Harvard Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Covina, California.
- Location
- 519 W. Badillo St., Covina, California 91722
- CMS Provider Number
- 055544
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Harvard Creek Post Acute during CMS and state inspections, most recent first.
A resident with pneumonia, type 2 DM, dysphagia, and severe cognitive impairment experienced a fever, after which the NP ordered monitoring of vital signs. The DON stated that following such a change in condition, staff should obtain vital signs every 2–4 hours. An LVN reported checking the resident's vital signs multiple times during the subsequent night shift but did not document them because they were within normal limits. Review of records showed no documented vital signs after the change in condition, despite facility policies requiring monitoring and documentation of objective observations, changes in condition, and responses to treatment.
A resident with hemiplegia and severe cognitive impairment did not receive passive range of motion (PROM) exercises to the left arm as required by the care plan and facility policy. Staff provided PROM to other limbs but omitted the left arm, resulting in pain and joint stiffness when PROM was eventually performed, indicating a decline in range of motion.
A resident with severe cognitive and physical impairments repeatedly crawled on the floor, a behavior observed by staff and another resident. Despite this, the care plan did not include interventions or goals to address the crawling, focusing only on general fall precautions. Staff confirmed the behavior was frequent, and the DON acknowledged the care plan should have been updated to include it.
A resident with a history of falls, confusion, and impaired mobility was not assessed for injury when found crawling on floor mats, and their care plan was not updated to address repeated crawling behavior. Staff, including a CNA and the DON, confirmed the resident frequently crawled on the floor and into the hallway, but this was not reflected in the care plan. An LVN also failed to document a wander guard device trial in the medical record, contrary to facility policy. These failures placed the resident at risk for harm.
A nurse did not document a wander guard trial for a resident with severe cognitive impairment and high fall risk, despite facility policy requiring such documentation. The omission led to incomplete medical records and risked miscommunication among the care team regarding the resident's condition and interventions.
A resident with acute respiratory failure and end-stage renal disease experienced diarrhea, prompting a physician's order for a stool sample to test for C. difficile. The facility failed to collect the sample, potentially delaying care. Interviews with the ADON and DON highlighted the importance of following physician orders, which was not done in this case.
The facility failed to ensure call lights were within reach for three residents, all of whom had severe cognitive impairments and were at high risk for falls. Observations revealed that the call lights were positioned out of reach, contrary to the facility's policy and care plans. Staff confirmed the inaccessibility and the importance of having call lights within reach for residents to request assistance.
The facility failed to follow its policy on the use of side rails for three residents, leading to deficiencies in care. A resident with a history of falls did not have alternative interventions attempted or informed consent obtained before bed rail installation. Another resident with severe cognitive impairment had side rails installed without documentation of alternative measures. A third resident, with intact cognition, had side rails installed without understanding their purpose, and no alternative interventions were documented.
The facility failed to label and date food items when opened, as observed in a refrigerator containing unlabeled tortillas. The Lead Cook and Dietary Supervisor confirmed the requirement for labeling to track food lifespan, as per the facility's policy.
A facility failed to obtain informed consent from a resident before administering an increased dosage of Mirtazapine, a psychoactive medication. The resident, who had the capacity to understand and make decisions, did not sign or date the consent form for the medication increase. The facility's policy required informed consent before administering or increasing the dosage of psychotropic medications, which was not followed in this case.
A resident with surgical aftercare and chronic kidney disease was inaccurately recorded in the MDS as discharged to an acute hospital, despite being discharged home with home health services. The MDS Coordinator admitted the error, and the DON highlighted the importance of accurate documentation for CMS reporting.
A resident with Parkinson's disease and dementia, assessed as high risk for falls, did not have bilateral landing mats properly positioned as ordered. The mats were intended to minimize injury in case of a fall, but one was found placed a foot away from the bed. Interviews with the ADON and DON confirmed the mats should be closer to the bed, as per the facility's fall risk policy.
A resident with respiratory failure was observed receiving five liters of oxygen per minute instead of the prescribed two liters. The facility staff failed to document the resident's oxygen usage as required, and the licensed nurse did not monitor the oxygen levels to ensure compliance with the physician's order. The facility's policy for oxygen administration was not followed, resulting in a deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident undergoing hemodialysis with a permacatheter, despite the facility's policy requiring EBP for residents with indwelling medical devices. The resident, with end-stage renal disease and other conditions, was not placed on EBP, which was confirmed by the ADON and acknowledged by the DON. This oversight had the potential to expose the resident to infection.
The facility did not meet the required 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Despite this, staff reported being able to provide care without difficulty. A room waiver request was submitted, indicating compliance with care and privacy standards.
Failure to Monitor and Document Vital Signs After Change in Condition
Penalty
Summary
Facility nurses failed to provide treatment and care in accordance with professional standards of practice when they did not monitor and document a resident's vital signs after a documented change in condition. The resident was admitted with pneumonia, type 2 diabetes mellitus, and dysphagia, and had severe cognitive impairment and dependence on staff for most activities of daily living. On 2/28/2026 at 6:21 PM, the resident had an elevated temperature of 100.2°F, and the nurse practitioner was contacted. The SBAR form and progress note indicated that the nurse practitioner ordered monitoring of the resident's vital signs following this elevated temperature. The DON stated that nurses normally monitor residents' vital signs once a day, but when instructed to monitor vital signs after a change in condition, staff should check them every 2–4 hours. The nurse practitioner confirmed that orders included monitoring vital signs. An LVN reported checking the resident's vital signs 2–3 times during the night shift following the fever but acknowledged not documenting them because they were within normal limits. The DON stated that if vital signs were not documented, then staff did not monitor them. Review of facility policies on acute condition changes and charting/documentation showed that staff were required to monitor and document the resident's progress, responses to treatment, and any changes in condition, including objective observations and services performed.
Failure to Provide PROM to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decrease in range of motion (ROM) for a resident with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was not given passive range of motion (PROM) exercises to the left arm as required by the care plan and the facility's policies. Record reviews and staff interviews confirmed that PROM was only provided to the resident's right arm, right leg, and left leg, omitting the left arm despite documented impaired mobility in the left shoulder. During an observation, when PROM was finally provided to the resident's left shoulder, the resident exhibited pain and joint stiffness, indicating a decline in ROM. The care plan specifically identified the risk for decline in ROM and included interventions for PROM to both arms and legs, but these interventions were not implemented for the left arm. The facility's own policies required that residents with limited ROM receive appropriate treatment to prevent further decline, which was not followed in this case.
Failure to Address Crawling Behavior in Resident Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's behavior of crawling on the floor. Despite multiple assessments and staff observations indicating that the resident had a history of confusion, impaired cognition, decreased coordination, and required extensive assistance with mobility and activities of daily living, the care plan only addressed general fall risk interventions such as floor mats and call light accessibility. The care plan did not include specific interventions or goals related to the resident's repeated behavior of crawling on the floor, which was observed and reported by both staff and another resident as occurring multiple times daily, including instances where the resident crawled into the hallway and attempted to pull himself up using hallway rails. Interviews with staff, including a CNA and LVN, confirmed that the resident frequently crawled out of bed and onto the floor, requiring staff assistance to return him to bed or his wheelchair. The DON acknowledged that the care plan should have been updated to reflect this behavior, in accordance with facility policy, but it was not. As a result, there were no nursing interventions in place to address the resident's crawling behavior, which was a significant omission given the resident's cognitive and physical impairments.
Failure to Implement Fall Risk Policy and Update Care Plan for Resident with Repeated Crawling Behavior
Penalty
Summary
The facility failed to implement its Falls and Fall Risk Management Policy and Procedure for one resident who was at high risk for falls due to a history of falls, confusion, impaired gait and balance, and use of antihypertensive medication. The resident's care plan included interventions such as providing bilateral floor mats, keeping the call light within reach, and maintaining a safe environment. However, staff did not assess the resident for injury whenever he was found crawling on the floor mats, as required by the care plan. Additionally, the resident's care plan was not updated to reflect his repeated behavior of crawling on the floor, despite multiple staff observations and reports from a roommate that the resident crawled out of bed and around the room several times a day. Staff, including a CNA and the DON, confirmed that the resident frequently crawled on the floor and sometimes into the hallway, but the care plan did not address this specific behavior. Furthermore, an LVN failed to document the use of a wander guard device trial in the resident's medical record, contrary to facility policy. The DON acknowledged that documentation and care plan updates were not completed as required, and that staff did not consistently follow procedures for monitoring and assisting the resident when found on the floor. These failures placed the resident at risk for harm and injury.
Failure to Document Wander Guard Trial for High-Risk Resident
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to document a wander guard trial for one resident in the medical record, as required by the facility's Charting and Documentation policy. The resident, who had a history of cerebral infarction, cognitive communication deficit, and was assessed as a high fall risk due to confusion, balance problems, and use of antihypertensive medication, was admitted with multiple care interventions in place to prevent falls. Despite these risks and the use of a wander guard device, LVN 1 did not record the trial in the resident's medical record during assigned shifts. This omission was confirmed during interviews with LVN 1 and the Director of Nursing (DON), both of whom acknowledged that documentation and staff endorsement of the wander guard trial should have occurred according to facility policy. The lack of documentation resulted in incomplete medical records for the resident and created a risk of miscommunication among the interdisciplinary team regarding the resident's condition and response to care.
Failure to Follow Physician's Order for Stool Sample Collection
Penalty
Summary
The facility failed to follow a physician's order to collect a stool sample for a resident, which had the potential to delay care and services. The resident, who was admitted with acute respiratory failure with hypoxia, end-stage renal disease, and dependence on renal dialysis, was experiencing signs and symptoms of diarrhea. A physician's order was issued for a stool sample to be collected to test for C. difficile, but this order was not completed by the facility staff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the importance of following physician orders to provide proper care and interventions. The facility's policy and procedure for stool specimen collection, which includes verifying physician orders and documenting the procedure, was not adhered to. This oversight was identified during a review of the resident's records and interviews with facility staff.
Call Lights Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident 17, who had severe cognitive impairment and required assistance with daily activities, was found to have their call light positioned behind the headboard, making it inaccessible. This was confirmed during an observation and interview with the Activity Director, who acknowledged that the call light should be within easy reach to allow the resident to request help. Similarly, Resident 13, who had severe cognitive impairment and was assessed as high risk for falls, was observed with their call light clipped to the upper right side of the bed, out of reach. A Certified Nursing Assistant confirmed that the resident could not reach the call light and emphasized the importance of having it accessible for the resident to call for assistance. The resident's care plan also indicated the need for the call light to be within easy reach. Resident 35, who also had severe cognitive impairment and was at high risk for falls, was found with their call light hanging on top of the headboard, making it unreachable. The Assistant Director of Nursing confirmed the inaccessibility of the call light and reiterated the necessity for it to be within reach. The facility's policy on answering call lights also stated that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Implement Bed Rail Policy for Three Residents
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of side rails for three residents, leading to deficiencies in care. For Resident 21, the facility did not ensure that appropriate alternative interventions were attempted before installing side rails. Additionally, there was no assessment for the risk of entrapment, nor was informed consent obtained prior to the installation of the bed rails. Resident 21 had a history of falls and was capable of giving informed consent, yet the necessary evaluations and consents were not documented. For Resident 33, the facility did not document any attempts at alternative interventions before the automatic installation of side rails upon readmission. Resident 33 had severely impaired cognition and was dependent on staff for various activities of daily living. Despite these conditions, the facility failed to follow its policy of attempting less restrictive measures before resorting to side rails. Similarly, for Resident 48, there was no documentation of alternative interventions being attempted before the installation of side rails. Resident 48, who had intact cognition, was not using the side rails and was unaware of their purpose. The facility's policy required an assessment of the resident's symptoms, risk of entrapment, and the reason for using side rails, along with obtaining consent after discussing potential benefits and risks, none of which were documented for Resident 48.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to proper food handling practices by not labeling and dating food items when they were first opened, as observed in one of the facility's refrigerators. During an inspection, an unlabeled bag of tortillas and a 2-pound open bag of corn tortillas were found without any labels or dates indicating when they were opened. The Lead Cook acknowledged that the tortillas were not labeled or dated and stated that the staff responsible for opening food items should label them with the date opened to track their duration. The Dietary Supervisor confirmed that all food items should be labeled with the date opened to determine their use-by date and lifespan. The facility's Policy and Procedure on Labeling and Dating of Goods, dated 2020, requires newly opened food items to be closed and labeled with a delivery and open date, as well as a use-by date.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident was informed in advance about the risks and benefits of a psychoactive medication, specifically Mirtazapine, which was prescribed to treat depression. The resident, who had the capacity to understand and make decisions, was admitted with diagnoses including diabetes mellitus, anemia, and dysphagia. Despite having moderately impaired cognition, the resident was capable of making informed decisions. However, the informed consent for the increased dosage of Mirtazapine from 30 mg to 45 mg was neither signed nor dated by the resident, indicating a lack of informed consent. The facility's policy required that informed consent be obtained and documented before administering psychotropic medications or increasing their dosage. The Assistant Director of Nursing acknowledged that the resident should have consented prior to the medication use, emphasizing the importance of informed consent for psychotropic medications. The facility's failure to obtain and document informed consent before administering the increased dosage of Mirtazapine violated the resident's right to make an informed decision regarding their treatment.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the discharge status of a resident, identified as Resident 51. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery and chronic kidney disease. According to the Physician's Order, the resident was scheduled to be discharged home with home health services, including nursing, physical therapy, occupational therapy, and mobility aids. However, the MDS inaccurately recorded the resident's discharge status as being transferred to an acute hospital. During a review of the Licensed Personnel Progress Notes, it was confirmed that the resident was discharged home in stable condition. The MDS Coordinator acknowledged the error, stating that the discharge status was incorrectly coded in the MDS. The Director of Nursing emphasized the importance of accurate assessments and documentation for proper reporting to the Centers for Medicare and Medicaid Services (CMS). The facility's policy on resident assessments requires the interdisciplinary team to conduct timely and appropriate assessments, which was not adhered to in this case.
Failure to Properly Position Fall Prevention Mats
Penalty
Summary
The facility failed to utilize bilateral landing mats as ordered for a resident with a history of falls. The resident, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was assessed as being at high risk for falls due to disorientation, being chair-bound, and requiring assistive devices. The resident's care plan and order summary report both indicated the need for bilateral floor mats as a fall precaution. However, during an observation, it was noted that one of the floor mats was placed approximately one foot away from the resident's bed, which was not in accordance with the care plan. Interviews with the facility's Assistant Director of Nursing and Director of Nursing confirmed that the floor mats needed to be placed closer to the resident's bed to effectively minimize injury in the event of a fall. The facility's policy and procedure on fall risk assessment emphasized the importance of using landing mats to minimize potential injuries. The failure to properly position the floor mats as ordered had the potential to result in serious consequences for the resident, who had severely impaired cognition and was dependent on staff for daily activities.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to ensure that a resident received the prescribed two liters of oxygen per minute as needed, according to the physician's order. Instead, the resident was observed receiving five liters per minute of oxygen through a nasal cannula on multiple occasions. The resident, who was admitted with diagnoses including sepsis, respiratory failure, and a urinary tract infection, had an order to maintain oxygen saturation above 92% for acute respiratory failure with hypoxia. Despite this, there was no documentation in the Medication Administration Record (MAR) for the use of two liters per minute of oxygen as needed for the month of December. Interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse was responsible for monitoring the resident's oxygen levels to ensure compliance with the physician's order. The ADON emphasized the necessity of monitoring the resident's oxygen levels to check for respiratory distress and determine the effectiveness of interventions. The facility's policy and procedure for oxygen administration required reviewing the physician's orders, adjusting the oxygen delivery device to the proper flow, and recording oxygen administration in the resident's medical record. However, these procedures were not followed, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions for Resident on Hemodialysis
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to prevent the transmission of communicable diseases for a resident undergoing hemodialysis with an indwelling medical device. The resident, who was admitted with end-stage renal disease and other conditions, required hemodialysis through a permacatheter in the right upper chest. The facility's care plan for the resident included monitoring the dialysis access site for signs of infection. However, during an observation, it was noted that the resident was not placed on Enhanced Barrier Precautions (EBP), which are necessary to prevent the spread of multidrug-resistant organisms. The Assistant Director of Nursing confirmed that the resident was not on EBP, and the Director of Nursing acknowledged that the resident should have been placed on EBP due to the presence of a central line. The facility's policy on infection control clearly stated that EBP should be used for residents with indwelling medical devices, such as central lines. This oversight had the potential to expose the resident to infection, as the necessary precautions were not implemented as per the facility's policy.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Specifically, rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, and 122 did not meet the minimum space requirement. The deficiency was identified through observations, interviews, and record reviews. During observations, it was noted that rooms with two beds had only 154 square feet instead of the required 160 square feet, and rooms with four beds had 280 square feet instead of the required 320 square feet. Interviews with the facility's Administrator confirmed the deficiency, and a room waiver request was submitted, indicating that the rooms had enough space for care and did not negatively affect residents' dignity or privacy. Further interviews with Certified Nurse Assistants revealed that despite the space deficiency, staff were able to move equipment and provide care without difficulty. However, the facility's failure to meet the square footage requirement had the potential to affect residents' privacy and the adequacy of space for nursing care and emergency services.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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