High Valley Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunland, California.
- Location
- 7912 Topley Lane, Sunland, California 91040
- CMS Provider Number
- 055856
- Inspections on file
- 28
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at High Valley Lodge during CMS and state inspections, most recent first.
A resident with intact cognition and multiple chronic conditions reported an incident with an LVN via email to the DON, stating the nurse’s response was unacceptable and later reporting that no one had followed up or explained any investigation. Although the DON acknowledged receiving the grievance and verbally informing the SSD, review of the grievance binder showed the complaint was never filed, the required grievance form was not completed, and no investigation was initiated within the 24-hour timeframe required by the facility’s grievance policy, which guarantees residents the right to voice grievances without discrimination or reprisal.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Four large containers of canned fruit in the kitchen refrigerator were found with only a preparation date and no use-by date, exceeding the recommended three-day consumption period. The Dietary Supervisor confirmed the containers were not labeled or discarded according to facility policy, which requires both an open date and a use-by date for refrigerated food items.
A resident with multiple diagnoses, including dementia and diabetes, was incorrectly assessed on the MDS as having no oral or dental issues, despite lacking natural teeth and reporting difficulty chewing. The MDS nurse confirmed the assessment was inaccurate and did not reflect the resident's true oral/dental status, resulting in incorrect data being sent to CMS.
A resident with diagnoses of depression, dementia, and diabetes had an active depression diagnosis documented in their MDS and was dependent on staff for ADLs, but the facility failed to include depression in the resident's care plan. Staff interviews and record reviews confirmed that no individualized goals or interventions for depression were developed or implemented, contrary to facility policy.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines for care delivery.
A nurse failed to flush a resident's gastrostomy tube with the physician-ordered amount of water before and after medication administration, instead using a lesser volume than prescribed. The resident, who had severe cognitive impairment and was dependent on staff for care, was at risk due to this deviation from the care plan and physician orders. The DON confirmed that the nurse should have followed the physician's order rather than the facility's default policy.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify or adapt meals to accommodate specific dietary requirements or physical limitations.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
A resident with chronic medical conditions was found to have opened, unlabeled perishable food items at their bedside that were not refrigerated as required by facility policy. Staff interviews confirmed that the items should have been labeled and stored in the refrigerator, but this was not done, resulting in a failure to follow established procedures for food safety.
The facility's Infection Preventionist did not complete the required ten hours of annual continuing education in infection prevention and control, as confirmed by interviews and lack of documentation. The DON stated that this training is necessary for the IP to effectively educate staff and stay current with infection control practices.
A CNA assisted a resident with severe cognitive and physical impairments by feeding them while the resident was reclined in a Geri chair and not at eye-level, contrary to facility policy and best practices for dignity and aspiration prevention. Both an LVN and the DON confirmed that the resident should have been positioned more upright and that feeding should occur at eye-level to maintain dignity and safety.
A deficiency was identified when 24 resident rooms were found to be below the required 80 sq. ft. per resident, with most two-bed rooms measuring about 149.38 sq. ft. and a four-bed room at 282.87 sq. ft. Despite the space shortfall, no adverse effects on resident care, privacy, or safety were observed during the survey, and the facility acknowledged the deficiency through a waiver request.
A facility failed to follow protocols for administering medications via G-tube for two residents. One resident did not receive the required water flush between medications, risking drug interactions. Another resident's G-tube placement was not verified before medication administration, risking leakage and infection. These actions violated facility policy and posed health risks.
The facility failed to act on pharmacist recommendations for two residents, including adding vitamin B12 and discontinuing docusate sodium. Additionally, a physician disagreed with a recommendation to discontinue vitamin B without providing a rationale. These actions did not comply with the facility's policy, potentially placing residents at risk.
The facility failed to ensure proper medication management, including leaving medications unattended and not labeling an open vial of Lidocaine. A nurse left medications on a cart unattended, and another left prepared medications at a resident's bedside multiple times. The resident had severely impaired cognition and was dependent on staff for assistance. The facility's policies require medications to be attended and properly labeled.
The facility failed to properly label and store food, risking foodborne illnesses. Unlabeled French toast and moldy food were found in refrigerators, lacking preparation dates and resident identifiers. The Dietary Supervisor and DON confirmed the importance of labeling to prevent spoilage, as per facility policy.
The facility failed to maintain proper infection control practices by not labeling residents' urinals and improperly storing them, as well as by allowing staff food to be stored with residents' food in the kitchen refrigerator. These actions were acknowledged by staff and administration as contrary to facility policies, posing potential infection risks.
The facility failed to ensure call lights were within reach for two residents, potentially delaying assistance. One resident with severe cognitive impairment and another with multiple health issues were found without accessible call lights, despite care plans and facility policy requiring them to be within reach for safety.
A resident with cognitive impairments verbally abused another resident in the dining room, calling them an offensive name. The incident was reported to the Social Service Director, and the Activity Director witnessed the event, attempting to redirect the behavior. Despite the facility's abuse prevention policy, the measures were insufficient to prevent this occurrence.
A facility failed to report an allegation of verbal abuse involving two residents to the State Survey Agency (SSA). A resident with cognitive impairments used offensive language towards another resident, who reported the incident to the Social Service Director (SSD). The SSD informed the Administrator, but the Administrator did not report the incident to the SSA as required by the facility's policy. This resulted in a delay of an onsite inspection and potential risk to other residents.
The facility failed to update care plans for two residents, one with hypertension, diabetes, and dementia, and another with encephalopathy and hemiplegia. The care plans were not revised quarterly as required, potentially impacting the delivery of necessary care and services.
The facility did not implement a bowel and bladder retraining program for two residents identified as candidates. One resident, with conditions like arthritis and diabetes, was not started on the program despite an assessment indicating suitability. Another resident, with hypertension and depression, was also not offered the program due to non-ambulatory status, although the assessment suggested it was needed. The facility's policy to restore normal bowel and bladder function was not followed.
A resident with severe cognitive impairment and total immobility was observed with all four bed rails up, contrary to an evaluation recommending against their use. The MDS Nurse confirmed the inappropriate use and noted it was the charge nurses' responsibility to monitor this. Despite the facility's policy on bedrail management, the resident's condition and evaluation were not adequately considered.
A facility failed to accurately document the administration of Ambien for a resident, leading to discrepancies between the Controlled Drug Record and the MAR. The LVN documented the administration time incorrectly, which was acknowledged during an interview. The facility's policy required immediate and accurate documentation of controlled substances, which was not adhered to in this case.
A resident experienced a delay in laboratory services when a urine specimen ordered for urinalysis and culture was not picked up promptly. The specimen, ordered due to a change in condition indicating a burning sensation upon urination, was still awaiting collection the following day. The Infection Preventionist noted a lack of communication with the lab, which contributed to the delay, contrary to the facility's policy on timely lab services.
An LVN at the facility was found to have willfully falsified the medication administration record for a resident by documenting incorrect administration times for Ativan. The resident, with a history of anxiety disorder, was supposed to receive the medication at a specific time, but the LVN administered it later and recorded false times in the MAR and Controlled Drug Record. The facility's policy mandates accurate documentation of medication administration, which was not followed in this case.
A facility failed to ensure hospice staff attended IDT meetings for a resident with dementia, hypertension, and diabetes, leading to potential delays in hospice care coordination. The resident's MDS indicated impaired cognitive skills and dependence on staff for daily activities. The DON cited communication breakdown as the reason for the absence, despite a contract requiring hospice nurse attendance.
The facility failed to meet the federal requirement of 80 square feet per resident in 23 out of 24 rooms, with rooms only having about 149.38 square feet for two residents. Despite this, residents could move freely, and staff provided care without issues. A waiver was submitted, indicating no adverse effects on residents' health or safety.
Failure to Initiate and Investigate Resident Grievance per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and promptly investigate a resident’s complaint. Resident 1, who had intact cognition and required varying levels of staff assistance for activities of daily living, was admitted with diagnoses including diabetes mellitus with diabetic nephropathy, chronic kidney disease, and an anxiety disorder. On the morning of 3/4/2026, an incident occurred between Resident 1 and Licensed Vocational Nurse 1 (LVN 1) at approximately 6:30 a.m. Later that morning, at 8:36 a.m., Resident 1 emailed the Director of Nursing (DON) describing the incident and expressing that LVN 1’s response was not acceptable and was wrong. By 3/6/2026, Resident 1 reported that no facility staff had asked about the incident, and no one had explained whether the incident had been investigated. Record review and staff interviews confirmed that the grievance was not processed or investigated in accordance with facility policy. The DON acknowledged receiving the resident’s email on the morning of 3/4/2026 and stated that the Social Services Director (SSD), who was responsible for filing grievances, had been verbally informed. However, review of the facility’s Grievances and Complaints binder showed that the grievance had not been filed and no investigation had been initiated. The Administrator confirmed that the grievance should have been entered into the grievance filing system and that an investigation should have been started. The SSD also confirmed that the required Complaint/Grievance form had not been used to initiate the grievance process and that no investigation had begun. This was inconsistent with the facility’s written policies, which state that residents have the right to voice grievances without discrimination or reprisal and that the Grievance Officer must conduct an initial investigation within 24 hours of receiving a grievance, using prescribed forms.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Improper Labeling and Storage of Prepared Canned Fruit
Penalty
Summary
The facility failed to ensure that plastic containers of canned fruit stored in the refrigerator were properly labeled and dated. During an observation in the kitchen with the Dietary Supervisor, four large plastic containers of canned fruit were found with only a preparation date and no use-by date. The Dietary Supervisor confirmed that the fruit should be consumed within three days of preparation to maintain quality and safety, but the containers exceeded this period and were not labeled with a use-by date as required. The facility's policy and procedures indicated that all food items in the refrigerator should be labeled with both an open date and a use-by date, which was not followed in this instance.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the oral and dental status of a resident. The resident, who had a history of schizophrenia, bipolar disorder, dementia, and diabetes mellitus, was assessed as not having any oral or dental issues on the MDS. However, during an observation and interview, the resident reported difficulty chewing food due to the absence of natural teeth. This discrepancy was confirmed during a review of the MDS with the MDS nurse, who acknowledged that the coding was inaccurate and did not represent the resident's actual oral and dental condition. The facility's policy required that resident assessments accurately reflect the resident's status and be certified by a registered nurse. Despite this, the MDS for the resident did not document the lack of natural teeth, resulting in incorrect data being transmitted to CMS. The MDS nurse stated that accurate coding is important for quality measures, care monitoring, outcome measurement, and care planning, and acknowledged that the inaccuracy could lead to unmet care needs and services for the resident.
Failure to Address Depression Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the depression diagnosis for one resident. Review of the resident's face sheet and Minimum Data Set (MDS) confirmed an active diagnosis of depression, along with dementia and diabetes mellitus. The MDS also indicated impaired cognition and total dependence on staff for activities of daily living. Despite these findings, the care plans reviewed from March through August did not address the resident's depression diagnosis, and there were no documented goals or interventions specific to depression. Interviews with the MDS nurse and the Director of Nursing confirmed that the omission of a care plan for depression was contrary to facility policy, which requires all active diagnoses to be addressed with individualized goals and interventions. Both staff members acknowledged that the lack of a care plan for depression meant the resident was not properly monitored or provided with necessary services related to their mental health needs. Review of the facility's policy further supported the requirement for comprehensive care plans to address each resident's medical, nursing, mental, and psychological needs.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Follow Physician Orders for GT Flushing
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow physician orders for gastrostomy tube (GT) care for a resident with severe cognitive impairment, diabetes mellitus, and dementia. During a medication pass, the LVN flushed the resident's GT with only 30 milliliters (mL) of water before and after administering medications, instead of the prescribed 50 mL. The LVN acknowledged the error, stating she was nervous and did not follow the physician's order, despite being responsible for verifying the correct amount prior to administration. The resident's care plan required nurses to provide fluids via GT as ordered to maintain adequate nutritional intake and prevent dehydration. The Director of Nursing confirmed the importance of adhering to physician orders, noting that the facility policy specified 30 mL but the nurse was required to follow the current physician order of 50 mL. The facility's job description for medication nurses also required treatments to be performed according to physician orders. This failure to follow prescribed GT flushing protocols was identified through observation, interview, and record review.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted as required to accommodate specific dietary requirements or physical limitations of residents, such as texture modifications or other individualized food preparations.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of food service practices, which revealed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Label and Refrigerate Perishable Food Brought by Visitors
Penalty
Summary
The facility failed to follow its policy and procedure regarding the labeling and storage of food items brought in by family or visitors for a resident. Specifically, an unlabeled, opened ketchup bottle and an unlabeled, opened jar of red raspberry preserves were observed at the bedside of a resident over several days. Both items were labeled by the manufacturer to be refrigerated after opening, but were instead left at room temperature in the resident's room. The resident reported that the items had been opened for several weeks and that staff had not offered to store them in the refrigerator. Interviews with a CNA and the Infection Preventionist Nurse confirmed that the food items should have been labeled with the resident's name, room number, and date received, and stored in the refrigerator as per facility policy. The staff acknowledged that improper storage of such items could lead to foodborne illness. Review of the facility's policy indicated that perishable foods must be stored in resealable containers with tightly fitting lids in the refrigerator and labeled appropriately, with nursing staff responsible for discarding perishable foods on or before the 'use by' date.
Infection Preventionist Did Not Complete Required Annual Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed the required ten hours of continuing education in infection prevention and control for the year 2024. During an interview, the IP was unable to provide documentation of having completed the necessary education hours for that year. The IP acknowledged that while he had completed continuing education hours for his nursing license renewal, those hours were not obtained in 2024 and did not specifically pertain to infection prevention and control. The IP also stated it was his responsibility to complete the annual education to stay current with new guidelines and practices. Further interviews with the Director of Nursing (DON) confirmed that the IP was responsible for educating staff on current infection prevention and control practices and that staying up to date with training was essential for this role. The DON stated that failure to complete the required annual training could result in the IP missing critical updates, which could affect the consistency of infection prevention measures. A review of the California Department of Public Health All Facilities Letter indicated that the IP should complete ten hours of continuing education in infection prevention and control annually.
Failure to Provide Dignified, Safe Feeding Assistance at Eye-Level
Penalty
Summary
A certified nursing assistant (CNA) was observed providing feeding assistance to a resident with severe cognitive impairment, hemiplegia, epilepsy, diabetes mellitus, and dysphagia. The resident was dependent on staff for eating and required a pureed, consistent carbohydrate, no added salt diet. During the lunch observation, the CNA was seated in front of the resident, who was in a Geri chair that was not in an upright position. The CNA and the resident were not at eye-level during feeding. The CNA stated the chair was reclined to prevent the resident from falling forward. A licensed vocational nurse (LVN) confirmed that the resident was lying back while eating and should have been positioned more upright to prevent aspiration. The director of nursing (DON) stated that residents should be positioned upright as much as tolerated to prevent aspiration and that CNAs should be at eye-level with residents during feeding to maintain dignity. Facility policies and the CNA job description require feeding to be provided with attention to safety, comfort, and dignity, including not standing over residents and treating them with respect at all times. The observed actions did not align with these requirements.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. A review of the facility's Client Accommodations Analysis form showed that 24 rooms did not meet the 80 sq. ft. per resident requirement, with most two-bed rooms measuring approximately 149.38 sq. ft. and a four-bed room measuring 282.87 sq. ft., both below the minimum required space. The facility had previously submitted a Room Waiver Request Letter acknowledging that these rooms did not meet the standard and outlining that accommodations would be made to ensure residents could move freely and have necessary furniture. Observations conducted during the survey period did not reveal any adverse effects on residents' care, privacy, health, or safety related to the reduced living space. The facility's policy indicated that rooms under 80 sq. ft. per resident would only be used when allowed under grandfathering provisions and would remain safe and functional. The administrator confirmed that the facility was aware of the space deficiency and maintained that residents' needs were being met despite the lack of compliance with the current room size requirements.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for a resident with a gastrostomy tube (G-tube), specifically regarding the flushing of the tube between medication administrations. Resident 6, who was admitted with severe cognitive impairment and required assistance with all activities of daily living, had specific orders to flush the G-tube with five to 10 milliliters of water between each medication. However, during an observation, a Licensed Vocational Nurse (LVN 1) was seen administering multiple medications through the G-tube without performing the required flushes. This oversight was acknowledged by the Director of Nursing (DON), who confirmed that the failure to flush could lead to medication interactions and affect the effectiveness of the medications. Additionally, the facility did not ensure proper verification of G-tube placement before administering medications to Resident 17, who had dysphagia, Type 2 Diabetes Mellitus, and dementia. During a medication administration observation, LVN 2 failed to check the placement of the G-tube by auscultating and aspirating stomach contents, as required by facility policy. This lapse was admitted by LVN 2, who recognized the risk of medication leakage into the abdominal cavity, potentially leading to infection and sepsis. The facility's policy on medication administration via enteral tubes, which mandates flushing between medications and verifying tube placement, was not followed in these instances. These deficiencies posed significant risks to the residents involved, potentially leading to drug interactions and serious health complications.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon the pharmacist's recommendations for two residents, leading to potential risks of unnecessary medication or adverse side effects. For one resident, the pharmacist recommended adding vitamin B12 to the medication regimen due to long-term use of metformin, which can decrease vitamin B12 absorption. However, there was no documentation indicating that the physician responded to or acted upon this recommendation. Additionally, the pharmacist suggested discontinuing docusate sodium for the same resident, as they were already receiving multiple other medications for constipation. Again, there was no evidence that the physician addressed this recommendation. Another deficiency involved a different resident, where the pharmacist recommended discontinuing vitamin B, as the resident was already receiving a multivitamin. The physician disagreed with this recommendation, but there was no documented rationale for the disagreement. This lack of documentation is contrary to the facility's policy, which requires that any disagreement with a pharmacist's recommendation be accompanied by an explanation. The facility's policy on Medication Regimen Review and Reporting mandates that recommendations from the pharmacist be documented and acted upon within a reasonable timeframe. The policy also requires that if a physician disagrees with a recommendation, they must provide a rationale for their decision. The failure to adhere to these policies resulted in the deficiencies noted in the report, potentially placing residents at risk of receiving unnecessary medications or experiencing adverse side effects.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications were not left unattended by licensed nurses, which could lead to serious side effects if accessed by unauthorized individuals. During an observation, a nurse left two medicine cups with medications on top of a medication cart unattended for two minutes while she went into an activity room. The facility's policy clearly states that medications should not be left on top of the cart and must be visible to the personnel administering them. Additionally, the facility did not label an open multi-dose vial of Lidocaine 1% with an open date, which could compromise the medication's therapeutic effectiveness. During an observation, a nurse confirmed that all opened multi-use vials should be dated for safety. The facility's policy requires that the date opened and the initials of the first person to use the vial be recorded on multidose vials. Furthermore, a nurse left prepared medications unattended at a resident's bedside multiple times. The resident had severely impaired cognition and was dependent on staff for assistance with all activities of daily living. The nurse left the medications out of eyesight while attending to other tasks, which could result in unauthorized access. The Director of Nursing confirmed that medications should never be left unattended at the bedside, as it could lead to negative outcomes for the resident.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, which could potentially lead to foodborne illnesses among residents. During an observation, a kitchen refrigerator was found to contain an unlabeled bag with prepared French toast, which should have been labeled with the date it was prepared. Additionally, a designated resident refrigerator in the staff break room contained a plastic bag with moldy, unidentifiable food that was labeled with a resident's name but not the date it was placed inside. Another unlabeled bag containing refried beans was also found, lacking both a resident identifier and the date it was placed inside the refrigerator. Interviews with the Dietary Supervisor and the Director of Nursing revealed that it is the responsibility of charge nurses or CNAs to label food items with the date they are stored or prepared, as well as with a resident identifier. The facility's policy requires that all food items in storage be labeled and dated, with leftovers covered, labeled, and dated. The failure to adhere to these procedures could result in residents consuming spoiled or expired food, potentially leading to foodborne illnesses.
Infection Control Deficiencies in Urinal Handling and Food Storage
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices concerning the handling and labeling of urinals for residents. In one instance, a resident's urinal was found hanging on a trash receptacle next to the resident's bed without a label. The Certified Nursing Assistant (CNA) acknowledged that the urinal belonged to the resident and admitted that it should have been stored in the restroom with the resident's name on it. The CNA also recognized the importance of labeling the urinal to prevent cross-contamination and ensure proper identification. In another case, a different resident's urinal was observed hanging on the side rail of the bed, also without a label and containing liquid. The CNA confirmed the urinal's ownership and stated that the contents should be discarded and the urinal stored properly with the resident's name. The facility's administrator reiterated that urinals should not be placed on trash receptacles and should be labeled to prevent infection risks. Additionally, the facility did not maintain proper separation of staff and residents' food in the kitchen refrigerator. A staff member's personal food was found stored alongside residents' food, which the Dietary Supervisor and Director of Nursing acknowledged was against facility practice. They emphasized the importance of keeping staff food separate to prevent potential cross-contamination and foodborne illnesses among residents. However, the facility lacked a specific policy addressing this issue.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, potentially delaying the provision of services and not meeting residents' needs. Resident 6, who was readmitted with conditions including gastrostomy, hypotension, and dysphagia, was observed with a call light not within reach. Despite having a care plan intervention to keep the call light accessible, it was found hanging off the side rail during an observation. A Certified Nursing Assistant (CNA) confirmed the call light should be within reach for safety. Similarly, Resident 25, with diagnoses including hypertension, chronic obstructive pulmonary disease, and osteoarthritis, was found without a call light within reach. The resident was heard yelling for help, and upon investigation, the call light was discovered on the floor behind the headboard. A CNA retrieved and placed it within reach, acknowledging the importance of accessibility for safety. The facility's policy, reviewed in April 2024, mandates that call lights be within easy reach when residents are in bed or confined to a chair.
Verbal Abuse Incident in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when one resident verbally abused another in the main dining room. On the specified date, a resident with intact cognitive skills and independence in activities of daily living was called an offensive name by another resident who has cognitive impairments due to dementia and Alzheimer's disease. The incident was reported by the verbally abused resident to the Social Service Director, who confirmed the occurrence of verbal abuse. The Activity Director witnessed the incident, noting that the resident with cognitive impairments was cursing and looking in the direction of the other resident. Although the Activity Director attempted to redirect the behavior, the facility's policy on abuse prevention and protection was not effectively implemented to prevent this incident. The facility's policy, last revised in March 2023, outlines procedures for the prevention, identification, investigation, and reporting of abuse, but these measures were not sufficient to prevent the verbal abuse from occurring.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically verbal abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an allegation of verbal abuse involving two residents to the State Survey Agency (SSA). Resident 36, who was cognitively intact and independent in activities of daily living, reported to the Social Service Director (SSD) that Resident 32, who had cognitive impairments and required assistance with daily activities, used offensive language towards them in the main dining room. The SSD acknowledged the incident as verbal abuse and informed the Administrator, who is the designated abuse coordinator. Despite being informed of the incident, the Administrator did not report the allegation to the SSA, as required by the facility's policy and procedures. The facility's policy, last revised in March 2023, mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. The failure to report the incident resulted in a delay of an onsite inspection by the SSA, potentially compromising the safety of other residents and leading to unidentified abuse.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and renew comprehensive person-centered care plans for two residents, Resident 18 and Resident 4, as required. Resident 18 was originally admitted with diagnoses including hypertension, type 2 diabetes mellitus, and dementia. The Minimum Data Set (MDS) for Resident 18 indicated impaired cognitive skills and dependence on staff for daily activities, with a care area assessment triggering a fall risk care plan. However, the care plan was last evaluated in February 2021 and not updated in May 2024, despite the Director of Nursing (DON) acknowledging the necessity of quarterly evaluations to ensure appropriate care and services. Similarly, Resident 4, who was readmitted with conditions such as encephalopathy and hemiplegia following a cerebral infarction, had a care plan for wandering that was not updated since December 2023. The DON confirmed that the care plan should have been updated in March 2024 and quarterly thereafter. The facility's policy mandates care plan updates at least quarterly or when there is a significant change in the resident's condition, a readmission, or unmet desired outcomes. The failure to update these care plans as per policy could result in inadequate care and services for the residents.
Failure to Implement Bowel and Bladder Retraining Program
Penalty
Summary
The facility failed to implement a bowel and bladder retraining program for two residents, Resident 47 and Resident 45, who were identified as candidates for such a program. Resident 47 was admitted with conditions including arthritis, hyperlipidemia, muscle wasting, and diabetes mellitus. Despite an assessment indicating that Resident 47 was suitable for bowel and bladder training, the facility did not initiate the program. The MDS Nurse confirmed that the training should have been started to prevent further loss of bowel and bladder function. Similarly, Resident 45, who was admitted with hypertension, depression, and constipation, was also identified as a candidate for bowel and bladder training. Although Resident 45 was not ambulatory, the MDS Nurse acknowledged that the training should have been offered based on the assessment results. The facility's policy emphasizes restoring normal bowel and bladder function, yet the training was not initiated or documented for Resident 45, contrary to the facility's procedures.
Inappropriate Use of Bed Rails for Immobile Resident
Penalty
Summary
The facility failed to ensure the appropriate use of bed rails for a resident, identified as Resident 6, who was observed with all four side rails up despite an evaluation indicating that side rails were not recommended. Resident 6 was readmitted to the facility with several diagnoses, including a degenerative disease of the nervous system, hypotension, and dysphagia, and was noted to have severely impaired cognition. The Minimum Data Set (MDS) assessment dated 6/26/2024 indicated that Resident 6 was dependent on staff for various activities of daily living and was totally immobile, leading to the recommendation against the use of side rails. On 8/11/2024, during an observation and interview, the MDS Nurse confirmed that Resident 6 should not have any side rails in place based on the evaluation. The MDS Nurse acknowledged that it was the responsibility of the charge nurses to monitor residents and ensure side rails were not used inappropriately. Despite this, the MDS Nurse expressed a belief that there would be no negative outcomes from having the side rails up, as Resident 6 was unable to be entrapped. The facility's policy on bedrails, reviewed on 4/17/2024, emphasized the need for adequate management to ensure residents' well-being, which was not adhered to in this instance.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to implement its policy on medication administration by not ensuring that the administration of Ambien for one resident was accurately documented on the Controlled Drug Record. The resident, who was originally admitted in 2017 and readmitted in 2019, had diagnoses including anxiety disorder, unspecified mood disorder, and hypertension. The resident's cognition was intact, and they were independent with toileting but required assistance with other personal care tasks. A physician's order indicated that Ambien was to be administered at bedtime for insomnia. On the date in question, the Licensed Vocational Nurse (LVN) documented administering Ambien at 8:58 p.m. on the Medication Administration Record (MAR), but the Controlled Drug Record indicated it was administered at 6:45 p.m. During an interview, the LVN acknowledged the discrepancy and stated that the administration time should match on both records. The Director of Nursing confirmed that controlled drug administration should be accurately reflected on both the Controlled Drug Record and the MAR. The facility's policy required immediate documentation of the administration details on the accountability record, which was not followed in this instance.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, identified as Resident 45, which placed the resident's well-being at risk. Resident 45 was admitted with diagnoses including encephalopathy, essential hypertension, and type 2 diabetes mellitus. On June 21, 2024, a change of condition was noted for Resident 45, indicating a burning sensation upon urination. Consequently, a physician ordered a urinalysis and culture with sensitivity testing. However, the urine specimen was not picked up promptly, as it was still awaiting collection on June 22, 2024, despite being ordered on June 21, 2024. During an interview and record review, the Infection Preventionist confirmed that the lab specimen should have been obtained and picked up on the same day the labs were ordered. The delay was attributed to a lack of communication with the laboratory regarding the readiness of the urine specimen for pick-up. The facility's policy on laboratory services, which emphasizes the timeliness and quality of lab services, was not adhered to, as there was no documented evidence of communication with the lab to ensure timely specimen collection.
Falsification of Medication Administration Record by LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 3) did not willfully falsify the medication administration record for a resident. On the specified date, LVN 3 was observed administering Ativan to Resident 19 at 6:45 p.m., which was later than the scheduled time of 5:00 p.m. However, LVN 3 documented in the Medication Administration Record (MAR) and the Controlled Drug Record that the medication was administered at 5:46 p.m. and 5:45 p.m., respectively. During an interview, LVN 3 admitted to falsely documenting the administration times, acknowledging that the medication was actually given at 6:45 p.m. Resident 19, who had been admitted to the facility with diagnoses including anxiety disorder and unspecified mood disorder, was supposed to receive Ativan twice daily as per the physician's order. The facility's policy requires that medication administration be documented immediately after the medication is given, reflecting the actual time of administration. The Administrator confirmed that LVN 3's actions were against the facility's policy, which prohibits willful material falsification of medical records. This incident resulted in the resident's clinical record inaccurately reflecting the care provided.
Absence of Hospice Staff at IDT Meetings
Penalty
Summary
The facility failed to ensure that hospice care staff was present for two Interdisciplinary Team (IDT) meetings for a resident receiving hospice care. The resident, who was originally admitted to the facility in March 2022 and readmitted in August 2023, had diagnoses including hypertension, Type 2 Diabetes Mellitus, and dementia. The resident's Minimum Data Set (MDS) assessment indicated impaired cognitive skills for daily decision-making and dependence on staff for various activities of daily living. Despite these needs, the hospice care provider representative was absent from IDT meetings held in February and May 2024. During an interview and record review, the Director of Nursing (DON) acknowledged the absence of the hospice nurse at the IDT meetings, attributing it to a breakdown in communication between the facility and the hospice care staff. The facility's contract with the hospice provider, dated February 2017, stipulated that a hospice nurse or RN Supervisor should attend care plan meetings. The lack of hospice staff presence at these meetings potentially resulted in a delay or lack of coordination in the delivery of hospice care and services to the resident.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 23 out of 24 resident rooms met the federal regulation requirement of 80 square feet per resident in multiple resident rooms. During the recertification survey conducted from August 9, 2024, to August 11, 2024, it was observed that the rooms did not meet the minimum square footage requirement. Specifically, rooms intended for two residents were required to have at least 160 square feet, but the rooms in question only had approximately 149.38 square feet each, with one room having 148.29 square feet. Despite this, observations and interviews indicated that residents were able to move freely within their rooms, and there was adequate space for the use of mobility aids such as wheelchairs and walkers. The facility had submitted an application for a Room Variance Waiver for these 23 rooms, acknowledging that they did not meet the required square footage. The waiver request indicated that the lack of space did not adversely affect the health, safety, or well-being of the residents. Residents interviewed during the survey did not express any concerns regarding the room sizes, and staff were able to provide care without issues related to space constraints. The facility maintained that the rooms were comfortable and that resident needs were being met despite the variance from the building code requirements.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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