Hillcrest Heights Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 4033 Sixth Avenue Ext, San Diego, California 92103
- CMS Provider Number
- 555630
- Inspections on file
- 46
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hillcrest Heights Healthcare Center during CMS and state inspections, most recent first.
A resident with vascular dementia and substance abuse history, identified as high risk for elopement, was able to leave the facility unnoticed through an unlocked and unalarmed front door. Staff responsible for monitoring the entrance were either not present or unaware of the resident's risk. After being found in the community and hospitalized, the resident was discharged back to the facility by taxi without supervision, and did not enter the building, remaining unattended until located by emergency services. The facility lacked procedures for ensuring safe transportation and adequate supervision for high-risk residents.
A resident with significant ADL needs and incontinence was discharged to a sober living facility that did not provide medical or physical assistance, despite staff and documentation indicating the resident required substantial support. The resident expressed concerns about the discharge, which were not addressed, resulting in an unsafe transfer, a 911 call, hospitalization, and readmission to the facility.
A resident with hemiplegia was discharged without an effective discharge plan, resulting in the resident feeling rushed, unheard, and unprepared. The Social Service Director scheduled the discharge and arranged transport without addressing the resident's concerns or creating a care plan, and staff were not properly informed of the discharge process.
Two residents were discharged without the development or implementation of required discharge care plans. One resident, admitted after surgery, and another with hemiplegia, both lacked documented discharge planning in their records. Staff interviews confirmed that care plans were not created as required by facility policy.
A resident with hypertension developed rashes and later reported a previous unwitnessed fall with a scalp wound. The LPN documented the rashes but did not notify the physician or monitor the skin changes, and failed to thoroughly assess or document the wound before hospital transfer. The fall incident was also not documented, resulting in delayed care and incomplete records.
A facility failed to ensure proper accountability and administration of medications. Controlled Drug Records did not match Medication Administration Records for several residents, leading to discrepancies in narcotic pain medication documentation. A resident did not receive Creon for 13 days due to an insurance issue, and another resident was given metformin without food, against prescriber's orders.
A resident with pancreatic insufficiency did not receive Creon for 13 days after re-admission to a facility, despite having physician orders. The medication was delivered but not administered, leading to symptoms like oily stool and abdominal pain. Facility records showed multiple entries of the medication being unavailable or incorrectly marked as given, and the resident's discomfort was documented.
The facility failed to honor the food preferences of five residents during a lunch service. A resident who dislikes fish was initially served it, another who prefers double portions received a single portion, and a vegetarian was served meat due to a shortage of veggie patties. Additionally, a resident who dislikes tomato soup was served it, and another who dislikes cranberries received a cranberry dessert. The facility's policy requires adherence to food preferences, which was not initially followed.
A facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their medical history. One resident's MARs incorrectly showed doses of Creon administered when the medication was unavailable, while another resident's Dialysis Communication Forms inaccurately documented a graft instead of a Perma-cath. Interviews revealed a lack of training and discrepancies in documentation, highlighting a failure to adhere to the facility's standards for accurate record-keeping.
A resident with dementia was inaccurately coded as a non-smoker on their annual MDS, despite being observed smoking and identified as a smoker in the facility's Smoking Safety Evaluation. The MDSN admitted the oversight, and the DON emphasized the importance of accurate MDS assessments for CMS reporting.
A resident with severe cognitive impairment was observed smoking without the required protective apron, despite facility protocols mandating its use for safety. The smoking monitor, aware of the risk, did not enforce the apron use after the resident expressed displeasure. Facility records and staff interviews confirmed the necessity of the apron to prevent potential accidents.
The facility failed to follow the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. White rice was served instead of brown rice, and two residents did not receive the required fortified additives in their meals until it was pointed out. The facility's policies for menu changes and meal fortification were not properly followed.
A resident who primarily speaks Spanish experienced miscommunication and anxiety due to the facility's failure to develop a comprehensive care plan addressing language barriers. The facility did not utilize available translation resources, leading to confusion during care. The DON acknowledged the oversight, as the resident's admission data indicated the need for a communication care plan, which was not created.
A resident reported $2,400 missing from his room after selling his truck, but the facility failed to conduct a thorough investigation. The Administrator admitted to not interviewing all relevant staff or documenting the investigation properly. The resident's grievance was not resolved in writing, violating the facility's policy on handling grievances.
A resident with a history of falls, dementia, and polyneuropathy experienced unwitnessed falls on two occasions. The facility failed to update the care plan with new interventions, despite the Interdisciplinary Team not determining a specific root cause. The Director of Nursing acknowledged the oversight, which placed the resident at risk for continued falls.
The facility did not inform residents or their representatives about updates to care plans and physician's orders after water tested positive for Legionella bacteria. Despite having care plans for monitoring signs of Legionnaires' disease, residents with chronic conditions were not notified, violating the facility's policy on resident rights.
Failure to Prevent Elopement and Ensure Safe Return of High-Risk Resident
Penalty
Summary
A facility failed to provide adequate supervision and ensure a safe environment for a resident assessed as high risk for elopement. The resident, who had vascular dementia and a history of psychoactive substance abuse, was identified on admission as ambulatory with exit-seeking behaviors and a desire to leave the facility. Despite being listed as high risk in the facility's elopement binder, the resident was able to leave the facility unnoticed through an unlocked and unalarmed front door, which was routinely left open during the day. Staff responsible for monitoring the entrance, including receptionists and nursing staff, were either not present or unaware of the resident's elopement risk at the time of the incident. The resident was later found in the community and required emergency department evaluation after testing positive for methamphetamine. Further deficiencies were observed in the facility's handling of the resident's return from the hospital. The facility did not confirm the type of transportation arranged for the resident, who was discharged by taxicab without supervision, despite the known elopement risk. Staff did not meet the resident upon arrival, and the resident did not enter the facility, remaining unattended in the community until located by emergency services. The facility lacked a policy or procedure for ensuring safe or supervised transportation for high-risk residents returning from the hospital, and staff interviews revealed a lack of clarity and responsibility regarding this process. Observations and interviews also revealed that the facility's front entrance was frequently left unlocked and unalarmed, with the expectation that the receptionist would monitor the entrance. However, the reception desk was sometimes left unattended, and staff acknowledged this presented a safety issue for residents at risk for elopement. Additionally, some staff were unaware of which residents were classified as high risk for elopement, and the resident in question was not wearing a wander guard bracelet prior to the incident. The facility's elopement policy did not address verification of safe or supervised transportation for returning residents at risk for elopement.
Failure to Ensure Safe and Coordinated Discharge for Dependent Resident
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge for a resident who required substantial assistance with activities of daily living (ADLs), including dressing, transferring, bathing, toileting, and was frequently incontinent of urine and bowel. Despite the resident's documented need for significant support and his own expressed concerns about the appropriateness of the discharge destination, facility staff informed him that he needed to leave due to insurance issues and being considered 'high functioning.' The resident was discharged to a sober living facility that did not provide any medical or physical assistance and required residents to be independent in all ADLs. Interviews with certified nursing assistants confirmed that the resident was always incontinent, never used the bathroom independently, and required help with showering, dressing, and transfers. The social services director acknowledged that the resident had voiced concerns about the lack of support at the sober living facility, but the case manager assured him that caregivers would be available, which was not accurate. Upon arrival at the sober living facility, staff there were surprised by the resident's care needs, as they had been informed he was independent and ambulatory. The facility representative stated they would not have accepted the resident had they known the extent of his needs. The resident was unable to receive necessary care at the sober living facility, leading to a 911 call and transfer to the hospital, after which he was readmitted to the skilled nursing facility. The facility's own policy required the care planning team to assess the availability and capability of caregivers at the discharge location and to address factors that could make the resident vulnerable to preventable readmission, which was not followed in this case.
Failure to Develop and Communicate Effective Discharge Plan
Penalty
Summary
The facility failed to develop an effective discharge plan that ensured a resident's discharge goals were identified and addressed. The resident, who had hemiplegia, was informed by the Social Service Director (SSD) only one day prior to discharge that he would be leaving the facility. Despite expressing concerns regarding finances and the need for a wheelchair, the resident felt that the SSD did not listen or address these issues. The resident was also unaware of his discharge destination and had to contact family members himself to inform them of the impending discharge. Staff interviews revealed a lack of communication and preparation for the discharge. The Certified Nursing Assistant (CNA) was not informed of the discharge by the licensed nurse, learning about it from another resident instead, and had to hurriedly gather the resident's belongings. The licensed nurse was also unaware of the discharge until reviewing the medical record, which showed that the SSD had scheduled the discharge and arranged transport without a care plan or physician's order. The SSD acknowledged that a discharge care plan should have been created and that the resident's preferences were not considered. The facility's policy requires advance preparation and a post-discharge plan, which was not followed in this case.
Failure to Develop and Implement Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement discharge care plans for two of three sampled residents. For the first resident, who was admitted following surgery, there was no evidence in the medical record that a discharge care plan was created prior to their discharge. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that a discharge care plan should have been completed at admission, but was not present for this resident. The second resident, admitted with hemiplegia, was observed on the day of discharge without knowledge of their discharge destination. A review of this resident's medical record also revealed the absence of a discharge care plan. The SSD confirmed that a discharge care plan was not developed for this resident, despite facility policy requiring a baseline care plan within 48 hours of admission and a comprehensive, person-centered care plan to be implemented for each resident.
Failure to Notify Physician and Document Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition and to monitor skin changes for a resident who developed rashes on the head and above the forehead. Documentation showed that a licensed nurse noted the rashes but did not provide evidence of physician notification or ongoing monitoring. Additionally, the same resident reported a previous unwitnessed fall and a wound on the scalp, but there was no detailed assessment or documentation of the wound's appearance or size prior to the resident's transfer to the hospital. The medical record also lacked documentation of the fall incident itself. An interview with the Assistant Director of Nursing confirmed that changes in condition, such as falls, rashes, or wounds, should be reported to physicians and thoroughly documented, including detailed wound observations. The facility's policy requires prompt physician notification and comprehensive documentation of observations prior to contacting the provider. The lack of documentation and physician notification resulted in delayed care and incomplete medical records for the resident.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications and the accurate and timely administration of resident medications. For four residents, the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR), leading to discrepancies in the documentation of narcotic pain medications. Specifically, doses of oxycodone and hydrocodone with acetaminophen were signed out but not documented as administered in the MAR, raising concerns about potential duplicate administration and lack of proof that residents received their medications. Additionally, the facility did not provide a resident with Creon, a medication for pancreatic insufficiency, for 13 days due to an insurance coverage issue. The resident was discharged from the hospital with a new prescription for Creon, but the facility failed to follow up with the pharmacy in a timely manner to resolve the insurance issue and obtain the medication. The resident did not receive the medication until the facility signed an authorization form to pay for the medication, resulting in a delay in the management of the resident's pancreatic insufficiency. Furthermore, a resident was administered metformin, a diabetes medication, without food, contrary to the prescriber's orders. The medication was given before lunch, which had not yet started, potentially leading to gastrointestinal side effects. The facility's policy requires medications to be administered in accordance with orders, including any specified time frames, but this was not adhered to in this instance.
Failure to Administer Creon Leads to Resident's Digestive Symptoms
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they did not administer Creon, a medication for pancreatic insufficiency, to a resident for 13 days. The resident had been discharged from the hospital with a new prescription for Creon to be taken with meals and snacks due to pancreatic insufficiency. Despite having physician orders for the medication, the resident did not receive it upon re-admission to the facility, leading to digestive symptoms such as oily stool, abdominal pain, and nausea. Interviews and record reviews revealed that the pharmacy delivered the medication to the facility, but it was not administered to the resident. The Consultant Pharmacist and other pharmacists confirmed the delivery and the importance of the medication for the resident's condition. The Director of Nursing and Medical Director were informed of the missed doses, and the facility's records showed multiple entries indicating the medication was not available or incorrectly marked as administered. The resident experienced significant discomfort and symptoms due to the lack of medication, including abdominal pain and oily stools. The facility's policies on medication administration and error handling were not followed, as the medication was not given in accordance with the physician's orders, and the physician was not promptly informed of the missed doses. The resident's medical records and care plans documented the missed doses and the subsequent notification to the medical staff, highlighting the facility's failure to administer the medication as prescribed.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of five residents during a lunch service, as observed on 1/8/25. Resident 1, who dislikes fish, was initially served fish before it was replaced with a hamburger patty. Resident 11, who prefers double portions of meat, fish, or eggs, was served a single portion of fish, which was later corrected. Resident 75, who dislikes tomato soup, was served it before it was removed. Resident 151, a vegetarian, was served a meat patty instead of a veggie patty due to a shortage, which was later rectified. Resident 49, who dislikes cranberries, was served a cranberry dessert, which was replaced with vanilla ice cream. Interviews with the residents revealed that some were losing weight and had specific dietary preferences that were not initially honored. The Food Nutrition Service Manager and the Registered Dietician both stated that resident food preferences should be respected, as it is a resident's right. The facility's policy mandates that food preferences be adhered to within reason, with initial screenings to be completed within seven days of admission. The failure to adhere to these preferences was identified during a lunch tray line observation and subsequent interviews with the residents and staff.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure accurate and concise medical records for two residents, leading to potential inaccuracies in their medical history and response to care. For Resident 30, the Medication Administration Records (MARs) incorrectly indicated that nine doses of Creon, a medication for pancreatic insufficiency, were administered between December 25, 2024, and January 9, 2025, when the medication was not available and had not been administered. Interviews with Resident 30 and the Director of Nursing (DON) confirmed that the first dose was given on January 7, 2025, contradicting the MAR entries. A physical count of the Creon capsules further verified the discrepancy, as the number of capsules remaining did not align with the documented administrations. For Resident 71, the facility's Dialysis Communication Forms inaccurately documented the presence of a graft instead of a Perma-cath, which is the actual dialysis access site for the resident. This error was found in five out of sixteen forms reviewed, spanning from December 3, 2024, to January 7, 2025. Interviews with the Director of Staff Development (DSD) and Licensed Nurses (LN) revealed a lack of in-service training regarding dialysis access sites, contributing to the documentation errors. The DON acknowledged the importance of accurate post-dialysis assessments to identify potential complications and confirmed the inaccuracies in the documentation. The facility's policies on charting and documentation emphasize the need for complete and accurate records to facilitate communication among the interdisciplinary team. However, the discrepancies in the MARs for Resident 30 and the Dialysis Communication Forms for Resident 71 highlight a failure to adhere to these standards, potentially leading to confusion and miscommunication regarding the residents' conditions and treatments.
Inaccurate MDS Coding of Resident's Smoking Status
Penalty
Summary
The facility failed to accurately assess and code a resident's smoking status on their annual Minimum Data Set (MDS), a clinical assessment tool required by the Centers for Medicare and Medicaid Services (CMS). The resident, who was admitted with a diagnosis of dementia, was observed smoking on multiple occasions, both with and without a protective smoking apron, under the supervision of a smoking monitor. Despite these observations and a facility Smoking Safety Evaluation identifying the resident as a smoker, the MDS inaccurately indicated that the resident was not a user of tobacco products. The Minimum Data Set Nurse (MDSN) acknowledged the error during an interview, stating that the resident's smoking status was missed during the assessment process. The Director of Nursing (DON) expressed an expectation for MDS assessments to be accurate to ensure CMS has a correct understanding of the resident's current health status. The inaccurate coding of the resident's smoking status on the MDS had the potential to misinform CMS about the resident's health condition.
Failure to Ensure Resident Safety During Smoking
Penalty
Summary
The facility failed to ensure the safety of Resident 50, who was identified as requiring a smoking apron while smoking, to prevent potential accidents. Resident 50, diagnosed with dementia and having severe impaired cognition, was observed smoking without the required protective apron on one occasion, despite being supervised by a smoking monitor. The smoking monitor admitted to not enforcing the use of the apron after Resident 50 expressed displeasure, even though the monitor was aware of the potential risk of the resident's clothing catching fire. The facility's records, including the Smoking Safety Evaluation and care plan, clearly indicated that Resident 50 was a smoker who required a smoking apron for safety. Interviews with the smoking monitor, a licensed nurse, and the Director of Nursing confirmed that the apron was a necessary safety measure. The facility's policy mandated that residents identified as needing assistance for smoking safety should not smoke unsupervised, and the apron was part of the required supervision. Despite these protocols, the failure to ensure Resident 50 wore the apron while smoking constituted a deficiency in resident safety measures.
Failure to Follow Menu and Provide Fortified Meals
Penalty
Summary
The facility failed to adhere to the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. During a lunch tray line observation, it was noted that white rice was served instead of the brown rice listed on the menu. The cook admitted to not closely reviewing the menu and preparing white rice without notifying the Registered Dietician, who confirmed that brown rice is more nutritious. The facility's policy requires that any menu changes be approved by the Registered Dietician or the Food Nutrition Service Director, which was not followed in this instance. Additionally, two residents did not receive the fortified meals as prescribed. Resident 32, diagnosed with moderate protein-calorie malnutrition, was served a meal without the required fortified additive, which was only added after being pointed out. Similarly, Resident 86, with a diagnosis of a displaced fracture, was served a meal lacking the fortified additive until it was noticed and corrected. The Food Nutrition Service Manager and Registered Dietician both emphasized the importance of fortified foods for residents experiencing weight loss, as they provide necessary additional calories. The facility's policy outlines the process for identifying residents needing fortification and the addition of calories or protein to their meals, which was not properly executed in these cases.
Failure to Develop Comprehensive Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who primarily communicates in Spanish, which had the potential to cause psychosocial harm. During an interview, the resident expressed difficulty in communicating with a CNA who did not understand Spanish, leading to confusion and anxiety during care. The facility's procedure for language barriers was not followed, as the language line or other translation resources were not utilized, resulting in miscommunication about the resident's needs. The Director of Nursing acknowledged that the resident's admission Minimum Data Set indicated a need for a communication care plan, which was not created. This oversight was attributed to a missed step in the care planning process. The facility's policy required care plan interventions to be based on a comprehensive assessment, but in this case, the necessary communication care plan was absent, impacting the quality of care provided to the resident.
Inadequate Investigation of Missing Money Grievance
Penalty
Summary
The facility failed to thoroughly investigate an allegation of missing money for a resident, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The resident, who had a cognitive score indicating intact cognition, reported that $2,400 was missing from his room after he had hidden it in a shoe. The resident had received the money from selling his truck and had asked the Social Service Director for assistance in opening a savings account, which was not provided. The resident reported the missing money to a charge nurse and filed a grievance with the Social Service Director, but there was limited documentation of the investigation. The facility's investigation into the missing money was inadequate. The Administrator admitted to not conducting a thorough investigation, as only two staff members were interviewed, and no written statements were taken. The facility did not contact the family friend who sold the truck to verify the transaction, and there was no documented evidence of a written resolution to the grievance. The Business Office Manager stated that residents were provided with instructions about safeguarding valuables, but the resident was not informed of this policy. Interviews with staff revealed inconsistencies in the handling of the grievance. The charge nurse who received the initial report did not document the incident, and the Manager of the Day was unsure if the incident was reportable. The Administrator acknowledged that the investigation could have been more thorough and that documentation should have been attached to the grievance. The facility's policy required a written response to grievances, which was not provided in this case.
Failure to Update Care Plan for Resident with Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was reviewed for falls, which resulted in a potential risk for further falls and injuries. The resident, who was admitted with diagnoses including repeated falls, dementia, and polyneuropathy, experienced unwitnessed falls on two separate occasions. Despite these incidents, the care plan was not updated with new interventions to prevent future falls. The Assistant Director of Nursing (ADON) acknowledged that the root cause of the falls was attributed to dementia, but no additional interventions were implemented beyond staff in-service training on falls. The Director of Nursing (DON) confirmed that the Interdisciplinary Team (IDT) did not determine a specific root cause for the falls and failed to update the care plan with patient-centered interventions. The facility's policy on falls, which requires continuous evaluation and reconsideration of interventions if falls persist, was not adhered to. This oversight placed the resident at risk for continued falls, as the care plan did not address new strategies to mitigate the risk of falling.
Failure to Inform Residents of Legionella Exposure
Penalty
Summary
The facility failed to notify residents and their representatives about updates to their care plans and physician's orders following exposure to Legionella bacteria. This deficiency was identified during an unannounced onsite visit, where it was discovered that the facility's water tested positive for Legionella bacteria. Despite this, the Assistant Director of Nursing (ADON) confirmed that residents and their families had not been informed of the exposure. The Director of Nursing (DON) also stated that residents did not need to be informed of physician's orders unless there was a change in their condition, although they should be involved in their care planning. Three residents were specifically mentioned in the report. Two of them were readmitted with chronic obstructive pulmonary disease, and one was admitted with chronic congestive heart failure. Physician's orders were obtained for all residents to be monitored for signs and symptoms of Legionnaires' disease, and care plans were developed accordingly. However, the residents and their representatives were not made aware of these updates, which is a violation of the facility's policy on resident rights, which mandates resident and family participation in care planning and notification of health conditions.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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