Kindred Hospital Brea D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Brea, California.
- Location
- 875 N Brea Blvd, Brea, California 92821
- CMS Provider Number
- 555859
- Inspections on file
- 25
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Kindred Hospital Brea D/p Snf during CMS and state inspections, most recent first.
A resident was transferred to an acute care hospital and elected a seven-day bed hold under the facility’s SAU bed-hold policy. Hospital notes documented that the resident’s condition stabilized and improved, and hospital staff informed the facility that the resident was ready to return. However, based on a phone call in which a hospital discharge coordinator reportedly said the resident would not be returning "any time soon" and would remain hospitalized a few more days, the Administrator cancelled the bed hold before it expired, discharged the resident from the room, and reassigned the room to another resident without further clarification. The facility later stated that only a limited number of unit rooms were covered by the resident’s insurance and that the resident was placed on a waiting list for a covered room, while a contracts official confirmed the room could have been held longer if the resident was expected to return.
Two residents were transferred or discharged without receiving required written notices detailing reasons for the move, appeal rights, and bed-hold information. One resident with decision-making capacity was discharged to an assisted living facility; staff documented only a telephone notification to the representative, with no evidence that a written notice was provided or mailed. Another resident on the SAU was transferred to an acute care hospital with a bed-hold election documented, but the family member later reported not receiving the written transfer/discharge notice or its contents. Nursing and medical records staff each believed the other was responsible for mailing the notices, resulting in the residents’ representatives not obtaining the mandated written information.
A respiratory therapist failed to promptly assess and call for help for a resident with severe cognitive impairment who was found unresponsive and jaundiced with an alarming pulse oximeter. The RT spent several minutes troubleshooting equipment and performing suctioning without first checking vital signs or immediately activating emergency response, and did not document the interventions as required by facility policy.
A resident with impaired cognitive skills underwent bedside debridement procedures for scrotal and perineal/perianal wounds without the required physician orders and informed consents, and wound assessments were not completed or documented after the procedures, contrary to facility policy. Staff interviews confirmed the absence of necessary documentation and consents.
The facility did not ensure proper pressure ulcer care for three residents, including failing to notify the physician when a wound worsened and not setting LAL mattresses according to residents' weights. Staff did not document required notifications or adjust support surfaces as per policy, leading to deficiencies in wound management.
The facility failed to attempt least restrictive alternatives before using bed rails for several residents, as required by its policy. Observations and interviews revealed that residents were found with elevated side rails without documented evidence of alternative measures being tried first. Staff confirmed the use of side rails and acknowledged the lack of documentation for alternative measures.
The facility's kitchen was found to have multiple sanitation deficiencies, including a dirty ice machine, microwave, and kitchen hood. Kitchen utensils and equipment were in poor condition, with several items being dirty, discolored, or damaged. Expired sanitizer test strips and food items were also found, posing a risk of foodborne illnesses. These issues were acknowledged by the facility's staff during the survey.
The facility failed to complete entrapment assessments and document bed rail measurements for several residents, potentially leading to serious injury or death. Observations and interviews revealed that necessary assessments for Zones 5 and 6 were not documented, and responsibility for these assessments was unclear among staff. The facility's policies require such assessments, but they were not followed, indicating a systemic issue in safety protocol adherence.
The facility failed to ensure proper care for residents with gastrostomy tubes (GT), as two residents had unlabeled feeding bottles and irrigation equipment, and two other residents did not have their GT dressings changed daily as ordered. These deficiencies were confirmed by staff during observations and interviews.
A facility failed to document necessary measurements and develop a care plan for a resident's PICC line, as required by their policies. The lack of documentation and planning was confirmed through medical record reviews and staff interviews, highlighting a deficiency in maintaining intravenous access care.
The facility failed to provide appropriate respiratory care, as several residents' nasal cannulas and nebulizer equipment were not labeled or stored properly. Additionally, the facility did not follow maintenance guidelines for a BiPAP machine and lacked necessary signage for oxygen usage. These deficiencies were acknowledged by staff, indicating systemic issues in maintaining respiratory care protocols.
The facility did not follow the pureed recipe for steamed green beans for two residents on a pureed diet. The preparation deviated from the specified recipe, resulting in a runny consistency instead of the required smooth, pudding-like texture. RD 2 confirmed the recipe was not followed, which could alter the nutritional content of the meal.
The facility failed to ensure proper storage and labeling of medications, including missing temperature logs, improper disposal of an empty bottle, and medication residue on a cart. A resident's sodium chloride irrigation bottle was found opened and undated, which was confirmed by staff and acknowledged by the DON.
A resident with neuromuscular dysfunction of the urinary bladder had an indwelling urinary catheter, which was not placed inside the dignity bag as required by the physician's order. During an observation, the catheter bag was found outside the dignity bag, compromising the resident's privacy. Staff interviews confirmed the oversight, highlighting a failure to adhere to protocols ensuring resident dignity.
The facility failed to properly store garbage in four of nine dumpsters, as observed during a survey. The facility's waste management policy requires dumpster lids to be closed, and the FDA Food Code mandates tight-fitting lids to prevent pest attraction. During an observation, four dumpsters had lids partially propped open by garbage, which the EVS Manager confirmed as an infection control issue.
A resident experienced verbal abuse from a CNA, who made derogatory comments about the resident's personal life and broke confidentiality. The incident was not reported in a timely manner, violating the facility's policies and procedures. The Director of Nursing was unaware of the incident until a complaint was filed, and there was no documentation or care plan addressing the altercation.
A resident developed a new skin discoloration on her wrist, but the facility failed to notify the physician, create a care plan, or monitor the condition. Despite the resident being on anticoagulant medication and the discoloration being reported by a CNA, there was no documentation or follow-up by the staff, indicating a failure to adhere to the facility's policy on managing changes in a resident's condition.
Failure to Follow Bed-Hold Policy Resulting in Loss of Resident’s Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its bed-hold policy and ensure an appropriate transfer/discharge process for a resident who was hospitalized. The facility’s policy for the Subacute Unit (SAU) required that at the time of transfer or discharge, the resident and representative receive written notice of the bed-hold policy, including the duration of the bed hold and readmission criteria, and that residents whose hospitalization exceeds the bed-hold period be allowed to return upon the first availability of a semi-private bed if they still require SAU services and are Medicaid-eligible. The policy also required that if a resident transferred with an expectation of return could not come back, the facility must provide written notice of transfer/discharge, including reasons for the move, effective date, new location, appeal rights, and contact information for the state LTC ombudsman and protection and advocacy agencies, and send a copy to the ombudsman. The resident was admitted to the facility and later transferred to an acute care hospital, with a Notice of Transfer/Discharge indicating the transfer was necessary for the resident’s welfare and that the resident’s needs could not be met in the facility. A SAU Form–Notice of Bedhold documented that the resident left for hospitalization and elected to hold the bed for a specified seven-day period. Hospital progress notes showed that within that period the resident’s condition stabilized and improved, and that the resident could begin planning to return to the facility and remained stable for return. The hospital case manager reported that hospital staff informed the facility that the resident was ready to return, but the facility stated there was no available bed on the unit where the resident had previously resided. The Administrator reported that, based on a telephone conversation with a hospital discharge coordinator indicating the resident would not be returning to the facility “any time soon” and would be in the hospital a few more days, he cancelled the resident’s bed hold, discharged the resident from the room, and reassigned the room to another resident before the end of the elected bed-hold period. The Administrator did not further clarify with hospital staff what was meant by the statement that the resident would not be returning “any time soon” and did not obtain a more specific anticipated return date. The Administrator also stated that only 14 rooms on the unit were covered by the resident’s insurance and that the resident was placed on a waiting list for a covered room. A Contracts Unit Chief later confirmed that the facility could have held the resident’s room for two weeks from the date of transfer if the resident was expected to return and acknowledged that the Administrator should not have cancelled the bed hold.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer/discharge, including appeal rights and bed-hold information, to residents or their representatives. Facility policy titled “Transfer Discharge Bed-Hold Procedure” required that the patient and, if known, the family member, surrogate, or legal representative be notified at least 30 days prior to transfer when applicable, and that the written notice include the reason for transfer/discharge, effective date, new location, appeal rights, and contact information for the state LTC ombudsman and protection and advocacy agencies. Surveyors found that for two of three sampled residents reviewed for transfer and discharge, these written requirements were not met. For one resident (Resident 39), the medical record showed admission in October 2025 and a physician’s order dated 11/11/25 for discharge to an assisted living facility. The H&P documented that this resident had capacity to understand choices and make health care decisions. Progress notes on 11/11/25 recorded that the resident was transferred to an assisted living facility. A Notice of Transfer/Discharge dated 11/11/25 identified the assisted living facility as the transfer location and stated that the resident’s health had improved sufficiently so that facility services were no longer required. The notice form contained language about the right to appeal an involuntary or inappropriate transfer/discharge and listed the DHCS Office of Administrative Hearings and Appeals, the state LTC ombudsman, and state agencies for developmentally disabled and mentally ill individuals, along with instructions to file an appeal within 10 calendar days. However, the section for the resident or representative signature indicated only that the notice was provided to the resident’s representative via telephone and did not contain a representative’s signature, and there was no documentation that a written copy of the notice was provided to the resident or representative. During interviews regarding Resident 39, RN 3 confirmed that the resident was discharged to assisted living on 11/11/25 and that the representative was informed of the transfer/discharge via telephone. RN 3 stated she was not aware whether the facility mailed written Notices of Transfer/Discharge when residents were transferred or discharged and could not verify that a written notice was provided to Resident 39’s representative. The Medical Records Director reported that she faxed the Notice of Transfer/Discharge to the ombudsman but did not mail written notices if the resident or representative was unable to sign at the time of transfer or discharge, and she verified that she did not mail a written notice to Resident 39’s representative. For another resident (Resident 42) on the Subacute Unit (SAU), the facility’s SAU Transfer, Discharge, Bed-hold Procedure required that at the time of transfer/discharge, the patient and family member or legal representative receive a written notice of the bed-hold policy specifying the duration of the bed hold and readmission criteria. The policy also required that if a patient transferred with an expectation of return could not return, the SAU must provide written notice of transfer/discharge and reasons, send a copy to the state LTC ombudsman, and include appeal rights and contact information for the appeal entity, ombudsman, and protection and advocacy agencies. Resident 42’s record contained a Notice of Transfer/Discharge dated 1/12/26 indicating transfer to an acute care hospital because the transfer or discharge was necessary for the resident’s welfare and the needs could not be met in the facility. An SAU Form–Notice of Bedhold dated the same day showed the resident left for hospitalization and elected to hold the bed for a specified period. Progress notes for Resident 42 documented that Family Member 2 was called on 1/12/26 to inform them of the transfer to the acute care hospital. The Notice of Transfer/Discharge for that date indicated on the resident/resident representative signature line that Family Member 2 was informed via telephone of the transfer. The content of the notice included the reason for transfer and information about the appeal process if the resident or representative believed the discharge was inappropriate or involuntary. However, in a telephone interview, Family Member 2 stated they did not receive a copy of the Notice of Transfer/Discharge and were not aware of its contents. RN 3 stated that the notice was given to medical records staff and that nursing staff did not mail notices. The Medical Records Director stated she did not mail a copy of the notice of transfer/discharge to Resident 42’s responsible party and believed nursing staff mailed such notices. As a result, the resident’s interested parties did not receive the complete written information related to the transfer/discharge process, including appeal rights and bed-hold policy, as required by facility policy and regulation.
Failure to Provide Immediate Assessment and Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to meet professional standards of care for a resident experiencing a change of condition. The respiratory therapist (RT) responded to an alarming pulse oximeter for a resident with severe cognitive impairment, who was found to be lethargic, unresponsive, and jaundiced. The RT attempted to troubleshoot the pulse oximeter, changed the sensor, and suctioned the resident without first checking the resident's pulse or lung sounds. Despite the resident's continued unresponsiveness and abnormal appearance, the RT did not immediately call for assistance, instead spending approximately five to eight minutes performing interventions before activating the emergency response. During this period, the RT did not document any of the actions or interventions provided to the resident, as required by facility policy and professional standards. The RT only checked the resident's pulse after other interventions failed to yield a response, at which point no pulse was detected and emergency assistance was finally summoned. The delay in calling for help and the lack of documentation were confirmed through interviews with the RT, the Director of Nursing (DON), and the RT Supervisor, all of whom stated that immediate assessment and rapid response are expected in such situations. Facility policy and professional standards, as well as statements from the DON and RT Supervisor, indicate that licensed staff are required to promptly assess residents for consciousness, breathing, and pulse, and to call for help within less than a minute if a resident is unresponsive or in distress. The RT's actions did not align with these expectations, and the absence of documentation further failed to meet the facility's requirements for recording care provided during a change of condition.
Failure to Obtain Physician Orders, Informed Consents, and Complete Wound Assessments for Debridement Procedures
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for one resident. Specifically, the facility did not obtain the required physician's orders and informed consents prior to performing bedside debridement procedures on the resident's scrotal and perineal/perianal wounds. Facility policy required a new and separate consent for each debridement session, and the procedure listed on the consent was to match the physician's order. However, review of the medical record showed that for two debridement procedures, there were no corresponding physician orders, and for one of the procedures, no informed consent was obtained or signed. Additionally, the consent obtained for one procedure did not match the procedure actually performed, as documented in the physician's operative report. Further, the facility failed to ensure that wound assessments were completed after the bedside debridement procedures. According to facility policy and staff interviews, wound assessments should be performed after each debridement, including documentation of wound measurements, drainage, and tissue type. Review of the resident's wound assessments revealed that after the debridement procedures, there was no documentation of wound measurements or assessments for the scrotal and perineal/perianal wounds. This lack of documentation occurred both immediately following the procedures and in subsequent weekly assessments. The resident involved had severely impaired cognitive skills for daily decision making and was admitted with significant wounds requiring ongoing care. Despite the complexity of the resident's condition and the need for careful monitoring, the facility did not follow its own policies regarding consent, physician orders, and wound assessment documentation. These failures were confirmed by interviews with the DON and LVN, who acknowledged that the required documentation and consents were missing from the medical record.
Failure to Provide Appropriate Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services related to pressure injuries for three residents reviewed for wound management. For one resident with a Stage 4 sacrococcyx pressure injury, the wound increased in size and necrotic tissue, but there was no documentation that the Wound Care Physician was informed of these changes. The wound assessments showed a progression from partial granulation and necrotic tissue to 100% necrotic tissue and an increase in wound size over several weeks. Interviews with nursing staff confirmed that the physician should have been notified and that this notification should have been documented, but this did not occur. For two other residents, the facility failed to ensure that the Low Air Loss (LAL) mattress settings were consistent with each resident's current weight. One resident, weighing 141 pounds, was observed with the LAL mattress set for a weight range of 165 to 250 pounds, which did not match the resident's actual weight. Another resident, weighing 119 pounds, was observed with the LAL mattress set at 300 pounds. Staff interviews confirmed that the mattress settings should correspond to the resident's weight and that incorrect settings could affect wound healing. The responsible nurses did not check or adjust the mattress settings during wound care. Facility policies required individualized care plans, regular wound assessments, and appropriate use of pressure-redistributing support surfaces. Documentation and staff interviews revealed that these policies were not consistently followed, as evidenced by the lack of physician notification for wound deterioration and improper mattress settings for residents at risk for or with existing pressure injuries.
Failure to Attempt Least Restrictive Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to ensure that the least restrictive alternatives were attempted before the use of side rails for several residents. This deficiency was identified through observations, interviews, medical record reviews, and policy and procedure reviews. The facility's policy on restraints and bed rails required that appropriate alternatives be attempted before installing bed rails, but this was not documented or evidenced in the medical records of the residents reviewed. For instance, Resident 12 was observed with elevated side rails, and their medical record did not show any documented evidence of attempts to use less restrictive alternatives before the side rails were applied. Similarly, Resident 25 was found with all four side rails elevated, and their medical record also lacked documentation of attempts to use less restrictive measures. Interviews with staff confirmed the use of side rails and the absence of documentation for alternative measures. Other residents, including those who lacked the capacity to make healthcare decisions, were also found with elevated side rails without documented evidence of attempts to use less restrictive alternatives. The facility's staff, including CNAs, LVNs, and RNs, verified the use of side rails and acknowledged the lack of documentation for alternative measures. The Director of Nursing was informed and acknowledged these findings, indicating a systemic issue in the facility's adherence to its policy on the use of restraints and bed rails.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations during a survey. The ice machine, which was used by both residents and staff, was found to have a thick, yellowish residue on its interior top portion, indicating it was not cleaned according to the facility's policy and manufacturer's specifications. This was acknowledged by the Operational Engineer, who stated the ice would not be used due to its dirty condition. Additionally, the microwave used for warming food was observed to be dirty, with dry, white food residue and stains inside. The Culinary Service Manager confirmed the microwave's condition and noted it was old and needed replacement. The kitchen hood over the stove was also found to have black, grease residue, which the Culinary Service Manager acknowledged as a fire hazard, despite the dietary staff's weekly cleaning schedule. The facility's kitchen utensils and equipment were in poor condition, with several items such as ladles, potato mashers, strainers, and spatulas found to be dirty, discolored, or damaged. The Culinary Service Manager verified these findings and agreed that the items needed to be discarded and replaced. Furthermore, the cutting boards were heavily marred and had deep grooves, making them difficult to clean and sanitize. Expired sanitizer test strips and expired food items were also found, which could lead to inaccurate testing and potential foodborne illnesses.
Incomplete Entrapment Assessments and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure complete entrapment assessments and proper documentation of bed rail measurements for several residents, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not complete entrapment assessments for Zones 5 and 6 for multiple residents, including those who were sampled and nonsampled. This lack of documentation and assessment was observed during facility tours and interviews with staff, where it was confirmed that the necessary measurements were not recorded. For instance, Resident 12 was observed with elevated side rails, yet the entrapment assessment for Zones 5 and 6 was incomplete. Similarly, Resident 25 had all four side rails elevated, but the documentation failed to show assessments for the same zones. Interviews with CNAs and LVNs confirmed the use of side rails for repositioning, but the necessary safety assessments were not documented. The report also notes that the responsibility for completing these assessments was unclear, with some staff indicating that the engineering or maintenance department was responsible, while others stated it was the nursing staff's duty. The report further details that the facility's policies and procedures require the assessment of bed dimensions and the risks and benefits of side rail use. However, these procedures were not followed, as evidenced by the lack of documented measurements for several residents. Interviews with the Director of Nursing (DON) and other staff members confirmed the findings, indicating a systemic issue in the facility's adherence to safety protocols regarding bed rail use and entrapment risk assessments.
Deficiencies in GT Care and Labeling
Penalty
Summary
The facility failed to provide proper care for residents with gastrostomy tubes (GT), as evidenced by the lack of labeling on feeding bottles, water irrigation bags, and irrigation sets for two residents. Resident 15 and Resident 24 had their GT feeding formula and irrigation equipment without labels indicating the name and date, which was confirmed by LVN 5 during observations. The facility's policy requires labeling with two identifiers, feeding rate, and hang date and time, which was not adhered to in these cases. Additionally, the facility did not change the GT dressings daily as ordered for Residents 17 and 32. Both residents lacked the capacity to make healthcare decisions, and their physician orders specified daily dressing changes to maintain site hygiene and monitor for infection. Observations revealed that the dressings were not changed as required, with LVN 5 admitting to missing the changes. RN 1 confirmed that the dressings should be changed daily for continuous assessment, and the DON acknowledged these findings.
Failure to Document and Plan PICC Line Care
Penalty
Summary
The facility failed to provide necessary care and services for maintaining the intravenous accesses for a resident, specifically regarding the use of a PICC line. The facility did not ensure that the external catheter length and arm circumference measurements were completed and documented in the medical record for the resident. Additionally, there was no care plan developed for the use of the PICC line. These omissions were identified through a review of the facility's policies and procedures, medical records, and interviews with staff members. The medical record review revealed that upon admission, there was no documentation of the PICC line measurements, which is required for monitoring potential complications. Interviews with the LVN and RN confirmed the lack of documentation and the absence of a care plan for the PICC line. The Director of Nursing was informed and verified these findings, indicating a lapse in the facility's adherence to its own policies and procedures regarding intravenous care management.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by multiple observations and interviews. For instance, the nasal cannulas for some residents were not labeled with the date they were changed, and there were no plastic bags for storage when not in use. This was observed in residents who required oxygen therapy, and the lack of proper labeling and storage was acknowledged by the staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Additionally, the facility did not ensure that nebulizer equipment was properly labeled and stored. In one case, a resident's nebulizer mask, tubing, and bag were not dated, and there was no plastic bag for storage. The LVN confirmed that these items should have been dated and stored correctly. Furthermore, the facility failed to follow the manufacturer's maintenance care instructions for a BiPAP machine used by a resident, as there was no specific order for cleaning and maintenance per the manufacturer's guidelines. The facility also neglected to provide necessary signage for oxygen usage in residents' rooms, which is crucial for hazard precautions. Several residents' oxygen tubing was found unlabeled, undated, and in some cases, touching the floor, which poses a risk of contamination. These deficiencies were verified by the LVN and acknowledged by the DON, indicating a systemic issue in maintaining proper respiratory care protocols within the facility.
Failure to Follow Pureed Recipe for Steamed Green Beans
Penalty
Summary
The facility failed to adhere to the pureed recipe for steamed green beans for two residents who were on a pureed diet. The facility's document titled Patient Diet List indicated that these residents received pureed food from the kitchen without restrictions to steamed green beans. The Menu Plan Fall Winter 2024 included steamed green beans for the PU4 pureed diet. However, during the preparation of the pureed steamed green beans, the recipe was not followed as required. The recipe specified blending the green beans with three tablespoons of food thickener per 10 servings to achieve a smooth, pudding-like texture. Instead, the preparation involved adding half quarts of vegetable juice and an incorrect amount of food thickener, resulting in a runny consistency. During an observation and interview, it was confirmed by RD 2 that the pureed steamed green beans did not hold a form and were runny, indicating the recipe was not followed. RD 2 acknowledged that the pureed recipe should have been adhered to and that the final product should hold a shape and not be runny. Additionally, RD 2 noted that not following the recipe and adding more food thickener could increase the calorie content of the diet, potentially affecting the nutritional balance intended for the residents on a pureed diet.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by several deficiencies. There were missing records for the temperature log of the Medication Room and Medication Refrigerator on specific dates, which was confirmed by RN 5 and the Director of Nursing (DON). Additionally, an empty bottle of Hy[DATE] was found in the Treatment Cart, which should have been disposed of, as verified by LVN 5 and the DON. Furthermore, Medication Cart 1 was observed to have medication residue spillage, which was acknowledged by LVN 4 and confirmed by the DON. Resident 22 was affected by the facility's failure to label medications with an opened date. A bottle of 1000 ml of 0.9% sodium chloride irrigation was found opened and undated on the resident's overhead table. LVN 1 confirmed that the bottle did not have an opened date and should have been either discarded after the first use or dated by the staff. The DON was informed and acknowledged these findings. These failures had the potential to negatively impact the residents' well-being.
Failure to Ensure Privacy for Resident with Catheter
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident 10, who was one of the twelve residents sampled in the survey. Resident 10 had a medical diagnosis of neuromuscular dysfunction of the urinary bladder and had an indwelling urinary catheter as per a physician's order dated 9/26/24. The order specified that the catheter drainage bag should be placed inside a dignity bag every shift to maintain the resident's privacy. However, during an observation on 11/20/24, it was noted that Resident 10's catheter drainage bag, containing 100 ml of urine, was not placed inside the dignity bag. Instead, the dignity bag was found on the left side of the bed, while the catheter bag was on the right side. Interviews conducted with the facility staff, including RRT 1, RN 2, and the DON, confirmed the oversight. RRT 1 acknowledged that the catheter bag should have been inside the dignity bag. RN 2 explained that the dignity bag is used to ensure the urine is not visible, thereby maintaining privacy. The DON reiterated that the facility provides dignity bags for all residents with indwelling urinary catheters and that failing to use them as intended violates the residents' privacy. This oversight in following the physician's order and facility protocol resulted in a deficiency concerning the resident's right to privacy and dignity.
Improper Garbage Storage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in four out of nine dumpsters, as observed during a survey. The facility's policy and procedure for waste management, revised in June 2022, requires that dumpster lids or doors be closed before leaving the area and that no trash be left alongside or on top of the dumpsters. Additionally, the 2022 FDA Food Code mandates that outside garbage receptacles have tight-fitting lids to prevent pest attraction. During an observation and interview with the EVS Manager, it was noted that the lids of four dumpsters were partially propped open by garbage, preventing them from fully closing. The EVS Manager confirmed these findings and acknowledged that the lids should be fully closed to prevent animal intrusion and address infection control concerns.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved CNA 1 yelling at Resident 1, making derogatory comments about the resident's personal life, and breaking confidentiality by discussing the resident's personal issues with other staff. The verbal exchange occurred after Resident 1 repeatedly pressed the call light, seeking to speak with a social worker about her discharge. CNA 1, frustrated by the repeated calls, made inappropriate comments to the resident, which were overheard by other staff members. The facility's investigation confirmed the verbal abuse, and it was noted that CNA 1 had a history of unprofessional behavior. The facility staff failed to report the incident in a timely manner, as required by the facility's policies and procedures (P&P). The Director of Nursing (DON) was not informed of the incident until Resident 1 filed a complaint. There was no documentation or care plan addressing the verbal altercation between Resident 1 and CNA 1. The lack of timely reporting and intervention by the staff potentially exposed the resident to psychosocial harm, as the facility's P&P mandates immediate reporting of any alleged abuse to the appropriate authorities.
Failure to Address Resident's Skin Discoloration
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident maintained their highest physical well-being. Resident 2, who was cognitively intact and capable of making healthcare decisions, developed a new skin discoloration on her right wrist. Despite the facility's policy requiring communication with healthcare providers upon recognition of a significant change in status, the staff did not notify the physician, create a care plan, or monitor the skin discoloration. The resident, who was on anticoagulant medication, noticed the discoloration two days prior but did not recall informing the staff. A CNA observed the discoloration and reported it to an LVN, but there was no documentation in the medical record regarding the incident. An RN confirmed that a new skin assessment was not completed, even though the discoloration was identified the previous day. The lack of documentation and follow-up on the resident's condition indicates a failure to adhere to the facility's policy on managing changes in a resident's medical condition.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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