Harbor Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 21521 S. Vermont Avenue, Torrance, California 90502
- CMS Provider Number
- 056192
- Inspections on file
- 31
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Harbor Post Acute Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and severe cognitive impairment experienced an elevated uric acid level and finger swelling. Although the physician was notified and further tests were ordered, staff did not initiate a required change in condition (COC) to ensure proper monitoring and communication, as confirmed by interviews and facility policy review.
A resident with multiple complex medical conditions experienced both swelling and pain in a finger and a significant 50-pound weight loss after readmission. Despite these issues being documented, staff did not develop or implement care plans to address either the swollen finger or the weight loss, contrary to facility policy. Nursing leadership confirmed that no separate care plans were created for these conditions.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely follow-up for dental services, including tooth extractions and dentures, due to lack of tracking and verification by the Social Services Director. Additionally, the same resident missed a scheduled urology follow-up for a UTI, with no documentation or explanation for the missed appointment, and staff failed to ensure transportation and proper recordkeeping.
Surveyors found that several food items, including nutritional supplements, ice cream, roll dough, and liquid eggs, were stored in the kitchen without required labels or dates. Dietary staff and supervisors confirmed that facility policy mandates labeling with delivery, open, and use by dates, but these procedures were not followed.
The facility lacked a comprehensive water management program, with incomplete documentation and no interdisciplinary team or system to identify Legionella risks. Infection Prevention and Control Program policies were outdated, particularly regarding staff COVID-19 vaccination requirements, and were not updated to reflect current regulations or practices. Additionally, a nurse failed to wear gloves while disinfecting a bedside table and preparing wound care supplies for a resident with complex medical needs, contrary to facility policy.
The facility did not accurately complete SNF ABN forms for two residents, omitting required information about specific services received and the daily cost of care after Medicare Part A coverage ended. Both residents, one with cognitive impairment and one with intact cognition, had forms that failed to specify care areas and costs, as confirmed by the admissions coordinator.
Two residents had their MDS assessments completed inaccurately when their use of anti-convulsant medications (Depakote and Neurontin) was not properly coded in the medication section, despite physician orders and administration during the assessment period. The MDS nurse confirmed these omissions during interviews and record reviews, resulting in incorrect data being submitted to CMS.
A resident with an indwelling catheter and multiple health conditions was not monitored for UTI symptoms as required by their care plan. Although the care plan specified monitoring for signs such as urine sediment and other symptoms, there was no documentation by nursing staff in the TAR or clinical records. Observation revealed sediment in the catheter tubing, and both a nurse and the DON confirmed that monitoring and documentation had not been performed.
A nurse left four prescribed medications at the bedside of a resident with end stage renal disease and dementia, despite the resident's fluctuating decision-making capacity and need for moderate assistance. Staff interviews confirmed that facility policy requires nurses to remain with residents until medications are taken, and that the resident was not safe to self-administer medications.
A resident with significant neurological and physical conditions was not provided with activities consistent with their care plan, which included TV, music, and sensory stimulation. Observations showed the resident was not engaged in these activities, and staff interviews confirmed a lack of consistent implementation of planned interventions.
A resident at risk for skin breakdown was found lying on a low air loss mattress that was incorrectly set to 320 lbs and left in static mode, contrary to care plan requirements and manufacturer instructions. Staff interviews confirmed the settings did not match the resident's weight and were not providing appropriate pressure relief, as required for pressure ulcer prevention.
Two residents did not have their respiratory care equipment labeled or replaced according to facility protocol. One resident's oxygen nasal cannula and humidifier were not properly dated or changed weekly, and another resident's nebulizer tubing was not replaced every seven days as required, despite regular use. Staff confirmed these lapses during interviews and observations.
A resident with chronic pain did not receive a follow-up pain assessment after being given tramadol for severe pain. The nurse administered the medication but did not return to evaluate its effectiveness, despite the care plan and facility policy requiring post-administration assessment. The resident continued to experience moderate pain and reported that no reassessment occurred.
A resident receiving hemodialysis, who had a history of end stage renal disease and dementia, experienced an episode of confusion that was not communicated by nursing staff to the dialysis center. The required documentation in the Dialysis Communication Record was also not completed, despite facility policy and staff statements emphasizing the importance of timely communication for residents undergoing dialysis.
A resident with CHF and obesity, who was able to make decisions and communicate, was prescribed Furosemide oral solution to be given by mouth. Instead, an RN administered the medication via the resident's feeding tube, contrary to the physician's order and facility policy, as confirmed by record review and staff interview.
A resident with diabetes did not receive Hemoglobin A1C testing every three months as ordered by the physician, with a missed test resulting in inadequate monitoring of their diabetes. An LVN confirmed the lapse, and facility policy requiring prompt completion of diagnostic orders was not followed.
A resident with a history of lung transplant and diabetes experienced severe, unrecognized weight loss due to inaccurate monitoring and documentation of food and fluid intake. Staff failed to follow care plan interventions, did not notify the physician or RD of poor intake, and did not provide clear instructions for calculating food consumption. As a result, the resident's significant weight loss was not identified, leading to delayed care and hospitalization for severe malnutrition and related complications.
A resident with a lung transplant did not receive Tacrolimus as ordered after a family member requested the medication be held for a blood test. Nursing staff acted on the family member's request without obtaining a physician's order, resulting in the medication being withheld. The physician was not notified, and facility policy requiring medications to be given per prescriber orders was not followed.
A facility's call light system was found to be inaudible in a resident's care area and hallways, leading to delayed assistance. A resident reported waiting 30 minutes for help during the night shift, using her phone to call for assistance. The Maintenance Director demonstrated that the system's volume could be adjusted to be audible, but it had been left low for a long time. The DON confirmed the importance of audible call lights for resident dignity and timely care.
A resident was not readmitted to the facility after hospitalization due to an outstanding debt, despite being cleared for return by the hospital. The facility failed to provide a bed hold or discharge notice, resulting in the resident remaining at the hospital for 22 days. The facility's policies requiring a 30-day advance notice for transfers or discharges were not followed.
A facility failed to report a resident-to-resident altercation to the CDPH and Ombudsman within the required timeframe. One resident, with a history of aggressive behavior, verbally threatened another resident, which was witnessed by staff and family members. Despite recognizing the incident as verbal abuse, the facility did not report it promptly, violating their policy and residents' rights.
The facility failed to investigate a resident-to-resident altercation involving a resident with a history of verbally aggressive behavior. The incident, witnessed by family members and staff, involved one resident blocking another's room and yelling and cursing. Despite the facility's policy requiring immediate reporting and investigation of abuse, no investigation was conducted, and the incident was not reported to relevant authorities.
A resident with hemiplegia and hemiparesis required substantial assistance for transfers as per their care plan, which specified two or more staff members for safe transfers. However, an RNA transferred the resident alone, contrary to the care plan. Interviews revealed the RNA believed he could manage alone, while the care plan's instructions applied to all staff to ensure safety. The DON confirmed the care plan's requirements were not dependent on staff size or gender.
The facility failed to store food properly, leading to potential contamination risks for 106 residents. Observations revealed improperly dated and sealed food items, inadequate hand hygiene, and improper glove use by dietary staff, as well as a cook wearing an uncovered wristwatch during meal preparation, all contrary to facility policies.
The facility failed to maintain the dignity and privacy of residents during care. Two residents were exposed due to undrawn privacy curtains, and another resident's urinary bag was not fully covered, leaving it visible to others. These actions were contrary to the facility's policy on maintaining resident dignity and privacy.
The facility staff failed to ensure call lights were within reach for two residents, potentially delaying necessary assistance. One resident with severe cognitive impairment and another requiring maximum assistance were both observed with call lights on the floor. Staff interviews confirmed that this could lead to frustration and affect residents' psychosocial wellbeing.
The facility failed to submit MDS assessments for two residents within the required 14-day timeframe, as confirmed by the MDS Coordinator and CMS Submission Report. This delay could impact quality measures and care plans.
The facility failed to provide necessary social services to three residents, leading to deficiencies in their care. One resident's advanced directive was not followed up on, another experienced delays in receiving dentures, and a third was not seen by a podiatrist for six months, resulting in pain. These oversights highlight significant lapses in meeting residents' needs.
Two residents' refrigerated medications were improperly stored in a medication cart instead of a refrigerator, potentially affecting their potency. A resident with diabetes had an unopened vial of Insulin Glargine not refrigerated, and another resident's insulin pen lacked an opened date and was also not refrigerated. The facility's policy requires refrigerated medications to be stored securely in a refrigerator.
The facility failed to implement proper infection control measures, including the use of PPE for two residents under Enhanced Barrier Precautions, improper glove handling during medication administration, and incorrect isolation signage for a resident with ESBL. These lapses were acknowledged by staff and highlighted the need for adherence to infection control protocols.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. One resident was prescribed antibiotics for cellulitis despite normal WBC levels, another received antibiotics for a respiratory infection without meeting criteria, and a third was on long-term antibiotics without improvement. The facility did not consistently conduct culture and sensitivity tests to guide therapy.
A resident with a history of gastroenteritis, colitis, and myocardial infarction called 911 multiple times due to abdominal pain and constipation, leading to hospitalization for fecal impaction and stercoral colitis. The facility failed to assess the resident for a change of condition (COC) and notify the physician, as required by policy. Interviews with nursing staff revealed a lack of documentation and communication regarding the resident's condition and refusal of medication.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as prescribed, as staff failed to replace the nasal cannula after personal care. The oxygen concentrator was left on, posing a fire hazard, and the resident's call light was out of reach, preventing them from requesting assistance.
A resident was prescribed psychotropic drugs without documented necessity, as the facility failed to ensure the medication was required for a specific diagnosed condition. Despite the addition of mental health diagnoses, the resident's records showed no documented episodes of the behaviors the medications were meant to address. The lack of specific behavior monitoring and documentation led to the failure to attempt Gradual Dose Reduction, resulting in the use of unnecessary psychotropic drugs.
The facility exceeded the acceptable medication error rate with a 10.71% error rate involving three residents. A resident did not receive a Lidocaine patch on time, another received eye drops in both eyes instead of one, and a third was given Calcium Acetate tablets late and without a meal. The DON confirmed these as medication errors.
Three residents experienced medication administration errors in an LTC facility. A resident did not receive a prescribed lidocaine patch due to unavailability, another received eye drops in both eyes instead of just the right eye, and a third was given calcium acetate without a meal. The DON confirmed these were medication errors.
A resident in an LTC facility did not receive food items of their choice due to the facility's failure to document and communicate their food preferences. Despite the resident's capacity to make decisions and express preferences, the dietary profile lacked documentation of dislikes, and the dietician's intended changes were not implemented. This resulted in the resident receiving unwanted food items, contrary to the facility's policies.
A resident reported being left in a soiled diaper, but the facility failed to investigate the grievance as required by its policy. Despite the resident's cognitive capacity and dependency on staff for toileting, no documentation or investigation was conducted, and the Director of Nursing and Social Services Director could not recall the events. This lack of action indicates a failure to adhere to the facility's grievance policy.
Failure to Initiate Change in Condition for Abnormal Lab Result
Penalty
Summary
The facility failed to complete a required change in condition (COC) for a resident who exhibited a sudden and clinically significant deviation from baseline health status. The resident, who had a history of cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia, was found to have an elevated uric acid level of 10.3 mg/dl, which was above the normal range. Additionally, the resident presented with swelling, tenderness, and pain in the left third finger. Although the physician was notified and further diagnostic tests were ordered, the facility did not initiate a COC as required by their policy. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a COC should have been completed to ensure appropriate monitoring and communication among staff regarding the resident's abnormal lab result and change in condition. Review of facility policy indicated that prompt notification and documentation of changes in a resident's medical or mental condition are required, but this process was not followed in this instance.
Failure to Develop Comprehensive Care Plans for Swelling and Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was readmitted with multiple diagnoses, including cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia. Upon review, it was found that the resident had a severely impaired cognition and was dependent on staff for activities of daily living. Despite documentation of swelling and pain in the resident's left third finger and a significant weight loss of 50 pounds upon readmission, no care plans were created to address these issues. The absence of care plans was confirmed by both the Registered Nurse Supervisor and the Director of Nursing during interviews, with the latter stating that the weight loss was considered under an existing tube feeding care plan rather than a separate plan. Facility policies required that comprehensive, person-centered care plans be developed to address all identified problems and conditions, including undesirable or unintended weight loss. The policies also specified that individualized care plans should include causes, goals, benchmarks, and time frames for monitoring and reassessment. However, the facility did not follow these procedures for the resident's swollen finger or significant weight loss, as evidenced by the lack of corresponding care plans in the resident's records.
Failure to Provide Timely Follow-Up for Dental and Urology Services
Penalty
Summary
The facility failed to ensure timely follow-up and coordination of medically-related social services for a resident with multiple complex diagnoses, including cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia. The resident was severely cognitively impaired and fully dependent on staff for activities of daily living. Despite recommendations for dental services, including tooth extractions and dentures, the Social Services Director did not follow up on the necessary authorizations for several months. The dental company scheduled appointments, but the Social Services Director did not verify whether the services were completed, resulting in a significant delay and the need to obtain a new authorization. Additionally, the facility did not ensure that the same resident attended a scheduled urology follow-up appointment, which was necessary to confirm the resolution of a urinary tract infection. The Licensed Vocational Nurse entered the appointment order into the facility's system and provided it to Social Services, who were responsible for arranging transportation. However, there was no documentation explaining why the resident missed the appointment, and neither the Social Services Designee nor the Social Services Assistant could provide records or notes verifying communication with the transportation provider. The absence of documentation and lack of follow-up led to the missed appointment. Interviews with staff, including the Director of Nursing, confirmed that there was no explanation or documentation for the missed urology appointment and that the Social Services team did not track or verify completion of outside appointments. The facility's policies required prompt referral and follow-up for medically-related social services, but these were not followed in the resident's case, resulting in delays in necessary care and services.
Failure to Label and Date Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation practices in the facility's kitchen. Specifically, a box of Boost nutritional drink supplement with 19 remaining packs was found in the dry storage area without a date or label. In freezer #1, a box of chocolate fat free ice cream with 26 cups and a box of honey wheat roll dough were both stored without any date or label. Additionally, in refrigerator #1, a box of liquid whole eggs pasteurized with 11 remaining packs was also found without a date or label. Dietary staff interviewed during these observations confirmed that all food items should be labeled with the delivery date, the date opened, and the best buy date, in accordance with facility policy. The Dietary Service Supervisor acknowledged that the lack of labeling and dating made it impossible to track when food items were opened or when they should be discarded. The facility's policy and procedure on labeling and dating of foods requires that all food items be labeled with the received date upon delivery, the open date once opened, and a use by date. These deficiencies were identified during concurrent observations and interviews, and the practices observed were not in compliance with the facility's stated standards.
Deficiencies in Water Management, Policy Updates, and Infection Control Practices
Penalty
Summary
The facility failed to maintain a comprehensive water management program as required by its own policies and procedures. The water management binder only contained results of random Legionella testing and daily water temperature checks in a limited number of locations, without documentation of procedures for out-of-range temperatures, diagrams of the water system, or identification of all areas where water may collect or flow. There was no interdisciplinary water management team meeting routinely, nor a system to identify situations that could lead to Legionella growth, such as biofilm or sediment buildup. Interviews with the Infection Prevention Nurse and Maintenance Supervisor confirmed these gaps and the absence of a complete water management plan as outlined in facility policy. The Infection Prevention and Control Program (IPCP) policies and procedures were not current or reflective of national standards. The policy on staff COVID-19 vaccination was outdated, still requiring vaccination, booster, and additional testing or masking for unvaccinated staff, despite current practice and regulations no longer mandating these measures. The administrator acknowledged that the policy had not been updated and that staff were not required to provide evidence for vaccine refusal, nor were they subject to additional testing or masking, contrary to the written policy. The facility's process for policy review was also found to be ineffective in ensuring policies remained current and aligned with regulatory requirements. Additionally, staff failed to follow infection control protocols during wound care preparation for a resident with multiple complex medical conditions, including an unstageable pressure ulcer, diabetes, dementia, and quadriplegia. A treatment nurse was observed disinfecting the resident's bedside table and preparing wound care supplies without wearing gloves, in direct violation of the facility's policy on glove use. The nurse acknowledged the lapse and the potential for transferring bacteria to the resident's wound, which could result in infection.
Incomplete Beneficiary Notices for Two Residents
Penalty
Summary
The facility failed to accurately complete Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms for two residents. For one resident with Alzheimer's disease, type 2 diabetes, dysphagia, and osteoarthritis, the SNF ABN form did not specify which services were being received or the cost per day for those services after Medicare Part A coverage ended. This resident required maximal assistance with activities of daily living and had moderately impaired cognitive skills. Similarly, another resident with anemia, type 2 diabetes, end stage renal disease, and congestive heart failure, who required partial assistance with activities of daily living and had intact cognitive skills, also had an incomplete SNF ABN form lacking details about specific services and daily costs. During an interview and record review, the admissions coordinator confirmed that the SNF ABN forms for both residents were incomplete, as they did not indicate the specific care areas or the cost per day for continued services. The facility's policy and procedure on beneficiary notice of non-coverage states that the SNF ABN is intended to inform residents about the services received and the potential out-of-pocket costs, allowing them to make informed decisions. The incomplete forms did not meet these requirements.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of their medication regimens. For one resident with diagnoses including dementia, seizure disorder, and mood disorder, the MDS assessment did not reflect the use of Depakote, an anti-convulsant medication that had been ordered and administered during the assessment period. The MDS nurse confirmed that the resident began taking Depakote prior to the MDS completion date, but the medication was not coded as an anti-convulsant in the assessment. Similarly, another resident with neuropathy and paraplegia was prescribed Neurontin, a medication classified as an anti-convulsant, which was administered consistently during the MDS look-back period. However, the MDS assessment for this resident did not indicate the use of an anti-convulsant. The MDS nurse acknowledged that Neurontin should have been coded as an anti-convulsant in the MDS, as it was administered within the relevant assessment timeframe. Both instances were identified through interviews and record reviews, where the MDS nurse confirmed the inaccuracies in the MDS assessments. Facility policy requires that staff completing any portion of the MDS certify the accuracy of their entries, but in these cases, the medication information was not accurately documented, leading to the transmission of incorrect data to CMS.
Failure to Implement and Document UTI Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to implement a care plan intervention to monitor for signs and symptoms of urinary tract infection (UTI) for a resident with an indwelling foley catheter. The resident had diagnoses including obstructive uropathy, malignant neoplasm of the bladder, and generalized muscle weakness, and required moderate assistance with daily activities. The care plan specifically included monitoring for UTI symptoms such as chills, fever, sediment build-up, blood clots, bladder distention, and changes in urine output, with the goal of preventing UTI development. Despite these interventions being outlined in the care plan, there was no documentation in the Treatment Administration Record or clinical nursing notes indicating that the resident was monitored for UTI symptoms. During observation, a nurse identified the presence of yellow/white sediments in the resident's catheter tubing, which is a sign of UTI, but confirmed that monitoring and documentation had not occurred. The Director of Nursing also verified the absence of required documentation and emphasized the importance of following care plan interventions to detect and treat UTIs early.
Medications Left Unattended at Bedside for Resident with Cognitive Impairment
Penalty
Summary
A licensed vocational nurse (LVN) left four prescribed medications at the bedside of a resident who had diagnoses including end stage renal disease, hemodialysis, and dementia. The resident had fluctuating capacity to understand and make decisions, as documented in the history and physical, and required moderate assistance with personal care tasks according to the Minimum Data Set. The resident reported that the nurse left the medications at his request during the morning medication pass, and the medications remained at the bedside for over two hours. Interviews with nursing staff, including the LVN, a registered nurse (RN), and the director of nursing (DON), confirmed that facility policy and standard practice require nurses to remain with residents until all medications are taken, and that medications should not be left unattended at the bedside. The DON and RN both stated that the resident was not considered safe to self-administer medications. Review of facility policies indicated that standards of practice are intended to ensure safe and effective care, and that quality of care is governed by regulations focused on resident well-being and safety.
Failure to Provide Resident-Centered Activities per Care Plan
Penalty
Summary
The facility failed to provide resident-centered activities consistent with the care plan for one resident. The resident, who had a history of cerebral infarction, cardiac arrest, anoxic brain damage, aphasia, and scoliosis, was admitted and re-admitted to the facility. The resident's care plan indicated preferences for watching TV, joining small groups, listening to music, and exercising, with specific interventions such as 1:1 socialization, providing an iPad for music, and sensory stimulation. Despite these documented preferences and interventions, observations revealed that the resident was not engaged in these activities as planned. During observations, the resident was found lying in bed, staring straight up, and not watching TV, even though a TV was present in the room. The Activity Director confirmed that the resident was not watching TV at the time and acknowledged that the resident would feel sad if unable to do so. Interviews with staff indicated that while resources and activities were offered, the responsibility for engaging residents in activities was primarily assigned to the Activity Director, with nursing staff only assisting as needed. This lack of engagement and failure to follow the care plan interventions led to the deficiency.
Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown had a low air loss mattress (LALM) set to the appropriate settings as required by their care plan and physician orders. The resident, who had multiple diagnoses including bladder cancer, limb absence, osteoarthritis, and intervertebral disc degeneration, was identified as having a potential for skin breakdown and required a pressure-redistribution mattress. Observations revealed that the LALM was set at 320 lbs, which did not correspond to the resident's actual weight, and was in static mode rather than alternating mode as recommended by the manufacturer. The resident was unaware of the purpose of the mattress, and the treatment nurse confirmed the settings were incorrect and could impact the effectiveness of pressure relief. Further review of the resident's records, including the care plan and Minimum Data Set (MDS), confirmed the need for a pressure-reducing device and moderate assistance with mobility. Interviews with staff, including the treatment nurse and the Director of Staff Development, acknowledged the importance of correct LALM settings based on resident weight to prevent pressure injuries. The facility's policy and the manufacturer's instructional video both emphasized the necessity of adjusting the mattress to the resident's weight and using the appropriate mode to provide effective pressure redistribution. The failure to follow these protocols constituted the deficiency.
Failure to Label and Replace Respiratory Equipment per Protocol
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory care equipment for two residents. For one resident with end stage renal disease and anemia, an oxygen concentrator with a nasal cannula and humidifier was observed at the bedside. The nasal cannula was dated from the previous month, and the humidifier was not labeled with any date. The resident reported that the oxygen machine had not been used in the past two weeks. During an interview, a registered nurse confirmed that both the nasal cannula and humidifier should be labeled and changed at least weekly, and acknowledged that failure to do so could potentially cause infection. For another resident with chronic obstructive pulmonary disease and congestive heart failure, a review of records showed a physician's order for twice-daily Budesonide inhalation via nebulizer. The resident's care plan indicated a risk for infection, and medication administration records confirmed regular use of the nebulizer. During observation, the nebulizer tubing was found to be dated from eleven days prior, exceeding the facility's protocol of changing tubing every seven days. The mask attached to the tubing was dated more recently. A licensed vocational nurse stated that the tubing should have been changed according to the weekly schedule but was not. Facility policy and procedure for administering medications through a handheld nebulizer specified that equipment and tubing must be changed every seven days and stored in a plastic bag with the resident's name and date. The failure to follow these protocols for both residents resulted in deficiencies related to the safe and appropriate provision of respiratory care.
Failure to Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic back pain, generalized osteoarthritis, and muscle weakness did not receive appropriate pain management. The resident was prescribed tramadol 50 mg every 12 hours as needed for moderate to severe pain, with care plan interventions specifying that medication should be administered as ordered and its effectiveness monitored. On the day in question, the resident received tramadol for severe pain, but there was no follow-up assessment of pain level after administration, as required by both the care plan and facility policy. The resident later reported ongoing moderate pain and stated that the nurse did not return to reassess his pain after giving the medication. The nurse confirmed that she did not reassess the resident's pain level after administering tramadol, acknowledging that she should have done so within 30 minutes to an hour to ensure the medication's effectiveness. The DON also stated the importance of assessing pain before and after medication administration to evaluate effectiveness and monitor for side effects. The facility's policy required pain management interventions to be consistent with the resident's goals and specifically documented, which was not followed in this instance.
Failure to Communicate Change of Condition to Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center regarding a resident who was receiving hemodialysis treatment. The resident, who had diagnoses including end stage renal disease, hemodialysis, and dementia, experienced an episode of confusion that was documented in the facility's records. However, the licensed nursing staff did not communicate this change of condition to the dialysis center staff, nor did they document it in the Dialysis Communication Record, which is intended to facilitate information sharing between facility and dialysis staff. Interviews with facility staff confirmed that changes in a resident's condition, such as the episode of confusion, should be communicated immediately to the dialysis center to ensure appropriate management and continuity of care. The facility's policy also emphasized the importance of structured communication and documentation of any changes in condition. Despite these requirements, the failure to communicate the resident's change of condition represented a lapse in following established protocols for residents receiving dialysis services.
Medication Administered by Incorrect Route
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure and obesity, who was capable of making decisions and communicating effectively, did not receive medication as ordered by the physician. The physician's order specified that Furosemide oral solution was to be administered by mouth once daily. However, during a medication pass, a registered nurse was observed administering the Furosemide through the resident's feeding tube instead of by mouth. Upon review of the resident's records, including the care plan and physician orders, it was confirmed that the medication was not given via the prescribed route. The facility's policy on medication administration requires that medications be given according to prescriber orders. The nurse acknowledged that administering medication by an incorrect route could have negative effects and that the medication should have been given by mouth as ordered.
Failure to Complete Ordered Diabetes Lab Monitoring
Penalty
Summary
The facility failed to ensure that a resident with diabetes mellitus received Hemoglobin A1C (HgA1C) testing every three months as ordered by the physician. The resident, who was dependent on staff for dressing and bathing and had a care plan indicating a risk for hypoglycemia or hyperglycemia, had a physician's order dated 2/27/2024 for quarterly HgA1C testing. However, a review of laboratory results showed that the test was completed on 8/16/2024 and 3/25/2025, but not on 6/25/2025 as required by the order. During an interview and record review, an LVN confirmed that the HgA1C test was not completed as ordered and acknowledged that the test was necessary to monitor the resident's diabetes status. The facility's policy required that diagnostic orders be promptly carried out as instructed by the physician, but this was not followed in this case, resulting in inadequate monitoring of the resident's diabetes.
Failure to Recognize and Respond to Severe Weight Loss Due to Inaccurate Food Intake Monitoring
Penalty
Summary
A resident with a history of lung transplant and diabetes mellitus experienced a severe, unrecognized weight loss of 19.25 lbs. in less than a month, dropping from 92 lbs. to 72.75 lbs. Facility staff failed to accurately monitor and document the resident's food and fluid intake, resulting in discrepancies between the Weekly Summary Nurse Progress Notes and the Documentation Survey Reports. The resident's care plan required monitoring for weight loss or gain of three pounds in a week and five pounds in a month, but this was not followed. Additionally, there was no documentation of the percentage of high protein nutrition (HPN) shakes consumed, and staff did not provide clear instructions on how to calculate or record food intake percentages. The facility did not notify the resident's physician or the registered dietitian (RD) of the resident's poor dietary intake and significant weight loss, as required by facility policy and the resident's care plan. Interviews with staff revealed that CNAs estimated food and fluid intake rather than measuring it accurately, and that intake below 50% was not consistently reported to licensed nurses. The DON and DSD confirmed that if a resident's intake was less than 50% for a week or two, or if three meals were missed, the physician and RD should have been notified, but this did not occur for this resident. As a result of these failures, the resident's severe weight loss went unrecognized by facility staff, leading to a delay in care and treatment. The resident was eventually transferred to a general acute care hospital, where she was diagnosed with failure to thrive, severe electrolyte abnormalities, severe protein-calorie malnutrition, cachexia, and dehydration, and required nasogastric tube feeding. The facility did not follow its own policies and procedures for nutritional screening, assessment, and weight change protocol, which required early identification and intervention for significant weight changes.
Failure to Administer Immunosuppressive Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral lung transplant and mild cognitive impairment did not receive Tacrolimus, an immunosuppressive medication, as ordered by the physician. The resident's care plan included the administration of Tacrolimus to prevent shortness of breath related to the lung transplant, and the physician's orders specified the medication should be given twice daily. However, the medication was placed on hold and not administered on a specific date, as documented in the Medication Administration Record. The sequence of events leading to this deficiency began when a family member requested that the medication be held due to an upcoming appointment and blood test. A registered nurse received this request and relayed it to a licensed vocational nurse but did not contact the physician to obtain an order to hold the medication. The physician later confirmed that he was not notified of the request and emphasized that Tacrolimus is necessary to prevent lung transplant rejection. The facility's policy required medications to be administered according to prescriber orders, which was not followed in this instance.
Inaudible Call Light System in Resident Care Area
Penalty
Summary
The facility failed to ensure that the call light system was functioning efficiently, as the volume was not turned up to an audible level. On a specific date, it was observed that the call light system in one of the two nursing stations was not audible in a resident's care area and the facility's hallways. This deficiency was highlighted during an interview with a resident who reported that although the call light illuminated when pressed, she was uncertain if the staff could hear it. The resident recounted an incident where she had to wait 30 minutes for assistance during the night shift, eventually resorting to using her personal phone to call for help. Further observations and interviews revealed that the call light system's volume was adjustable, and when turned up by the Maintenance Director, it became loud and audible. The Registered Nurse Supervisor acknowledged that the system had been inaudible for a long time, relying on staff to visually notice the lights above resident rooms. The Director of Nursing confirmed that the call lights should be both seen and heard to ensure residents' needs are met promptly, as per the facility's policy on resident rights, which emphasizes maintaining residents' dignity and quality of life.
Failure to Readmit Resident After Hospitalization Due to Outstanding Debt
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the resident being cleared for return by the General Acute Care Hospital (GACH). The resident, who had been initially admitted to the facility with diagnoses of heart failure and chronic respiratory failure, was transferred to the GACH due to shortness of breath. The facility did not provide a bed hold or a notice of transfer discharge, which resulted in the resident remaining at the GACH for 22 days beyond the date they were cleared to return. The facility's administrator refused to readmit the resident due to an outstanding debt of over $14,500 owed by the resident. This decision was made without providing the resident or their responsible party with a bed hold or discharge notice, as required by the facility's policies. The resident's responsible party was informed of the potential eviction on the day of the hospital transfer, causing concern about the resident's potential homelessness. Interviews with the Director of Nursing Services and the Administrator confirmed the lack of proper documentation and communication regarding the resident's transfer and discharge. The facility's policies require a 30-day advance written notice for transfers or discharges, which was not adhered to in this case. The Director of Nursing Services acknowledged that the resident should have been readmitted to ensure continuity of care and to prevent feelings of abandonment.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to immediately report a resident-to-resident altercation to the California Department of Public Health (CDPH) and the State Long Term Care Ombudsman within the required two-hour timeframe. This deficiency involved two residents, both of whom were involved in an incident where one resident exhibited verbally aggressive and threatening behavior towards the other. The failure to report this incident in a timely manner hindered the CDPH's ability to investigate the allegations of abuse promptly and posed a risk of other abuse allegations going unreported. Resident 1, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage and hemiplegia, exhibited verbally aggressive behavior on several occasions as documented in their Medication Administration Record (MAR). On the day of the incident, Resident 1 blocked the door to Resident 2's room and began yelling and cursing at Resident 2 and the staff. This behavior was witnessed by family members of Resident 2 and staff, including a Licensed Vocational Nurse (LVN), who intervened before any physical harm occurred. Despite the aggressive behavior being recognized as verbal abuse, there was no investigation summary report for this incident. The facility's policy and procedure on abuse require that any incident constituting abuse be reported immediately or no later than 24 hours after identification. However, the facility did not adhere to this policy, as evidenced by the lack of a timely report to the appropriate authorities. Interviews with the Administrator and Director of Nursing confirmed that the incident was considered abuse and should have been reported. The facility's failure to report the incident promptly is a clear violation of the residents' rights to be free from abuse, as outlined in their policy and procedure.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident altercation involving two residents. Resident 1, who had a history of verbally aggressive and threatening behavior, was involved in an incident where they blocked the door to Resident 2's room and began yelling and cursing at Resident 2 and the staff. This incident was witnessed by family members of Resident 2, who reported feeling scared for Resident 2's safety. Despite this, the facility did not conduct an investigation into the incident or document it in their incident investigation summary reports. Resident 1 had been admitted to the facility with several diagnoses, including nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis, and was noted to have intact cognitive skills but required maximal assistance for activities of daily living. Resident 2, on the other hand, had moderate cognitive impairment and required moderate assistance for mobility and personal hygiene. The altercation between the two residents was not reported to the Department of Public Health, the ombudsman, or the police, as required by the facility's policy. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the incident was considered verbal abuse and should have been reported and investigated. The facility's policy mandates that any incident of abuse be reported immediately and investigated, with corrective measures implemented to prevent further occurrences. However, in this case, the facility did not adhere to its policy, resulting in a failure to protect residents from potential abuse.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required substantial assistance during transfers due to hemiplegia and hemiparesis following a cerebral infarction. The resident's care plan specified the need for two or more staff members to assist with transfers to prevent falls or injuries. However, during an observation, a Restorative Nursing Assistant (RNA) transferred the resident from a wheelchair to a bed without assistance from another staff member, contrary to the care plan's requirements. Interviews with the resident, RNA, and other staff members revealed that the RNA believed he could perform the transfer alone, while the care plan clearly indicated the necessity of two or more staff members for safe transfers. The Director of Nursing confirmed that the care plan's instructions apply to all staff members, regardless of their size or gender, to ensure resident safety. The facility's policy on comprehensive care plans emphasized that interventions are designed after careful consideration of the resident's needs, yet this protocol was not followed in this instance.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 106 out of 108 residents. During an observation, it was noted that various food items in the dry storage room were not properly dated, labeled, or sealed. Items such as vanilla pudding mix, lemon gelatin mix, and various types of pasta were found without proper 'used by' dates, and some containers were not tightly sealed. The Dietary Supervisor acknowledged the responsibility of all dietary staff to ensure food items are labeled, dated, and stored correctly to prevent contamination. Additionally, during a tray line observation, a Dietary Aid failed to perform proper hand hygiene and glove changes between tasks, which could lead to cross-contamination. The Dietary Aid was observed handling various items, including refrigerator doorknobs and ice scoops, without changing gloves or washing hands. This was contrary to the facility's policies on handwashing and glove use, which emphasize the importance of changing gloves and washing hands between different tasks to prevent foodborne illnesses. Furthermore, a cook was observed wearing a wristwatch that was not fully covered by gloves while assisting in checking food temperatures during meal preparation. This was against the facility's dress code policy, which requires jewelry and wristwatches to be covered with gloves during food handling to prevent the spread of germs. The Registered Dietitian confirmed that proper hand hygiene and PPE use are essential to prevent cross-contamination during meal preparation.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of four residents during care, as observed by surveyors. For two residents, the privacy curtain was not drawn while personal care was being provided, resulting in exposure of the residents' bodies to passersby in the hallway. Resident 26 was observed with an exposed left breast, and Resident 27 was seen with their back exposed while wearing an incontinent brief. Both residents required assistance for all activities of daily living and had no cognitive impairments, emphasizing the importance of maintaining their dignity and privacy during care. Additionally, the facility did not ensure that Resident 213's indwelling urinary bag was fully covered with a privacy bag, leaving the urine visible to visitors and other residents. Resident 213 had the capacity to understand and make decisions and required substantial assistance with personal care. The failure to cover the urinary bag was acknowledged by a CNA, the Infection Preventionist Nurse, and the Director of Nursing, all of whom stated that the privacy bag was necessary to maintain the resident's dignity. The facility's policy on Quality of Life-Dignity emphasizes the importance of treating residents with dignity and respect, including maintaining bodily privacy during personal care. The policy explicitly prohibits demeaning practices and requires staff to assist residents in keeping urinary catheter bags covered. The observations and interviews conducted during the survey highlight the facility's failure to adhere to these policies, resulting in a deficiency in maintaining resident dignity and privacy.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility staff failed to ensure that the call lights were within reach for two residents, Resident 12 and Resident 16, which could prevent them from receiving necessary assistance. Resident 16, who was admitted with severe cognitive impairment and required assistance for all activities of daily living, was observed on two occasions with the call light on the floor and not within reach. The care plan for Resident 16 included an intervention to keep the call light available and answer it promptly, but this was not adhered to during the observations. Similarly, Resident 12, who had no cognitive impairment but required maximum assistance for activities of daily living, was also observed with the call light on the floor and not within reach. The care plan for Resident 12 also included the intervention to keep the call light available and answer it promptly. Interviews with the Director of Staff Development, a Certified Nursing Assistant, and a Registered Nurse confirmed that the unavailability of the call light could lead to frustration and affect the psychosocial wellbeing of the residents, as well as delay the care needed.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents were transmitted within the required 14-day timeframe after completion. Specifically, the assessments for Resident 69 and Resident 83 were submitted late, as indicated by the MDS submission forms dated 05/16/2024 and 06/24/2024, respectively. This delay was confirmed during an interview with the MDS Coordinator, who acknowledged that the discharge assessments from the hospital for these residents were not submitted on time. The MDS Coordinator admitted that the late submission could impact the quality measures, the plan of care, and the accuracy of the assessments. A review of the Centers for Medicare and Medicaid Services (CMS) Submission Report dated 08/07/2024 further confirmed that the final validation reports for both residents' assessments were completed more than 14 days after the required timeframe. The facility's policy and procedure on MDS Completion and Submission Timeframes, although undated, stated that assessments should be conducted and submitted in accordance with federal and state submission timeframes.
Deficiencies in Social Services and Ancillary Care
Penalty
Summary
The facility failed to provide necessary social services to three residents, leading to deficiencies in their care. For Resident 37, the facility did not follow up on the advanced directive, which is crucial for ensuring that the resident's healthcare decisions are respected. Despite having the capacity to understand and make decisions, Resident 37's California Power of Attorney form was incomplete, lacking dates and signatures. The Social Service Director acknowledged the absence of an advance directive since the resident's admission in 2015, which could lead to conflicts regarding healthcare decisions. Resident 93 experienced a lack of follow-up regarding dentures, which affected his comfort and well-being. Although the resident had undergone dental procedures, there was no documentation or follow-up on the need for dentures, despite the resident expressing his frustration and the facility being aware of the issue since February 2024. The Social Service Director admitted to knowing about the denture issue but failed to document any follow-up actions, leading to a delay in addressing the resident's needs. Resident 94 was not seen by a podiatrist for six months, resulting in untrimmed toenails and pain in her right toe. Despite the facility's policy of podiatrist visits every two months, a pending authorization from the resident's health insurance delayed the visit. The Registered Nurse Supervisor and Director of Nursing acknowledged the oversight, emphasizing the importance of timely podiatric care, especially for residents with diabetes. The facility's failure to ensure timely podiatric care for Resident 94 highlights a significant lapse in meeting the residents' ancillary service needs.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to appropriately store medications that required refrigeration for two residents, leading to a potential loss of medication potency. Resident 80, who has Type 2 diabetes mellitus with diabetic neuropathy and anemia, was found to have an unopened vial of Insulin Glargine that was not stored in the refrigerator as required. The medication instructions specified that it should be refrigerated before use and discarded 28 days after opening. However, the insulin was found in the medication cart instead of being refrigerated, which could affect its effectiveness. Similarly, Resident 5, who has Type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease, had an insulin pen that was also not stored in the refrigerator. The insulin pen lacked an opened date, and the Licensed Vocational Nurse (LVN) acknowledged that the insulin should have been refrigerated and disposed of properly. The facility's policy on medication storage mandates that medications requiring refrigeration must be stored in a refrigerator located in a secure location, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Usage and Isolation Protocols
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, Resident 4 and Resident 213, who were under Enhanced Barrier Precautions (EBP) due to their medical conditions. Certified Nursing Assistant (CNA) 1 did not wear a gown while assisting Resident 4 with activities of daily living and changing bed linen, despite the requirement to do so in an EBP room. Similarly, CNA 7 failed to wear a gown while handling Resident 213's urinary catheter bag. Both CNAs acknowledged their lapses, attributing them to forgetfulness, and recognized the importance of wearing PPE to prevent infection. Another deficiency was observed during the medication administration for Resident 25. Licensed Vocational Nurse (LVN) 4 was seen removing gloves from her pocket instead of the dispensing box, which is against the facility's policy. LVN 4 admitted that this practice could lead to contamination and expose residents to infection. The facility's policy clearly states that gloves should be removed from the dispensing box to maintain hygiene standards. The facility also failed to place correct isolation signage for Resident 62, who was supposed to be under contact isolation for ESBL in urine. Instead, the signage indicated red cohort isolation, which required different PPE. LVN 3 entered the room without the appropriate PPE, as the signage was misleading. The Infection Preventionist Nurse confirmed the error in signage and emphasized the importance of correct isolation protocols to prevent ineffective infection control.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for three residents. Resident 12 was prescribed Clindamycin for left foot cellulitis despite having a normal white blood cell count, and the antibiotic was later changed to Keflex without clear justification. The Infection Preventionist Nurse (IPN) acknowledged that the resident's WBC was within the normal range and that the decision to prescribe antibiotics was based on McGeer's Criteria, which may not have been fully met. Resident 78 was treated with Levaquin for a respiratory tract infection based on a chest x-ray showing lower left lobe infiltrate, despite not having a cough or fever and only one of the required respiratory subcriteria being met. The IPN admitted that the McGeer's Criteria was incorrectly documented and that the resident did not have a confirmed diagnosis of pneumonia. Additionally, Resident 78 was later prescribed Clindamycin for right arm cellulitis without a significant change in clinical status or WBC count. Resident 100 was on long-term antibiotics, including Clindamycin and Rifampin, for cellulitis and recurrent wound infections. Despite ongoing treatment, the resident reported that the condition had not improved, and the wound size remained unchanged over several assessments. The facility's policy indicated that antibiotics should be prescribed under the guidance of the Antibiotic Stewardship Program, but there was no evidence of culture and sensitivity tests being conducted to guide antibiotic therapy. The IPN and RNS acknowledged the importance of reassessing the need for antibiotics and conducting cultures, but these steps were not consistently followed.
Failure to Assess Change of Condition and Notify Physician
Penalty
Summary
The facility failed to assess a resident for a change of condition (COC) and notify the physician when the resident called 911 due to abdominal pain and constipation. The resident, who had a history of gastroenteritis, colitis, and myocardial infarction, was dependent on nursing staff for various activities and had the capacity to understand and make decisions. Despite the resident's complaints of abdominal pain and constipation, there was no documentation of a COC assessment or physician notification, leading to the resident calling 911 multiple times and being hospitalized for abdominal pain, fecal impaction, and stercoral colitis. Interviews with the nursing staff, including an LVN and the Registered Nurse Supervisor (RNS), revealed that the resident had requested pain medication, which was not administered as scheduled, and subsequently called 911. The LVN acknowledged the lack of COC documentation and physician notification, while the RNS confirmed that the resident was hospitalized after calling 911 due to feeling hot, nauseated, and unable to have a bowel movement. The RNS also noted that the resident had refused medication for constipation, but this refusal was not documented or communicated to the physician. The Director of Nursing (DON) admitted that the nursing staff did not have time to assess the resident for a COC before the paramedics arrived. The facility's policy and procedure required prompt notification of the physician and documentation of any changes in the resident's condition, which was not followed in this case. The resident's medical records from the general acute care hospital indicated diagnoses of abdominal pain, fecal impaction, and stercoral colitis, highlighting the severity of the situation and the facility's failure to provide appropriate care and communication.
Failure to Ensure Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received continuous oxygen therapy as prescribed. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, heart failure, and schizoaffective disorder, required assistance for all activities of daily living and had no cognitive impairment. The care plan for the resident included administering oxygen for shortness of breath due to chronic respiratory failure and monitoring its effectiveness. However, during observations on multiple occasions, the resident's nasal cannula was found on top of the bed, not in the resident's nostrils, while the oxygen concentrator was on. Interviews revealed that staff sometimes forgot to replace the nasal cannula after providing personal care, and the resident was unable to call for assistance as the call light was on the floor. The Director of Staff Development and a Licensed Vocational Nurse confirmed that the oxygen concentrator should be turned off when not in use to prevent fire hazards and ensure safety. The facility's policy on oxygen administration emphasized the importance of removing flammable items from the area and ensuring the call light is within easy reach of the resident.
Failure to Ensure Necessary Use of Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for a resident, identified as Resident 24, by not confirming that the medication was necessary to treat a diagnosed specific condition documented in the clinical record. Resident 24 was admitted with diagnoses including dementia and cerebral infarction, and later schizoaffective disorder, major depressive disorder, and anxiety disorder were added. Despite these diagnoses, the Minimum Data Set (MDS) indicated that Resident 24 had no hallucinations, delusions, or behavioral symptoms, yet was prescribed antipsychotic, antianxiety, and opioid medications. The facility's records showed that there were no documented episodes of the behaviors that the medications were intended to address, such as mood swings, anger outbursts, or paranoid ideation, from June to July 2024. The Registered Nurse Supervisor acknowledged that the behaviors being monitored were not specific and that the lack of documentation could lead to improper Gradual Dose Reduction (GDR) practices. The Psychiatry Physician's Assistant admitted that the decision not to attempt GDR was based on staff reports of behavior issues, which were not documented, leading to potential unnecessary medication use. The Director of Nursing confirmed that the facility should have attempted GDR based on the resident's behavioral episodes and that psychotropic medication use should be minimized. The facility's policies required monitoring for effectiveness and side effects of psychotropic medications, with specific behaviors documented in the resident's health record. However, the lack of specific behavior monitoring and documentation led to the failure to provide the minimum effective dose for Resident 24, resulting in the use of unnecessary psychotropic drugs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.71 percent. This was identified through four medication errors out of 28 opportunities involving three residents. For Resident 90, a Lidocaine patch prescribed for left shoulder pain was unavailable, leading to a delay in administration. The LVN acknowledged the absence of the patch and informed the resident and the nurse practitioner about the delay, which could potentially increase the resident's shoulder pain. Resident 310 experienced a medication error when the LVN administered an eye drop intended only for the right eye into both eyes. The LVN admitted to the mistake during an interview. For Resident 81, the LVN administered Calcium Acetate tablets late and without a meal, contrary to the prescribed order. The Director of Nursing confirmed that not following the doctor's order constitutes a medication error and emphasized the importance of timely medication administration as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. Resident 90 did not receive a prescribed lidocaine patch for left shoulder pain because it was unavailable. The Licensed Vocational Nurse (LVN) acknowledged the absence of the patch and informed the resident, the nurse practitioner, and the pharmacy about the delay. This oversight had the potential to increase Resident 90's shoulder pain and limit arm movement. Resident 310 received an incorrect administration of eye drops. The LVN administered brimonidine tartrate eye drops in both eyes, although the medication was prescribed only for the right eye to treat glaucoma. Additionally, Resident 81 was given calcium acetate tablets without a meal, contrary to the prescription that required administration with meals to lower phosphorus levels. The Director of Nursing confirmed that not following the doctor's orders constitutes a medication error and emphasized the importance of timely medication administration as per the facility's policy.
Failure to Honor and Document Resident's Food Preferences
Penalty
Summary
The facility failed to honor and document the food preferences of a resident, leading to the resident not receiving food items of their choice. The resident, who had the capacity to understand and make decisions, was on a regular renal diet and expressed dissatisfaction with the food provided, specifically mentioning a dislike for mocha mix and a preference for regular milk. Despite the resident's requests for meal substitutes, these preferences were not communicated to the kitchen staff, resulting in the resident receiving unwanted food items. The dietary profile and nutritional review screening for the resident lacked documentation of food dislikes and specific preferences. The dietary supervisor acknowledged that food preferences should be documented upon admission and updated as needed, but this was not done for the resident. The registered dietician confirmed that the resident's diet was supposed to be changed to regular milk upon admission, but this change was not implemented. The facility's policies required food preferences to be identified and documented within a specific timeframe, but these procedures were not followed, contributing to the deficiency.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to implement its grievance policy and procedure, which requires that all grievances be investigated promptly after being filed. This deficiency was identified in the case of a resident who had been admitted with a diagnosis of traumatic hemorrhage of the left cerebrum and was cognitively intact. The resident was dependent on staff for toileting hygiene and was always incontinent. Despite these needs, the resident reported being left in a soiled diaper, and a family member allegedly took pictures of the incident. However, the facility did not document any investigation into this grievance, and no progress notes or interdisciplinary team meetings were conducted to address the concern. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) revealed that neither could recall the events related to the grievance, and no documentation was found to indicate that an investigation had been conducted. The facility's policy requires that grievances be initiated as soon as practicably possible and that residents be kept informed of the resolution process. The lack of documentation and investigation into the resident's grievance indicates a failure to adhere to this policy, potentially affecting the resident's quality of life.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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