La Sierra Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merced, California.
- Location
- 2424 M Street, Merced, California 95340
- CMS Provider Number
- 055271
- Inspections on file
- 20
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at La Sierra Care Center during CMS and state inspections, most recent first.
Nursing staff did not complete required documentation or head-to-toe assessments for a resident repeatedly found on the floor, contrary to facility policy, and failed to notify the physician or update care plans. Additionally, two CNAs were observed working without visible ID badges, in violation of facility procedures for staff identification.
The facility did not assess dietary preferences for several residents within 48 hours of admission, leading to meals being served without considering their preferences. This delay was acknowledged by the RD and DM, who noted potential negative effects on residents' recovery and nutritional status.
The facility failed to provide palatable meals, with residents reporting cold, tasteless food. Observations showed food served at inadequate temperatures, and residents expressed dissatisfaction with meal quality. The Dietary Manager acknowledged temperature complaints, attributing them to slow tray distribution.
The facility failed to ensure proper food safety and hand hygiene practices. Meal service temperatures were documented before food was placed on the steam table, contrary to protocol. Additionally, a dietary staff member did not change gloves after touching clothing during food preparation, violating hygiene standards.
The facility did not comply with room size requirements, as 19 out of 23 rooms failed to meet the minimum square footage per resident. Despite this, staff and administration reported no complaints or concerns about room sizes, and waivers were mentioned for some rooms.
A long-term care facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received atenolol without a required blood pressure check, while another was given lisinopril and amlodipine without a pulse check. The errors were attributed to incomplete adherence to physician orders and MAR prompts.
The facility failed to ensure that three residents were free from significant medication errors. For two residents, the facility did not obtain all required vital signs before administering antihypertensive medications, as the electronic MAR did not prompt for all necessary checks. Another resident received medications despite vital signs being outside physician-ordered parameters. The DON emphasized the importance of following physician orders to ensure resident safety.
The facility failed to ensure accurate MDS assessments for two residents. One resident was documented as using hearing aids, which they did not have, and another resident's discharge disposition was incorrectly recorded. Staff interviews revealed a lack of awareness and verification, leading to these inaccuracies.
A facility failed to submit an accurate PASRR for a resident with bipolar disorder, major depressive disorder, and anxiety disorder. The resident's PASRR Level I Screening inaccurately indicated negative results for serious mental illness, omitting key diagnoses and medication use. Staff interviews revealed a lack of formal PASRR policy and reliance on hospital-provided screenings, with the MDS Coordinator missing the inaccuracies. The DON acknowledged frequent issues with hospital PASRRs, requiring resubmission, which was not done in this case.
A resident with a history of hemiplegia and a contracted left hand had an outdated care plan that was not revised to reflect their current needs. Despite the resident's ability to communicate, the care plan included interventions that were no longer relevant, such as range-of-motion exercises and the use of a brace, which were not being performed or provided. Staff interviews confirmed the lack of updates to the care plan, and facility leadership acknowledged the need for revisions.
A resident with protein-calorie malnutrition did not receive fortified food as recommended by the RD due to a failure in entering the diet order. The SLP omitted the fortified portion from the order, and the DM was unaware of the need for fortified foods. Interviews revealed that staff did not ensure the correct diet orders were entered, leading to the resident not receiving the necessary nutritional supplementation.
A resident with COPD did not receive proper monitoring during nebulizer treatments, as required by facility policy. Observations showed the resident was left unattended, and medication was not fully administered. Interviews confirmed that staff should have stayed with the resident to ensure effective treatment and monitor for side effects.
Two residents in the facility did not receive their prescribed medications due to unavailability and lack of timely follow-up by staff. One resident, with a history of heart disease and depression, missed doses of escitalopram and prazosin, while another resident with major depressive disorder did not receive clonazepam, alpha-lipoic acid, and FiberChoice. The facility's protocol for obtaining medications was not adequately followed, leading to this deficiency.
The facility failed to transcribe physician orders for vital signs to the MAR for two residents, leading to incomplete monitoring before administering antihypertensive medications. One resident's atenolol order required blood pressure and pulse checks, but only pulse was documented. Another resident's orders for lisinopril and amlodipine required both blood pressure and pulse checks, but only blood pressure was recorded. This resulted from incomplete transcription and misunderstanding of the orders by LVNs.
The facility failed to maintain copies of daily staffing numbers, potentially affecting all residents. The Staffing Coordinator did not have records for a specific period due to a system glitch and did not keep handwritten forms. The Administrator confirmed that these records should be kept for at least a year for the facility's annual PPD review.
Failure to Document Falls and Ensure Staff Identification
Penalty
Summary
The facility failed to follow its own policies and procedures that meet professional standards of quality in two key areas. First, nursing staff did not complete required nursing documentation or head-to-toe assessments for a resident who was found on the floor 346 times within a month. Although the resident had diagnoses including Parkinsonism, persistent mood disorder, muscle spasms, difficulty walking, and lack of coordination, and was cognitively intact, only eight of the 354 episodes of being found on the floor were documented in the progress notes. Interviews with staff revealed that these incidents were not considered falls by the Director of Nursing, but rather resident behaviors, and thus were not assessed or documented according to facility policy. Both the facility's policies and staff interviews confirmed that each incident should have been documented, assessed, and communicated to the physician, but this did not occur. Further review of the facility's policies, including those on assessing falls and their causes, and behavior assessment, confirmed that staff are required to document all falls or incidents of residents being found on the floor, conduct head-to-toe assessments, notify the physician, and update care plans as needed. However, interviews with licensed nursing staff indicated that these protocols were not followed for the resident in question. Staff admitted that full assessments, documentation, and notifications were not completed, and that the resident was not placed under observation or had care plans updated as required by policy. Additionally, the facility failed to ensure that all Certified Nursing Assistants (CNAs) wore identification badges while on duty, as required by facility policy. During observations, two CNAs were found not wearing their ID badges and admitted to not having them at work, despite understanding the importance of proper identification for residents and families. The Director of Nursing confirmed that this was a violation of facility policy and could potentially cause confusion or delay in care if staff could not be properly identified.
Failure to Assess Dietary Preferences Timely
Penalty
Summary
The facility failed to assess dietary preferences for seven out of ten sampled residents within 48 hours of their admission, as required by their policy. This oversight resulted in the dietary preferences of these residents not being considered when meals were provided. For instance, one resident repeatedly informed staff that she does not drink milk, yet milk continued to be served to her. The Registered Dietitian (RD) and Dietary Manager (DM) acknowledged that the dietary profiles for several residents were either incomplete or delayed beyond the 48-hour window post-admission. The RD and DM both stated that the delay in completing dietary preferences could lead to negative side effects such as delayed wound healing, slower recovery, increased length of stay, and weight loss. The Director of Nursing (DON) confirmed the expectation for dietary preferences to be completed within 48 hours of admission, emphasizing the potential impact on residents' recovery and nutritional status. The facility's policy and procedure document also highlighted the importance of considering residents' food preferences to provide a well-balanced diet that meets their nutritional needs.
Deficiency in Meal Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable meals to its residents, as evidenced by multiple observations and resident complaints. The facility's policy on Food and Nutrition Services, revised in 2017, mandates that each resident is provided with a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs. However, during a lunch meal service, the food was observed to be served at inadequate temperatures, with the rosemary roast pork at 90 degrees, mashed potatoes at 100 degrees, and zucchini/tomatoes at 100 degrees by the time the last resident tray was served. Residents reported the food as cold, tasteless, and unappetizing, with some stating they could not identify the vegetables served. The Dietary Manager acknowledged awareness of complaints about food temperatures but attributed the issue to slow meal tray distribution by staff. Several residents, including those with intact cognitive status, expressed dissatisfaction with the meals, citing issues such as cold temperatures, lack of seasoning, and unappetizing presentation. During a Resident Council Meeting, attendees reported the need for more seasoning and less spice in meals, and specific complaints were made about the lunch meal's lack of flavor and warmth. The Director of Nursing and the Administrator both expressed expectations for food to be served at appropriate temperatures and to be visually and tastefully appealing, indicating a disconnect between expectations and the actual service provided.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper documentation and adherence to food safety protocols during meal service. During an initial tour of the facility's kitchen, it was observed that the meal service temperature logs for lunch were documented before the food was placed on the steam table. The Dietary Manager and staff confirmed that this practice was unacceptable and acknowledged that meal service temperatures should only be recorded when the food is placed on the steam table. Dietary Staff #15 admitted to pre-filling the temperature logs based on assumptions rather than actual measurements, despite knowing the importance of accurate temperature documentation to ensure food safety. Additionally, the facility failed to maintain proper hand hygiene during meal preparation. Dietary Staff #14 was observed wearing gloves while handling various surfaces and then preparing food without changing gloves. The staff member touched her clothing and continued food preparation without changing gloves or washing hands, which was against the facility's policy. Both the Dietary Manager and the Director of Nursing expressed that they expected staff to change gloves when necessary, especially after touching clothing or other surfaces, to prevent contamination.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to ensure that resident rooms met the required square footage per resident, as outlined in their policy and federal and state requirements. Specifically, 19 out of 23 resident rooms did not provide the minimum 80 square feet per resident in multiple occupancy rooms. The Client Accommodations Analysis, signed by the Maintenance Supervisor, documented that several rooms provided less than the required space, with measurements ranging from 70 to 78 square feet per resident. Interviews with facility staff, including the Maintenance Supervisor, Director of Nursing, and Administrator, revealed a lack of awareness or concern regarding the room sizes. The Maintenance Supervisor mentioned that waivers were in place for some rooms, and no complaints had been received from staff or residents. Similarly, the Director of Nursing and Administrator reported no complaints about room sizes, and the Administrator stated that as long as residents were comfortable and staff could provide care, he did not see an issue with the room sizes.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations during medication administration. Out of 28 opportunities, there were 3 medication errors, resulting in a 10.71% error rate. This affected two residents, one of whom was administered atenolol without the required blood pressure check, and another who received lisinopril and amlodipine without a pulse check. Resident #9, admitted in 2017 with a history of hypertension, had an order for atenolol with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the pulse was below 60 BPM. On a specific date, an LVN administered atenolol after checking only the resident's pulse, which was 84 BPM, but failed to check the blood pressure as required by the order. The LVN later acknowledged the oversight, realizing the need to read the full order and obtain all necessary vital signs. Resident #32, admitted in 2020 with chronic ischemic heart disease and hypertension, had orders for lisinopril and amlodipine with instructions to hold the medications if the pulse was below 60 BPM, SBP below 110 mmHg, or DBP below 60 mmHg. An LVN administered these medications after checking only the blood pressure, which was 122/78 mmHg, without obtaining the pulse. The LVN admitted to not checking the pulse, as the MAR only prompted for a blood pressure reading. Both the DON and the Administrator emphasized the importance of following physician orders and obtaining all necessary vital signs before medication administration.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors during medication administration. For Resident #9, the facility did not obtain the required vital signs before administering atenolol, an antihypertensive medication. The order specified that the medication should be held if the resident's pulse was less than 60 BPM or if the systolic blood pressure was less than 110 mmHg. However, the Licensed Vocational Nurse (LVN) administering the medication did not check the resident's blood pressure, as the electronic Medication Administration Record (MAR) only prompted for the pulse. This oversight was acknowledged by the LVN and the Director of Nursing (DON), who stated that all necessary vital signs should be obtained prior to medication administration. Resident #32 also experienced a similar issue where the facility did not obtain all required vital signs before administering lisinopril and amlodipine, both antihypertensive medications. The orders required that the medications be held if the resident's pulse was less than 60 BPM, systolic blood pressure was less than 110 mmHg, or diastolic blood pressure was less than 60 mmHg. During an observation, the LVN only obtained the resident's blood pressure and not the pulse, as the MAR only prompted for the blood pressure. The DON reiterated the importance of obtaining all necessary vital signs and following physician orders. For Resident #19, the facility failed to hold medications when the resident's vital signs were outside the physician-ordered parameters. The resident's MAR indicated that medications such as diltiazem, metoprolol tartrate, and hydrochlorothiazide should be held if the systolic blood pressure was less than 110 mmHg, diastolic blood pressure was less than 65 mmHg, or the pulse was less than 60 BPM. Despite this, the medications were administered on multiple occasions when the vital signs did not meet these parameters. Interviews with the LVNs involved revealed that they were aware of the parameters but did not hold the medications as required. The DON emphasized the importance of adhering to physician orders to ensure resident safety.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #46 was reported to have intact cognition and the use of a hearing aid in both annual and quarterly MDS assessments. However, interviews with the resident and staff revealed that the resident did not have hearing aids, contrary to what was documented. The MDS Coordinator and the Director of Nursing (DON) were unaware of this discrepancy, indicating a lack of communication and verification in the assessment process. Resident #69 was documented in the MDS assessment as having been discharged to a short-term general hospital. However, progress notes and a signed statement indicated that the resident left the facility against medical advice (AMA). The MDS Coordinator admitted to selecting the wrong discharge disposition, and the DON acknowledged the error, highlighting a failure in ensuring the accuracy of discharge information. Both cases demonstrate a deficiency in maintaining accurate resident assessments as per the facility's policy.
Inaccurate PASRR Submission for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a history of serious mental illness. The resident, admitted on 07/25/2024, had a medical history that included bipolar disorder, major depressive disorder, and anxiety disorder. Despite these diagnoses and the use of psychotropic medications, the PASRR Level I Screening dated 07/25/2024 indicated negative results for serious mental illness, failing to include the resident's actual diagnoses and medication use. Interviews with facility staff revealed a lack of a formal policy for PASRR, with reliance on a letter from the State Department of Health Care Services for guidance. The admissions department received the PASRR from the hospital, which was then reviewed by the Assistant Director of Nursing and Director of Nursing. However, the MDS Coordinator, responsible for ensuring the accuracy of the PASRR, admitted to missing the inaccuracies in the resident's Level I PASRR. The Director of Business Development and Marketing stated her role was limited to obtaining the Level I PASRR prior to admission, while the MDS Coordinator was tasked with reviewing it for accuracy. The Director of Nursing acknowledged issues with hospitals related to PASRRs, often requiring resubmission due to inaccuracies. The facility's Administrator confirmed that the interdisciplinary team should have reviewed the PASRR for accuracy upon receipt and resubmitted it if found inaccurate, which did not occur in this case.
Failure to Revise Resident's Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #15, who was admitted with a medical history of hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, affecting the left nondominant side, and a contracted left hand. The care plan, which was supposed to be comprehensive and person-centered, included interventions for lymphedema and limited mobility that were outdated and no longer relevant to the resident's current condition. Despite the resident's intact cognition and ability to communicate, the care plan had not been updated to reflect the resident's current needs, such as the absence of a brace for the left wrist and fingers and the lack of range-of-motion exercises. Interviews with staff revealed that CNAs were not performing range-of-motion exercises on the resident's left hand due to contractures, and there was no documentation of such exercises in the resident's electronic medical record. The MDS Coordinator and the Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current status, including the removal of interventions related to a brace, assistive device, ROM, and compression stockings. The Administrator also confirmed that care plans should be updated when a resident's status changes, indicating a lapse in the facility's adherence to its policy on maintaining current and relevant care plans.
Failure to Provide Fortified Food for Nutritional Supplementation
Penalty
Summary
The facility failed to provide fortified food intended for nutritional supplementation to a resident diagnosed with protein-calorie malnutrition. The resident, who had a medical history including hyperlipidemia, peripheral vascular disease, hypertension, and other conditions, was admitted with a nutritional risk. The Registered Dietician recommended fortifying the resident's diet to prevent further weight loss. However, the Speech Language Pathologist did not include the high protein/fortified portion in the diet order, and the Dietary Manager was unaware of the need for fortified foods. The deficiency was identified during interviews and record reviews, which revealed that the diet order for high protein/fortified foods was not entered into the system. The Director of Nursing and the Administrator both expressed expectations that staff should ensure diet orders are correctly entered and residents receive the appropriate diet. Despite these expectations, the oversight resulted in the resident not receiving the necessary fortified foods as part of their nutritional care plan.
Failure to Monitor Nebulizer Treatment
Penalty
Summary
The facility failed to provide proper monitoring during the administration of a nebulizer treatment for a resident with chronic obstructive pulmonary disease (COPD) and other respiratory conditions. The facility's policy required staff to remain with the resident during the treatment, monitor for side effects, and ensure the medication was fully administered. However, observations revealed that the resident was left unattended during nebulizer treatments, with the nurse leaving the room before the medication was completely nebulized. The resident, who had a medical history of COPD, pneumonia, and shortness of breath, was observed on multiple occasions with a nebulizer machine on the nightstand and a medication cannister that was not fully utilized. On one occasion, the resident reported not receiving a nebulizer treatment that day, despite the medication cannister being partially full. This indicated a lack of adherence to the prescribed treatment schedule and monitoring requirements. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required nurses to stay with the resident during nebulizer treatments to ensure the medication was administered effectively and to monitor the resident's response. The failure to adhere to these procedures resulted in a deficiency in providing safe and appropriate respiratory care for the resident.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure prescribed medications were available for two residents, leading to a deficiency in pharmaceutical services. Resident #2, who was admitted with a history of hypertensive heart disease and depression, did not receive their prescribed medications, escitalopram and prazosin, on multiple occasions. The Medication Administration Record (MAR) indicated that these medications were coded as 'Other,' meaning they were not administered due to pending pharmacy delivery. Despite the resident's statement that they had not refused any medications, the medications were not available on the medication cart, and the staff failed to follow the facility's policy for obtaining medications from the pharmacy or using the emergency medication kit. Resident #29, who had a history of major depressive disorder, also experienced a lack of medication availability. The resident's prescribed medications, including clonazepam, alpha-lipoic acid, and FiberChoice, were not administered as they were pending delivery from the pharmacy. The MAR and progress notes documented that these medications were on hold or coded as 'Other' due to unavailability. The central supply person informed the nurse that FiberChoice was not on the formulary list, and the nurse was expected to contact the physician for an alternative or order the medication from the pharmacy, which was not done in a timely manner. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's protocol required nurses to contact the pharmacy, physician, and DON if medications were not available. They were also expected to follow up until the medications were received. However, this protocol was not adequately followed, resulting in the residents not receiving their prescribed medications on time. The deficiency highlights a failure in the facility's medication management and communication processes.
Failure to Transcribe Physician Orders for Vital Signs
Penalty
Summary
The facility failed to ensure that physician orders for vital signs were accurately transcribed to the medication administration records (MAR) for two residents during medication administration. Resident #9, who was admitted with a diagnosis of primary hypertension and had moderate cognitive impairment, had an order for atenolol with specific instructions to monitor blood pressure and pulse before administration. However, the MAR only prompted staff to document the resident's pulse, leading to a lack of blood pressure monitoring prior to administering the medication. This oversight was identified when a Licensed Vocational Nurse (LVN) realized the full order required blood pressure monitoring as well. Similarly, Resident #32, with a history of primary hypertension and chronic ischemic heart disease, had orders for lisinopril and amlodipine that required monitoring of both blood pressure and pulse. The MAR, however, only prompted for blood pressure documentation, resulting in the omission of pulse monitoring. LVN #13 administered the medications without obtaining the resident's pulse, as she was unaware of the complete order requirements. Both instances highlight a failure in the transcription process and understanding of the complete physician orders, leading to potential medication administration errors.
Failure to Maintain Daily Staffing Records
Penalty
Summary
The facility failed to maintain copies of the posted direct care daily staffing numbers, which had the potential to affect all residents residing in the facility. According to the facility's policy, revised in August 2022, the facility was required to post daily nursing staff data for each shift and maintain these records for a minimum of eighteen months or as required by state law. However, during an interview, the Staffing Coordinator admitted that she did not have the daily staffing postings for the period from July 23, 2024, through July 30, 2024, due to a glitch in their system. Although she handwrote the staffing numbers, she did not keep the forms. The Administrator confirmed that the daily staffing postings should be kept for at least a year for the facility's annual PPD review from the State and should be accurate, maintained together, and organized.
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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