Hillcrest Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Petaluma, California.
- Location
- 450 Hayes Lane, Petaluma, California 94952
- CMS Provider Number
- 555127
- Inspections on file
- 26
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Hillcrest Post Acute during CMS and state inspections, most recent first.
The facility did not properly implement infection prevention and control measures, including failing to remove a face shield after a resident was cleared from COVID-19 isolation and not providing required PPE outside the rooms of several residents on Enhanced Barrier Precautions. Staff confirmed these lapses, which were not in line with CDC guidelines or facility policy.
Three outside dumpsters near the kitchen were found uncovered and overflowing with garbage, producing a foul odor and attracting flies. The DM confirmed the dumpsters should have been covered and that maintenance was responsible for keeping them closed, in accordance with facility policy.
A resident room was found with a privacy curtain and ceiling vent visibly soiled with thick, dripping substances. Both the curtain and vent were confirmed dirty by staff, and the facility lacked a policy for cleaning vents. These conditions were present in a room with four medically fragile residents.
A CNA was employed without a completed background check, as required by facility policy. Review of the employee file and confirmation from HR revealed that the necessary screening was not conducted before the CNA began work, despite procedures mandating background checks prior to employment.
A resident was incorrectly coded in the MDS as having an active diagnosis of viral hepatitis, despite not receiving any treatment or medication for the condition. The resident had a history of Chronic Viral Hepatitis C, but review of medical records and staff interviews confirmed the diagnosis was not active and should not have been reported as such.
A resident requiring maximal assistance for bathing due to hemiplegia did not receive a shower or bed bath for 16 days, despite being scheduled for twice-weekly showers. The resident was observed with poor hygiene and expressed dissatisfaction with grooming frequency. There was no documentation of care refusals, and the DON confirmed the missed care.
A resident with a left-hand contracture and dementia, requiring total care, did not have a physician-ordered hand roll applied during multiple observations. Staff confirmed the hand roll should have been in place, but it was not, and the facility could not provide a policy for following physician orders.
Two residents experienced medication errors when a nurse administered an incorrect dosage of Baclofen to a resident with chronic pain syndrome and gave Metformin without food to another resident with type 2 diabetes, resulting in a medication error rate of 6%, above the acceptable threshold. Facility policy required confirmation of orders and adherence to administration instructions, which was not followed in these cases.
A resident's naloxone nasal spray with an expired date was found stored in a medication cart. During observation and interview, an LVN confirmed the medication should have been discarded, and the DON stated that expired medications are to be discarded per facility policy.
The facility failed to submit a timely report of an alleged elder abuse investigation to the State Survey Agency. The incident occurred, and the report was due within five days. The Administrator acknowledged the delay, citing personal business as the reason for not sending the report. As of the latest review, the report was still unavailable.
A facility failed to report an abuse incident involving a resident with Parkinson's Disease and other conditions, who experienced rough handling by an unlicensed staff member during a brief change. The staff member did not follow the policy requiring two staff for Hoyer Lift use, and the resident's repeated requests to stop were ignored. The administrator did not report the incident to authorities, citing the resident's alleged aggression, and was unaware of the staff member's history of rights violations.
A resident with a pressure ulcer was not given pain medication before treatment, despite having a physician's order for PRN pain relief. The resident requested medication, but Licensed Staff A proceeded with the treatment without assessing pain, causing discomfort. Interviews revealed that staff were expected to manage pain prior to treatment, but this was not done.
The facility did not post complete daily staffing information, missing the census, total staff numbers, and clear staff identification. The Administrator acknowledged these omissions during an interview.
The facility failed to designate a qualified Infection Preventionist (IP) after the resignation of the previous IP. Licensed Staff H and I filled in without proper credentials, with Staff I working 15 shifts as IP before obtaining certification. The facility lacked documentation of IP training and failed to comply with infection prevention policies, potentially exposing residents to infections.
The facility failed to provide two residents with vegetarian or no meat food preferences a list of planned vegetarian menu items to choose from. Despite having a vegetarian menu plan, the facility only distributed a regular menu without vegetarian alternatives. Both residents expressed dissatisfaction with the lack of choice, and the Dietary Manager and Registered Dietician acknowledged the oversight.
A resident with Parkinson's Disease and Diabetes Mellitus underwent left eye surgery, but the facility failed to monitor for post-surgical complications as required. Despite the surgery being a change of condition, there was no documentation of monitoring for signs of infection or discomfort, as confirmed by staff interviews and record reviews.
Two residents in the facility did not receive their prescribed ophthalmic medications on time, leading to potential health risks. One resident, post-eye surgery, experienced a three-day delay in receiving an antibiotic due to insurance issues, and the medication was not administered at the scheduled times. Another resident with glaucoma also faced delays in receiving eye medications. The facility's policy on medication administration was not followed, and the DON was unaware of the delivery issues.
The facility failed to address alleged verbal abuse incidents involving two residents by unlicensed staff. The DSD did not report these incidents to the ADM, who was the abuse coordinator, nor did she notify law enforcement or the State Agency. The ADM was unaware of the incidents, which were not discussed in management meetings, violating the facility's QAPI plan.
A facility failed to develop a person-centered care plan for a resident after left eye surgery, despite the facility's policy requiring care plans for changes in condition. Interviews with the DON and staff confirmed the oversight, which could lead to negative outcomes due to lack of communication and coordination among caregivers.
Expired COVID-19 vaccines and Arginaid were found in the facility's Medication Storage room and Medication Cart 1, violating the Medication Storage Policy. An LPN acknowledged the risks of administering expired medications, which could lead to ineffective vaccination and inadequate wound healing support.
A resident was prescribed Keflex indefinitely for a misdiagnosed facial rash, without proper tracking by the Infection Preventionist. The DON did not question the order, and the facility's policies on antibiotic stewardship were not followed, leading to the resident being on unnecessary antibiotics for 41 days.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by improper handling and availability of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. In one instance, a face shield was found hanging inside a resident's room after the resident had been cleared from COVID-19 isolation, with no labeling or dating, and no sign indicating isolation precautions. Staff interviews confirmed that the face shield should have been removed once isolation was discontinued, and its presence could have led to cross-contamination. Review of facility policy indicated that transmission-based precautions and associated PPE should be clearly identified and removed when no longer necessary. Additionally, seven residents on Enhanced Barrier Precautions (EBP) did not have PPE, such as gowns and gloves, available immediately outside their rooms, despite signage indicating EBP status. Observations and interviews with the Infection Preventionist, DON, and Administrator confirmed the absence of required PPE outside these rooms, which was not in accordance with CDC guidelines and facility policy. Facility documents and policies reviewed stated that PPE and alcohol-based hand rub should be readily accessible to staff when EBP is in place.
Uncovered and Overflowing Dumpsters Attracting Pests
Penalty
Summary
Three of four outside dumpsters located near the kitchen were observed to be uncovered and overflowing with garbage, emitting a foul odor and attracting many flies. This was directly observed during a walkthrough with the Dietary Manager (DM), who confirmed that the dumpsters should have been covered. The DM stated that the maintenance department was responsible for ensuring the dumpsters were maintained and closed, and acknowledged that dumpsters needed to remain closed to prevent attracting pests that could lead to food contamination. A review of the facility's policy and procedure on food-related garbage and refuse disposal indicated that outside dumpsters provided by garbage pickup services were to be kept closed and free of surrounding litter.
Failure to Maintain Sanitary and Homelike Resident Room Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary and comfortable environment in one of the resident rooms. Specifically, Bed A's privacy curtain was visibly soiled with a thick black substance dripping down in numerous areas. Both the Maintenance Assistant and the Administrator confirmed the curtain was dirty and acknowledged it should have been changed. The facility's policy on cleaning and repairing cloth furnishings indicated that such items should be cleaned regularly and repaired promptly, but this was not followed in this instance. Additionally, the ceiling vent above Bed C in the same room had a visible accumulation of a thick brown dripping substance. The Maintenance Assistant confirmed the vent was dirty and needed cleaning, and the Administrator agreed after viewing the vent. The facility did not provide a policy or procedure for cleaning vents in resident rooms. These deficiencies were observed in a room housing four medically fragile residents, potentially exposing them to unsanitary conditions.
Failure to Complete Required Background Check Prior to CNA Employment
Penalty
Summary
The facility failed to ensure that one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. During an interview and review of employee records, it was found that the CNA's file was missing documentation of a completed background check. The Administrator confirmed with Human Resources that the background check had not been conducted, despite the facility's policy requiring all employees to complete background screening, reference checks, and criminal conviction investigations before beginning employment. The policy specified that these checks should be initiated within two days of an employment offer and completed prior to the start of work. This lapse was identified during a review of the employee file and confirmed by facility leadership.
Inaccurate MDS Coding of Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses listed an active diagnosis of viral hepatitis for a resident who had a history of Chronic Viral Hepatitis C but was not receiving any treatment or medication for this condition. Review of the resident's active orders confirmed there was no treatment in place for viral hepatitis. The MDS Coordinator acknowledged that the resident was admitted with a previous diagnosis but had not received any related treatment, and the Administrator confirmed that the diagnosis should not have been coded as active. According to the CMS LTCF RAI 3.0 User's Manual, only diagnoses with a direct relationship to the resident's current status or treatment should be coded as active.
Failure to Provide Scheduled Showers or Bed Baths
Penalty
Summary
A resident with hemiplegia following a cerebral infarction, resulting in loss of movement on the right side of the body, was admitted to the facility and required maximal assistance for showering and bathing, as documented in the Minimum Data Set (MDS). Despite being scheduled for showers twice weekly, records showed that the resident did not receive a shower or bed bath for a period of 16 days. There was no documentation indicating that the resident refused care during this time. During an observation, the resident was noted to have an accumulation of dirt under her fingernails and dry, flaky skin on her right hand. The resident reported only receiving a couple of bed baths in the past month and expressed dissatisfaction with the frequency of grooming, stating a desire to be groomed more often. The Director of Nursing confirmed the lack of documentation for refusals and acknowledged that the resident should have received four showers or bed baths during the 16-day period, as per the facility's schedule and policy.
Failure to Apply Prescribed Hand Roll for Resident with Contracture
Penalty
Summary
A resident with a diagnosis of left-hand contracture and dementia was admitted to the facility and required total assistance with all activities of daily living due to limited mobility and cognitive impairment. The resident's care plan and physician order specified the use of a hand roll in the left hand each morning, to be removed at night, as a preventative measure against worsening contracture. Multiple observations over two days revealed that the resident was seated in a Geri-chair with the left wrist bent downward and without a hand roll, brace, or splint in place as ordered. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Director of Rehabilitation, confirmed that the hand roll should have been applied according to the physician's order. The facility was unable to provide a policy or procedure for following physician orders. The failure to apply the prescribed hand roll as ordered constituted a deficiency in care for the resident with a left-hand contracture.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosage and Timing
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by two medication errors out of 30 observed opportunities, resulting in a 6 percent error rate. In the first instance, a licensed vocational nurse administered only 10 mg of Baclofen to a resident with chronic pain syndrome, despite a physician order for 15 mg three times daily. The nurse acknowledged the error, confirming that only one tablet was given instead of the required one and a half tablets, and the facility's policy required confirmation of medication orders prior to administration. In the second instance, another resident with type 2 diabetes was administered Metformin 500 mg without breakfast, contrary to the physician's order specifying administration with breakfast and dinner. The nurse confirmed that the medication was not given within the appropriate time frame relative to the meal, and the facility's policy required medications with specific administration instructions to be given according to manufacturer recommendations. The pharmacist also confirmed that Metformin should be administered with food to prevent gastrointestinal discomfort.
Expired Medication Not Discarded
Penalty
Summary
A deficiency occurred when a resident's naloxone nasal spray, which had an expiration date of July 2025, was found stored in a medication cart. During an observation and interview, a Licensed Vocational Nurse acknowledged that the naloxone should have been discarded. The Director of Nursing also confirmed in an interview that all expired medications should be discarded. The facility's policy and procedure on medication labeling and storage indicated that discontinued, outdated, or deteriorated medications or biologicals require the dispensing pharmacy to be contacted for instructions on returning or destroying these items. The failure to discard the expired naloxone was identified through observation, interview, and record review.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to provide a report of the results of their investigations to the State Survey Agency within 5 working days of an alleged elder abuse incident. The alleged incident occurred on 3/14/25, and the report was due within five days. During an interview on 3/17/25, the Administrator acknowledged that the 5-day report was in process and needed to be completed and sent to the department soon. However, by 3/24/25, the report was still not available, and the Department had to request a copy via email. The Administrator admitted to being busy with personal business and forgetting to send the report. As of 3/27/25, the report was still not available in the facility's records.
Failure to Report Abuse and Protect Resident Rights
Penalty
Summary
The facility failed to adhere to its Abuse Reporting Policy when the administrator did not report an incident of alleged abuse within the required 24-hour period to the state licensing agency and local authorities. This incident involved a resident, who was not informed that the unlicensed staff member involved would be suspended during the investigation. The resident, who has a history of Parkinson's Disease, Polymyalgia Rheumatica, and other conditions, reported that the unlicensed staff member was rough during a brief change, causing significant discomfort. The incident occurred when the unlicensed staff member attempted to use a Hoyer Lift without assistance, contrary to the facility's policy requiring two staff members for such procedures. The resident repeatedly asked the staff member to stop pushing on her back due to pain, but the staff member did not comply. The resident eventually pushed the staff member's arm away, leading to an altercation. The resident expressed feeling unsafe and not wanting the staff member to care for her again, citing previous instances of rudeness and neglect. The facility's investigation into the incident was inadequate, as the administrator was unaware of the staff member's history of resident rights violations and did not conduct a thorough investigation. The administrator also failed to report the incident to the appropriate authorities, believing it was unnecessary since the resident allegedly hit the staff member. This oversight resulted in a lack of protection for the resident's rights and a delay in addressing the resident's concerns and pain management needs.
Failure to Administer Pain Medication Before Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 47, who was undergoing treatment for a pressure ulcer. Despite having a physician's order for pain medications, including Acetaminophen and Oxycodone, to be administered as needed for varying levels of pain, the resident was not given pain medication prior to the pressure ulcer treatment. During an observation, Resident 47 requested pain medication from Licensed Staff A before the treatment began, but was informed that it was not due until later. Licensed Staff A proceeded with the treatment without assessing the resident's pain level or administering the medication, resulting in the resident experiencing pain and discomfort during the procedure. Interviews with staff, including Licensed Staff A and the Director of Nursing (DON), revealed that there was an expectation for nurses to assess and manage pain prior to wound treatment. Licensed Staff A admitted to not administering pain medication before the treatment, despite acknowledging that pain could worsen during such procedures. The DON confirmed that pain management should be prioritized and that the resident had orders for PRN pain medications. The facility's policy on pain assessment and management emphasized the importance of appropriate pain assessment and treatment, which was not adhered to in this instance.
Deficiency in Daily Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted daily staffing schedule included all required information. Specifically, the schedule lacked the census, which is the number of residents in the facility, and the total numbers of licensed and unlicensed staff. Additionally, the schedule did not reflect staff absences due to call-outs and illness, nor did it clearly identify staff names in a readable format, as it only included first names without last names or initials. This deficiency was identified during an observation and interview with the Administrator, who acknowledged the absence of the required information and the issue with staff name identification.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a fully credentialed Infection Preventionist (IP) responsible for the infection prevention and control program. The Director of Nursing (DON) was unable to identify a current IP after the resignation of the previous IP, Licensed Staff H, on December 29, 2023. Since then, both Licensed Staff H and Licensed Staff I have been filling in, but neither was consistently signed in as the IP on staffing sheets. Licensed Staff H had limited workdays and was not signed in as the IP on any of those days. Licensed Staff I worked as the IP for 15 shifts without the necessary certification until March 1, 2024, which was 2.5 months after Licensed Staff H's resignation. The facility's policies and procedures require that the IP and DON receive ongoing training on the facility's antibiotic stewardship program and infection prevention and control responsibilities. However, there was no evidence of a policy for the IP role, and the facility failed to provide documentation of the IP's primary professional training and specialized training in infection prevention and control. The facility's governing board is responsible for oversight of facility care and services, including infection prevention and control, but there was no evidence of compliance with these responsibilities. The facility's failure to maintain a qualified IP and adhere to infection prevention and control policies potentially exposed residents to infections and unnecessary medications. The facility's assessment and administrative management policies emphasize the importance of aligning resources with resident needs, but the lack of a qualified IP indicates a misalignment in infection control resources. The DON's job description includes ensuring compliance with infection prevention procedures, but the absence of a designated IP suggests a gap in fulfilling this responsibility.
Failure to Provide Vegetarian Menu Options
Penalty
Summary
The facility failed to provide residents with vegetarian or no meat food preferences a list of planned vegetarian menu items to choose from, affecting two residents. Resident 19, a vegetarian, reported that the meals were repetitive and lacked variety, and she was not provided with a list of vegetarian menu options. Her diet order indicated a vegetarian meal plan, but she received the same menu as other residents without vegetarian alternatives. Similarly, Resident 158, who only eats fish and vegetables, did not receive a menu with vegetarian options, expressing a desire for more choice in her meals. The facility had two separate weekly menus, one with vegetarian options and one without, but only the latter was distributed to residents. The Dietary Manager acknowledged having a vegetarian menu plan but stopped providing it to residents. The Registered Dietician confirmed that the menus were reviewed monthly and agreed that the vegetarian options should have been included to offer residents a choice. The facility's policy stated that individual food preferences should be identified and incorporated into meal plans, but this was not followed, leading to the deficiency.
Failure to Monitor Post-Surgical Complications
Penalty
Summary
The facility failed to assess and monitor for signs of complications following a surgical procedure for one resident. Resident 20, who had a history of Parkinson's Disease and Diabetes Mellitus, underwent left eye surgery for the removal and retention of silicone oil used in retinal detachment repair. Despite the surgery being considered a change of condition, there was no documentation indicating that the resident was assessed or monitored for signs of complications such as eye infection or discomfort. Interviews with facility staff revealed that the expected protocol was to monitor the resident for complications every shift for 72 hours post-surgery and document these observations. However, a review of the nurses' progress notes from the period following the surgery showed no evidence of such monitoring or documentation. This lack of action and documentation was confirmed by both Licensed Staff D and the Director of Nursing, indicating a failure to adhere to the facility's policy on monitoring acute condition changes.
Failure to Administer Ophthalmic Medications Timely
Penalty
Summary
The facility failed to administer ophthalmic medications according to the doctor's orders for two residents, leading to potential health risks. Resident 20, who had undergone left eye surgery, did not receive the prescribed Ofloxacin Ophthalmic Solution 0.3% for three days after the order was placed. The medication was delayed due to issues with the resident's medical insurance, and the facility did not notify the physician about the delay. Additionally, the medication was not administered at the scheduled times, with significant delays noted in the administration record. Resident 41, diagnosed with glaucoma, also experienced delays in receiving his prescribed eye medications. The medications were consistently administered hours after the scheduled times, which could potentially affect the resident's eye health. Interviews with the residents and staff revealed that the facility's policy allowed for a one-hour window before and after the scheduled time for medication administration, but this policy was not adhered to in these cases. The Director of Nursing was unaware of the medication delivery issues and stated that antibiotics should be administered within four hours of being ordered. The facility's policy on medication administration was not followed, as evidenced by the delayed administration and lack of documentation for the reasons behind the delays. These deficiencies highlight a failure in the facility's pharmaceutical services to meet the needs of the residents, potentially compromising their health and well-being.
Failure to Report and Address Alleged Verbal Abuse Incidents
Penalty
Summary
The facility failed to ensure that two residents, Resident 9 and Resident 19, received appropriate action and feedback regarding incidents of alleged verbal abuse by unlicensed staff. The Director of Staff Development (DSD) did not report an incident involving Resident 9, where an Ombudsman reported that Unlicensed Staff L was verbally abusive and mocking the resident. The DSD filled out an employee warning form but did not inform the Administrator (ADM), who was the abuse coordinator, nor did she notify law enforcement or the State Agency as required. In another incident, Resident 19 attempted to report verbal abuse by Unlicensed Staff M and N to the DSD. The resident stated that the staff scolded her, causing distress, and although she informed the DSD, she did not receive any follow-up. The DSD acknowledged that Resident 19 wanted to speak to her but admitted she did not return to the resident's room or inform the ADM or other management about the complaint. The ADM, who was responsible for investigating abuse allegations, was unaware of both incidents involving Residents 9 and 19. The ADM stated that abuse allegations should be discussed in daily management meetings, but these incidents were not reported or discussed. The facility's QAPI plan requires systematic investigations and communication of such issues, but these processes were not followed, leading to a failure in addressing and resolving the residents' complaints effectively.
Failure to Implement Post-Surgery Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident 20 following their left eye surgery. Resident 20, who was admitted with diagnoses including Parkinson's Disease and Diabetes Mellitus, underwent a procedure for the removal and retention of silicone oil used in retinal detachment repair. Despite the change in condition due to the surgery, no care plan was initiated to address the specific care needs post-surgery. Interviews with the Director of Nursing (DON) and Licensed Staff D revealed that the facility's policy required nurses to initiate a care plan when a resident experiences a change in condition. The DON confirmed that the Interdisciplinary Team, including herself, was responsible for reviewing and ensuring the care plan was in place. However, upon reviewing Resident 20's electronic record, it was found that no such care plan was developed. This lack of communication and coordination among caregivers could potentially lead to negative outcomes for the resident.
Expired Medications Found in Storage and Cart
Penalty
Summary
The facility failed to adhere to its Medication Storage Policy, resulting in the presence of expired medications in the Medication Storage room and Medication Cart 1. Specifically, three expired COVID-19 vaccines and two boxes of expired Arginaid, a wound healing nutrition supplement, were found. These expired items were discovered during observations conducted by surveyors. The expired COVID-19 vaccines were located in the medication refrigerator, while the expired Arginaid was found both in the Medication Storage room and on Medication Cart 1. Licensed Staff C, when interviewed, acknowledged the potential risks associated with administering expired medications. She indicated that an expired COVID-19 vaccine might not effectively vaccinate a resident due to the deterioration of the medication. Similarly, she expressed concerns that expired Arginaid would not support wound healing, potentially leading to worsening of the wound. The facility's policy, dated 2007, mandates the immediate removal and proper disposal of outdated, contaminated, or deteriorated medications, which was not followed in this instance.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Clinician Roles Policy when a resident was prescribed Keflex, an antibiotic, indefinitely without proper tracking and surveillance by the Infection Preventionist. The resident was started on Keflex 500 mg twice daily for a supposed facial rash, which was not documented or observed during the survey. The resident, who had a BIMS score of 12 out of 15, was unaware of the reason for the antibiotic prescription. The Director of Nursing (DON) did not question the indefinite order, citing the doctor's authority, and was unsure of the facility's Antibiotic Stewardship Policy regarding start and stop dates. The medical records revealed that the resident's care plan and nurses' notes consistently mentioned the antibiotic was for a facial rash, despite no physical assessment or documentation supporting this diagnosis. The DON later discovered that the diagnosis of a facial rash was incorrect and that the antibiotic was actually prescribed for osteomyelitis of the left hip. This miscommunication and lack of proper documentation and oversight led to the resident being on an unnecessary antibiotic regimen for 41 days. The facility's policies and procedures, including the Antibiotic Stewardship Program, require staff to be trained on appropriate prescribing, monitoring, and surveillance of antibiotic use. However, the DON admitted to not being aware of the national standards the facility follows and had been filling in for the Infection Preventionist since their departure in December 2023. This lack of adherence to established protocols and insufficient oversight contributed to the deficiency in antibiotic stewardship at the facility.
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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