 67's Olanzapine order was changed from as needed to routine upon admission without an assessment for a psychosis diagnosis. There were no non-pharmacological interventions attempted prior to the implementation of Olanzapine and Lorazepam, and there was ineffective monitoring for behaviors, as evidenced by the absence of a target goal in the care plan. Furthermore, there was inadequate side effect monitoring for Olanzapine and Lorazepam, and no gradual dose reduction was attempted for Olanzapine. Interviews with staff indicated a lack of documentation for verbal aggression and non-pharmacological interventions. The deficiencies in the facility's handling of psychotropic medications for Residents 43 and 67 resulted in the potential for unnecessary medication use, increasing the risk of medical interactions and adverse reactions. The Director of Nursing and pharmacy consultant acknowledged the lack of documentation and the importance of non-pharmacological interventions and measurable goals in care plans. The facility's failure to document and implement appropriate interventions and monitoring contributed to the potential for harm to the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an 11.11 percent error rate. This was observed during a medication pass where three errors occurred involving three residents. For one resident, a blood glucose check was performed after the resident had started eating, contrary to the physician's order to check before meals. This led to an inaccurate assessment of the resident's blood glucose level, which could affect insulin administration. Another resident was administered Olmesartan despite having a blood pressure reading below the ordered parameters, which could potentially cause the resident's blood pressure to drop further. Additionally, a third resident was given a medication that was not ordered by the physician, as the administered tablet contained only sennosides and not the prescribed combination of sennosides and docusate. These errors were contrary to the facility's policy and procedure for administering medications, which requires verification of the right medication, dosage, and administration method.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during a survey. The room temperature for two medication storage rooms was not monitored, which posed a risk of medications being exposed to extreme temperatures, potentially altering their chemical composition and reducing their shelf life. During interviews, staff members acknowledged the absence of temperature logs and the importance of monitoring room temperatures to maintain medication effectiveness. Additionally, discontinued medications for two residents were found stored in the west wing medication cart, and another resident's discontinued ointment was stored in the east wing treatment cart. This oversight could lead to medication errors, as discontinued medications were not removed and discarded as per facility policy. Staff interviews confirmed that discontinued medications should have been removed to prevent potential administration errors. Furthermore, inhaler medications for multiple residents stored in the respiratory therapy cart lacked open date labels, increasing the risk of administering expired medications. The facility's policy required labeling of open medications to prevent the use of expired and ineffective drugs. An interview with the Assistant Director of Nursing highlighted the expectation for labeling medications with open and expiration dates to avoid adverse reactions and decreased efficacy. Lastly, a resident's medication in the treatment cart did not have an updated administration direction label, which could result in incorrect dosage and frequency administration.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain professional standards for food service safety, affecting 90 out of 91 sampled residents. During an observation, a towel and a pair of rubber gloves were found on the floor behind the three-compartment wash station, which the Dietary Aide acknowledged should not have been there due to the risk of cross-contamination. Additionally, the stove top was observed to have caramel-colored residue, dark shiny residue, and yellow particles, indicating it had not been cleaned properly. The Dietary Aide confirmed that the stove should be cleaned daily to prevent microbial growth that could lead to foodborne illness. Further observations revealed four pieces of toasted bread on the floor behind the toaster, which the Cook stated was due to a dislodged toaster panel. The Cook acknowledged that bread on the floor could lead to cross-contamination and pest infestation. The resident refrigerator was also found to have food residue and ice buildup, which the Certified Dietary Manager (CDM) stated should have been cleaned according to the schedule. The CDM noted that the presence of food residue could lead to foodborne illness. Additionally, four tiles in front of the ice machine were cracked and broken, creating an uneven surface. The CDM had notified the Director of Environmental Services (DES) about the issue, but repairs were delayed due to the need to order replacement tiles and wax. The Director of Nurses (DON) and DES both acknowledged that the broken tiles posed a safety hazard and infection risk, as they were difficult to sanitize. These deficiencies collectively increased the risk of cross-contamination and foodborne illness for the residents receiving food from the kitchen.
Incomplete POLST Forms in LTC Facility
Penalty
Summary
The facility failed to ensure accurate and complete medical records in accordance with professional standards of practice for three residents. The Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 31, 43, and 54 were found to be incomplete. Specifically, the forms lacked essential information such as the physician's license number, phone number, and signatures from both the physician and the resident or their responsible party. These omissions were identified during interviews and record reviews conducted by the surveyors. Resident 31 was admitted with multiple diagnoses, including metabolic encephalopathy, pulmonary edema, and dementia, and was found to have a POLST form that was missing critical information. The Medical Records Coordinator acknowledged that the incomplete POLST could lead to staff performing CPR on a resident who had a Do Not Resuscitate (DNR) order, as the POLST serves as a physician's order indicating the resident's end-of-life care preferences. The Licensed Vocational Nurse (LVN) also confirmed that the POLST was not fully completed, which could result in the resident's wishes not being honored in an emergency. Similarly, Resident 43, who was severely cognitively impaired, and Resident 54, who had Parkinson's disease and other health issues, also had incomplete POLST forms. The missing information on these forms included the physician's contact details and signatures, which are necessary for the POLST to be valid. The Director of Nursing (DON) stated that the expectation was for all POLST forms to be fully completed and signed, as they dictate the resident's code status and guide staff in emergency situations. The failure to complete these forms could result in the residents' end-of-life wishes not being respected, as staff would default to performing CPR in the absence of a valid DNR order.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for several residents, as observed during a survey. Resident 29's urinary catheter bag was found dragging on the ground while being pushed in a wheelchair, and later, the bag was observed lying on the floor in the resident's room. This was against the facility's policy and procedure for urinary catheter care, which mandates that catheter tubing and drainage bags be kept off the floor to prevent cross-contamination. Interviews with the Infection Preventionist and the Director of Nursing confirmed that these practices were unacceptable and posed a risk of infection to Resident 29. Resident 31's oxygen nasal cannula tubing was improperly stored, wrapped around the handle of the wheelchair, and the oxygen humidifier bottle was found on the floor. This improper storage was noted during an observation in the resident's room. The facility's lesson plan on oxygen supply handling and storage requires that such items be stored in bags when not in use to prevent contamination. The Infection Preventionist acknowledged that these practices could lead to cross-contamination and respiratory infection. Similar deficiencies were observed with Residents 73 and 84, where their oxygen nasal cannulas were not stored properly. Resident 73's nasal cannula was placed on top of the oxygen concentrator, and Resident 84's nasal cannula was found on the floor. Both instances were against the facility's guidelines, which require that oxygen tubing be stored in a clean, dry place, preferably in a bag, to prevent contamination. Interviews with staff, including a Respiratory Therapist and the Infection Preventionist, confirmed that these practices were not in compliance with the facility's infection control policies.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the state long-term care Ombudsman of a resident's transfer to a General Acute Care Hospital (GACH). This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including muscle weakness, end-stage renal disease, and chronic obstructive pulmonary disease, was transferred to the hospital due to shortness of breath. However, the facility did not send a copy of the transfer or discharge notification to the Ombudsman, as required by their policy. Interviews with the Director of Nursing and the Social Services Director confirmed that the Ombudsman was not notified by any means, such as phone, fax, or email. The Social Services Director acknowledged that the facility's policy and procedure for transfer or discharge was not followed, emphasizing the importance of notifying the Ombudsman as a patient advocate. The facility's policy, dated October 2022, clearly states that the Ombudsman should be notified at the same time as the resident and their representative in cases of transfer or discharge.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to a resident, identified as Resident 16, upon his transfer to the hospital. This deficiency was identified during interviews and record reviews. Licensed Vocational Nurse (LVN) 5 confirmed that Resident 16 was only notified of the bed hold policy via phone call and did not receive any written documentation. The Business Office Manager (BOM) also stated that Resident 16, being a long-term resident, was not given written notification of the bed hold policy at the time of his hospital transfer, as it was assumed unnecessary. The Director of Nursing (DON) corroborated that notifications were made only over the phone, and no written policy was provided to Resident 16. The facility's policy, titled "Bed-Holds and Returns," dated October 2022, mandates that all residents or their representatives receive written information about the facility and state bed-hold policies. This policy requires that residents be provided written notice at least twice: once in advance of any transfer, such as during admission, and again at the time of transfer, or within 24 hours if the transfer was an emergency. The failure to adhere to this policy resulted in Resident 16 not being informed in writing of the bed hold policy, violating his right to be informed of the facility's policies regarding bed holds during his absence.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for Resident 342, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The deficiency was identified when Resident 342's oxygen therapy was not administered according to the physician's order, and the oxygen tubing was not labeled to track when it needed to be replaced. This oversight was observed during a visit to Resident 342's room, where the oxygen concentrator was found turned off, and the nasal cannula tubing was tucked under the resident's pillow without a label indicating its first use. Interviews with Resident 342 and facility staff revealed that the resident did not receive the prescribed continuous oxygen therapy at 2 liters per minute via nasal cannula. The resident reported using oxygen only at night since admission and expressed feelings of tiredness and difficulty breathing. Licensed Vocational Nurses (LVNs) and the Infection Preventionist confirmed that the oxygen therapy was not administered as ordered, and the tubing was not labeled for replacement, which could lead to bacterial contamination. Further interviews with the Director of Nursing (DON) and Respiratory Therapists (RTs) highlighted the responsibility of licensed nurses to administer oxygen therapy as prescribed and to label the tubing for timely replacement. The facility's job description and policies emphasized the importance of following physician orders and maintaining proper oxygen equipment handling. Despite these guidelines, the failure to administer oxygen therapy as ordered and to label the tubing for replacement was evident, resulting in the deficiency.
Call Lights Out of Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential risk of them not receiving help when needed. Resident 20, who was readmitted with generalized muscle weakness, gait and mobility abnormalities, and a history of falling, was observed with a call light clipped to the privacy curtain, out of reach. This resident had a severe cognitive impairment, as indicated by a BIMS score of five. The care plan for Resident 20 specified that the call light should be within reach, but this was not adhered to during the observation. Similarly, Resident 65, who was admitted with hemiplegia, a history of falling, and cognitive communication deficits, was also found with a call light clipped to the privacy curtain, out of reach. This resident had no cognitive impairment, as indicated by a BIMS score of thirteen, and required maximum assistance with toileting and personal hygiene. The care plan for Resident 65 also indicated that the call light should be within reach. Interviews with staff, including a CNA, LVN, and the DON, confirmed that the call lights should have been placed on the bed within reach, not on the bedrail or privacy curtain, to ensure residents could request assistance when needed.
Space Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure that each resident bedroom provided the required 80 square feet of usable living space per resident. During the survey period, it was observed that four different rooms, specifically rooms 106, 108, 110, and 119, housed four residents each, with each resident having less than the mandated 80 square feet of space. Room 106 provided 79.5 square feet per resident, room 108 provided 73.7 square feet, room 110 provided 75 square feet, and room 119 provided 79.2 square feet per resident. Despite the space deficiency, the rooms were noted to meet the residents' needs in terms of privacy, storage, and accessibility for nursing care and mobility. The report suggests that the health and safety of the residents were not adversely affected by the space limitations, and a waiver for the space requirement was recommended to continue.
Failure to Administer Prescribed Medication for GERD
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident diagnosed with gastroesophageal reflux disease (GERD), among other conditions. The resident was prescribed omeprazole, a medication for GERD, to be administered daily. However, the medication was not administered for seven consecutive days, and there was no documentation indicating the reason for the missed doses or notification to the physician about the omission. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) responsible for administering the medication did not document the reasons for withholding the medication, nor did they notify the physician of the missed doses. The Medication Administration Report (MAR) showed blank entries and codes indicating the medication was not given, but the reasons were not documented in the progress notes. The Assistant Director of Nursing (ADON) confirmed the lack of documentation and stated that the physician should have been notified to consider alternative medication options. The facility's policies and procedures require medications to be administered as prescribed and any deviations to be documented, including reasons for withholding medication. The failure to administer the medication as ordered and the lack of documentation and communication with the physician were identified as departures from the standards of nursing care, potentially placing the resident at risk for increased symptoms of GERD.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
