Hayward Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayward, California.
- Location
- 25919 Gading Road, Hayward, California 94544
- CMS Provider Number
- 555398
- Inspections on file
- 35
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hayward Post Acute during CMS and state inspections, most recent first.
A resident with anxiety disorder and intact cognition repeatedly reported distress caused by another resident's disruptive behavior, including yelling and banging, to staff. Despite multiple complaints, no action was taken, and management was not informed, resulting in the resident feeling angry and sad. Staff interviews confirmed awareness of the complaints, but the DON and ADON were unaware, indicating a breakdown in the grievance process.
A resident with a nasogastric tube (NGT) experienced repeated dislodgement and clogging, leading to multiple hospital transfers for reinsertion. Despite the resident's medical history and impaired decision-making capacity, the facility did not update the care plan with new interventions to prevent these issues. Interviews with staff revealed that the care plan was not revised, contrary to facility policy, contributing to the repeated hospitalizations.
The facility failed to maintain safe food storage, preparation, and distribution practices, risking foodborne illnesses for 81 residents. Corn was rinsed in a handwashing sink, meat was thawed improperly, and the 3-part sink lacked an air gap. Hand hygiene protocols were not followed, with an employee using the same gloves for multiple tasks, leading to potential cross-contamination. The facility's food preparation policies were not adhered to.
Two residents did not receive scheduled showers, impacting their personal hygiene and satisfaction. One resident, with C-Diff and Osteomyelitis, had not been showered since admission, while another, with Hemiplegia, missed a scheduled shower. Staff interviews revealed documentation errors and lack of adherence to hygiene schedules, with no records explaining missed showers.
A facility failed to transmit a resident's MDS Discharge assessment within the required timeframe. The assessment, completed for a resident with idiopathic aseptic necrosis of the right femur, was delayed due to a computer system error, resulting in a transmission well beyond the 14-day requirement.
A resident with documented diagnoses of Schizophrenia and Depression had an inaccurately completed PASRR Level I assessment, which failed to indicate these serious mental disorders. This error was confirmed during a review of the resident's records and an interview with an LVN, who acknowledged the incorrect coding and its importance for determining the need for a Level II evaluation.
A resident with limited range of motion due to hemiplegia and hemiparesis was not using prescribed aids like a splint or rolled hand towel, as observed during multiple instances. Despite a physician's order, the facility failed to revise the resident's care plan in a timely manner, and staff were unaware of the resident's refusals to use these aids. The care plan was not updated until several months later, contrary to the facility's policy of quarterly reviews.
A resident with diabetes and cognitive communication deficit did not receive necessary podiatry services as ordered, resulting in thickened, discolored toenails and dry, scaly skin on the feet. Facility staff confirmed the need for podiatry services, but the Social Services Director noted a lack of podiatrist availability since October 2023.
A facility failed to properly dispose of non-controlled medications, as observed when an LVN discarded medications in a trash bin instead of following protocol. The DON confirmed the error, noting that medications should be disposed of in a collection receptacle to prevent misuse.
A resident with a history of stroke and paralytic syndrome, requiring total dependence on staff for bed mobility, fell from the bed while a CNA provided ADL care alone, resulting in a forehead laceration. The CNA was unaware of the need for a two-person assist, and the facility lacked a policy for accident prevention.
A resident's privacy was compromised during ADL care when a CNA did not fully draw the privacy curtain, exposing the resident's body. The resident, dependent on staff for ADLs, was in a two-bed room near a window, and staff were observed passing by, potentially exposing the resident to public view. Interviews confirmed the privacy breach, which violated the facility's policy on maintaining resident dignity and privacy.
A resident, dependent on two staff for ADLs due to conditions like blindness and muscle weakness, was assisted by only one CNA, causing pain and distress. Observations showed the resident's skin was red with abrasions, and interviews confirmed the need for two staff as per the MDS and facility policy.
A resident developed a Stage IV pressure injury, and the facility failed to notify the Resident Representative (RR) and the physician about the change in condition and treatment. Despite the resident's severe cognitive impairment and multiple wound debridements, the RR and physician were not informed, preventing timely medical interventions and participation in the care plan.
The facility failed to provide proper pressure ulcer care and documentation for a resident, including the absence of physician's orders for wound treatment and missing weekly skin assessments for multiple months. This placed the resident at risk for worsening pressure ulcers and slow healing.
Failure to Address Resident Grievance Regarding Disruptive Behavior
Penalty
Summary
The facility failed to follow up on a resident's grievance regarding disruptive behavior from another resident. The affected resident, who was cognitively intact and had a diagnosis of anxiety disorder, reported feeling angry and sad due to the ongoing yelling, screaming, and banging from a neighboring resident. Despite bringing these concerns to staff on multiple occasions, no action was taken to address the issue. Interviews with staff, including a CNA, LVN, and RN, confirmed that the resident had repeatedly complained about the disruptive behavior, and that management was aware of the complaints. However, both the Assistant Director of Nursing and the Director of Nursing stated they were not aware of the grievance and emphasized that nursing staff should inform management of such concerns. A review of the facility's grievance policy indicated that any resident or their representative may file a grievance regarding care or the behavior of other residents or staff. The lack of follow-up on the resident's grievance resulted in the resident experiencing ongoing distress without resolution.
Failure to Update Care Plan for NGT Management
Penalty
Summary
The facility failed to develop new interventions to prevent the displacement and clogging of a resident's nasogastric tube (NGT), which was dislodged or clogged five times over a period of several months. This resulted in the resident being transferred to the hospital emergency department for NGT reinsertion on multiple occasions. The resident, who had a history of cerebrovascular disease, dysphagia, and hemiplegia, was admitted with an NPO diet order and required Glucerna through the NGT. Despite the resident's impaired memory and decision-making capacity, the facility did not update the care plan with new interventions after the initial incidents of NGT dislodgement and clogging. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the care plan was not revised to address the recurring issues with the NGT. The LVN acknowledged that updating the care plan could have prevented some of the hospital transfers. The facility's policy required care plan updates when there was a significant change in the resident's condition or after a hospital readmission, but no such updates were made. The lack of documentation and care plan revision contributed to the repeated hospital transfers for NGT reinsertion.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary food storage, preparation, and distribution practices, which could potentially lead to foodborne illnesses for 81 residents. Observations revealed that corn was rinsed in a handwashing sink, which is not intended for food preparation, leading to potential bacterial or chemical cross-contamination. Additionally, meat was improperly thawed in still water instead of under cold running water, which is necessary to flush away loose particles and prevent contamination. Furthermore, the facility's 3-part compartment sink lacked an air gap, which is essential to prevent backflow of sewage into the equipment, as confirmed by the Maintenance Director. Hand hygiene protocols were also not followed during food preparation and tray line service. An employee was observed using the same gloves for multiple tasks without changing them, leading to potential cross-contamination. This included handling meat, touching various kitchen surfaces, and serving food without changing gloves or performing hand hygiene. The Registered Dietician confirmed that these practices were unacceptable and posed a risk of cross-contamination. The facility's policy and procedure on food preparation and service were not adhered to, as evidenced by the improper thawing of frozen food and handling of ready-to-eat food without suitable utensils.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 193 and Resident 43, received the necessary services to maintain good grooming and personal hygiene. Resident 193, who was admitted with diagnoses including C-Diff and Osteomyelitis, did not receive any showers since admission, only having one sponge bath, which left him unhappy. Resident 43, admitted with Hemiplegia, missed a scheduled shower and expressed dissatisfaction with the frequency of showers provided. The facility's records indicated that Resident 193 was supposed to have showers twice a week, while Resident 43 was scheduled for showers on specific days, but these schedules were not adhered to. Interviews with the residents and staff revealed that Resident 193 was not given a shower due to being on isolation and contact precaution, and a CNA admitted to mistakenly documenting a sponge bath that was not given. The Director of Nursing was unable to provide documentation explaining why Resident 43 missed a shower, and there was no record of shower refusals. The facility's policies emphasized the importance of maintaining cleanliness and observing residents' skin conditions, but these were not followed, leading to the deficiency.
Delayed Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) Discharge assessment for a resident within the required 14 days. The resident, who was admitted for idiopathic aseptic necrosis of the right femur, had their discharge assessment completed on February 16, 2024, but it was not transmitted until June 24, 2024. This delay was identified during a joint interview and record review with the MDS Coordinator and a Licensed Vocational Nurse, where it was revealed that an error in the computer system led to some MDS assessments being missed.
Inaccurate PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) assessment for a resident, identified as Resident 35, who had documented medical diagnoses of Schizophrenia and Depression. The PASRR Level I Screening, submitted earlier in the year, incorrectly indicated that the resident did not have a serious diagnosed mental disorder. This discrepancy was confirmed during a review of the resident's admission record and Minimum Data Set (MDS), which both listed Schizophrenia and Depression as diagnoses. During an interview and record review, a Licensed Vocational Nurse (LVN) acknowledged that the PASRR Level I assessment was incorrectly coded, which should have been marked 'Yes' to indicate the presence of a serious mental disorder. The LVN explained that accurate completion of the PASRR Level I assessment is crucial to determine if a Level II evaluation is necessary. Such an evaluation would help in identifying any special accommodations or recommended services needed for the resident's care and well-being.
Failure to Revise Care Plan for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with limited range of motion, specifically affecting the right side of the body due to conditions such as hemiplegia and hemiparesis. Observations revealed that the resident was not using a splint or rolled hand towel as prescribed, despite a physician's order for their use in case of splint refusals. The resident was observed on multiple occasions without these aids, and staff interviews indicated a lack of awareness and documentation regarding the resident's refusal to use the hand splint or rolled towel. The resident's care plan, initially created in September 2023, was not revised until June 2024, despite the resident's ongoing refusal to use the prescribed aids. The Assistant Director of Nursing was unaware of the resident's refusals until the day of the interview, indicating a lack of communication and documentation within the facility. The facility's policy requires care plan goals and objectives to be reviewed and revised at least quarterly, which was not adhered to in this case.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide proper foot care for Resident 33, who was diagnosed with type 2 diabetes mellitus and a cognitive communication deficit. The resident's admission record indicated a physician's order for podiatry services every 61 days to address hypertrophic toenails and other foot problems. However, during an observation, it was noted that Resident 33 had thickened, curly, and yellowish-gray toenails, with the left pinky toenail absent and the right pinky toenail covering only one-fourth of the nail bed. The resident's skin on both feet was also very dry and scaly. Interviews with facility staff, including an LVN, RN, and the Assistant DON, confirmed that Resident 33's toenails were too thick for staff to clip and required podiatry services. The Social Services Director revealed that residents had not received podiatry services since October 2023 due to the podiatrist rescheduling visits and reducing hours. The facility's policy on foot care indicated that residents should be assisted in making appointments with specialists as needed, but this was not adhered to, resulting in the deficiency.
Improper Disposal of Medications
Penalty
Summary
The facility failed to ensure the effective storage and disposal of non-controlled medications, which had the potential for misuse. During an observation, a Licensed Vocational Nurse (LVN) prepared medications for a resident but was unable to administer them. Instead of following proper disposal procedures, the LVN discarded the medications in a trash bin attached to the medication cart, leaving the bin open. This action was observed and confirmed during an interview with the LVN, who incorrectly stated that non-controlled medications could be discarded in a regular trash bin or flushed in the toilet. The Director of Nursing (DON) later retrieved the discarded medications from the trash bin and confirmed that they should not have been disposed of in that manner. The facility's policy, dated November 2022, requires that medications not returned to the pharmacy be disposed of in accordance with regulations, using a collection receptacle. The DON stated that when medications cannot be administered, they should be covered, labeled, and given to the DON or Assistant Director of Nursing (ADON) for proper disposal. The improper disposal of medications could lead to accidental ingestion, as noted by the DON.
Resident Falls Due to Inadequate Supervision During ADL Care
Penalty
Summary
The facility failed to ensure that a resident remained free from accidents, resulting in the resident falling from the bed while a CNA was providing Activities of Daily Living (ADL) care. The resident, who had a history of stroke and paralytic syndrome, was totally dependent on staff for bed mobility and required a two-person physical assist. However, the CNA providing care was not informed of this requirement and had been providing ADL care alone for several years. This oversight led to the resident falling and sustaining a forehead laceration, necessitating transport to the emergency department. Interviews with the CNA and the Director of Nursing Assistant revealed a lack of communication regarding the resident's care needs. The CNA stated that she was not informed that two CNAs were needed for the resident's ADL care, and the Director of Nursing Assistant confirmed that the facility did not have a policy and procedure for accidents. The facility's policy on Resident Rights emphasized the resident's right to be free from abuse and neglect, but there was no specific guidance on preventing accidents.
Failure to Maintain Resident Privacy During ADL Care
Penalty
Summary
The facility failed to maintain the privacy of a resident during the provision of activities of daily living (ADL) care. The incident involved a resident who was totally dependent on the assistance of two staff members for ADLs, as indicated by their Minimum Data Set (MDS) assessment. During an observation, it was noted that the privacy curtain was not fully drawn, exposing the resident's body, brief, and legs while a Certified Nursing Assistant (CNA) was assisting with a bed bath and incontinent care. This lack of privacy was observed in a two-bed room where the resident's bed was located near the window, and staff members were seen walking past the window, potentially exposing the resident to public view. Interviews with the CNA and the Director of Nursing (DON) confirmed that the privacy curtains were not fully drawn during the care process, which was against the facility's policy. The facility's policy and procedure documents emphasize the importance of maintaining residents' privacy and dignity during care, including closing the room entrance door and ensuring privacy curtains are fully drawn. The failure to adhere to these guidelines resulted in a deficiency related to the resident's right to a dignified existence and privacy during care.
Failure to Provide Adequate Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was totally dependent on two staff members for activities of daily living (ADLs). The resident, who had diagnoses including diabetes, generalized muscle weakness, lack of coordination, hypertension, and depression, was observed to be assisted by only one Certified Nursing Assistant (CNA) during a bed bath and incontinent care. Despite the resident's inability to assist in turning due to blindness and limited mobility, the CNA attempted to turn the resident alone, causing the resident to cry out in pain. The resident's skin was observed to be red with abrasions, and the resident had wounds on the right leg and left foot. Interviews with the CNA and Licensed Vocational Nurse (LVN) confirmed that the resident required two staff members for safe and comfortable repositioning, as indicated in the Minimum Data Set (MDS) and physician orders. The Director of Nursing (DON) and assistant DON acknowledged the requirement for two staff members for such dependent residents. A review of weekly summaries showed that only one person had been performing ADLs for the resident, contrary to the facility's policy and procedure, which specified the use of two people and a draw sheet to avoid shearing while turning or moving residents.
Failure to Notify Resident Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to ensure the Resident Representative (RR) was notified of changes in condition and treatment for a resident who developed an unstageable pressure injury that progressed to a Stage IV pressure injury. The resident, who had severe cognitive impairment and multiple medical diagnoses, was admitted in July 2023. Despite the resident's condition worsening and requiring multiple wound debridements, the RR was not informed about the pressure injury or its progression during care conferences or through other communication channels. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that there was no documentation or communication to the RR regarding the change in the resident's condition and treatment plan. Additionally, the facility failed to notify the resident's physician about the progression of the wound from a skin shear to a Stage IV pressure injury. The physician's notes indicated that the resident did not have the capacity to make decisions, and the Durable Power of Attorney (DPOA) was held by the resident's son. Despite this, the physician was not kept updated on the resident's condition, which prevented timely medical interventions. The facility's policy and procedure on Change of Condition required that both the resident's physician and family be notified of any significant changes, but this protocol was not followed. Interviews with the DON and ADON revealed that the facility had a binder system for communication updates on resident conditions to the attending physician, but this system was not effectively utilized. The treatment nurse also failed to notify the physician or nurse practitioner about the wound's progression. The facility's failure to communicate these critical changes prevented the RR from participating in the resident's care plan and left the physician unaware of the resident's deteriorating condition, which could have led to missed opportunities for necessary medical interventions.
Failure to Provide Proper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide treatment consistent with professional standards to promote the healing of a pressure ulcer for one resident. The resident did not have a physician's order for wound treatment, and no wound treatments were documented on the treatment administration record from late January to late February. The resident's treatment administration record and physician orders were reviewed, and it was confirmed that there were no documented wound treatments during this period. The facility's policy and procedures indicated that topical medications used in treatments should be recorded on the resident's treatment record, which was not followed in this case. Additionally, the resident's surgical wound notes indicated specific dressings to be used, but these were not documented in the treatment administration record as required by the facility's policy. The facility also failed to complete and accurately document the resident's weekly skin assessments for multiple months. The Director of Nursing and Medical Records Director reviewed the resident's weekly nursing skin assessment records and found that several weekly assessments were missing between January and March. The facility's policy required weekly skin assessments to identify any skin issues and document them accurately, which was not adhered to in this case. The lack of consistent and accurate documentation of the resident's skin assessments placed the resident at risk for worsening existing pressure ulcers and slow healing of a stage IV pressure injury.
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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