Lawndale Healthcare & Wellness Centre Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawndale, California.
- Location
- 15100 S Prairie, Lawndale, California 90260
- CMS Provider Number
- 555816
- Inspections on file
- 44
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Lawndale Healthcare & Wellness Centre Llc during CMS and state inspections, most recent first.
The facility failed to develop and implement a comprehensive care plan and abuse-prevention measures for a resident with a documented history of sexually inappropriate and aggressive behavior, leading to sexual and physical abuse of two other residents. The aggressive resident, who had schizoaffective disorder and prior incidents of exposing his genitals and harassing female staff and residents, repeatedly made sexually explicit comments and inappropriately touched staff without any corresponding behavioral care plan being created. Later, he entered a cognitively impaired resident’s room, kissed her, pulled his pants down, and digitally penetrated her vagina without consent, and on the same day entered his roommate’s room, repeatedly requested to perform oral sex, attempted to pull down the roommate’s blanket to expose his genitals, and punched the roommate’s leg multiple times when resisted. Despite these events and a hospital transfer for sexually and physically aggressive behavior, the facility did not revise the resident’s care plan to address his sexual behaviors or implement targeted monitoring and safety interventions, contrary to its own care-planning and abuse-prevention policies.
The facility failed to report to CDPH two separate allegations of sexual and physical abuse involving the same resident aggressor and two other residents. One resident with dementia and significant physical limitations reported that another resident entered her room, removed both their pants, kissed her face, and touched her vagina, which was corroborated by staff observations and documentation. Another dependent resident reported that the same resident entered his room, stated he wanted to suck his penis, tried to remove his blankets, and hit him on the leg multiple times, which was also documented and reported up the chain of command. Although staff notified the DON and Administrator, and facility policies defined such conduct as physical and sexual abuse and required all allegations to be reported to CDPH within two hours, leadership did not submit the required report, resulting in the cited deficiency.
The facility failed to investigate multiple alleged sexual and physical abuse incidents involving one resident with schizoaffective disorder and a history of sexually inappropriate behavior toward others. One resident with dementia and limited capacity reported that this resident entered her room, removed her pants, removed his own pants, and kissed her face, while documentation only described “inappropriate behavior” and showed no abuse investigation. Another dependent, bedridden resident reported that the same resident repeatedly requested to perform oral sex, tried to pull down his blanket to expose his genitals, and then punched his leg several times; a police report documented similar details. Despite SBAR notes and police involvement, the clinical records for the involved residents contained no documentation of an abuse investigation, and the Administrator stated he was informed of the sexual and physical assaults but did not initiate an investigation, contrary to the facility’s abuse policy requiring interviews of residents, witnesses, and others with relevant information.
A resident with muscle weakness, hypertension, fluctuating decision-making capacity, and dependence for toileting and other ADLs was not provided timely incontinence care and assistance, despite care plan directions to assist with ADLs as needed. The resident reported sitting in urine for hours and using the call light without response, and surveyors observed staff walking past the room and declining to provide care, citing workload and a rule prohibiting cleaning residents during meal tray pass. Staff later claimed the resident had refused care, which the resident denied. This conflicted with facility policy requiring incontinent residents to be kept clean, dry, and comfortable.
A resident with muscle weakness, HTN, fluctuating decision-making capacity, and dependence for toileting and transfers received incontinence care during which a CNA failed to change gloves or perform hand hygiene between dirty and clean tasks. The CNA cleaned the resident’s perineal area, handled the bed remote, repositioned the resident, removed a soiled brief, applied a clean brief, and then left the room to obtain a clean gown while still wearing the same contaminated gloves and without hand hygiene. This conduct was inconsistent with the facility’s PPE and hand hygiene policies, which require single-use gloves, proper disposal, and hand hygiene before and after glove removal and after contact with body fluids.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital, after which their bed was reassigned to another individual without providing the required written notice or reason for the room change, as mandated by facility policy. The DON confirmed the lapse in procedure.
A resident with severe cognitive impairment and multiple medical conditions was not readmitted to the facility after a hospital transfer due to the facility's failure to honor the required bed hold and miscommunication among staff, the hospital, and the public guardian. The resident's bed was reassigned, and the resident remained in the hospital longer than necessary.
A resident with multiple chronic conditions was not readmitted to the facility after a hospital stay, despite available beds and facility policy requiring readmission. The admissions coordinator reported the denial was due to an insurance change, a decision made by the regional marketer without informing the DON.
A resident with no cognitive impairment reported a grievance about her roommate's behavior to staff, but the concern was not documented in the grievance log or followed up on as required by facility policy. Interviews with the SSD and DON confirmed that the issue was not properly recorded or investigated, resulting in the resident's complaint remaining unaddressed.
A resident with a history of hypertensive heart disease and requiring substantial ADL assistance reported mild pain on two occasions, but staff did not document thorough pain assessments, administer ordered acetaminophen, or provide non-pharmacological interventions as directed. The DON confirmed that pain management protocols, including reassessment and documentation, were not followed.
Two residents who required substantial assistance with daily activities were found without working call lights or alternative alert systems at their bedsides. Both residents had no cognitive impairment and were unable to summon staff when needed, with one resident reporting the issue persisted for two weeks. Staff and maintenance records confirmed the ongoing malfunction and lack of alternative devices, contrary to facility policy.
A resident with severe cognitive and physical impairments experienced a fall and was found on the floor with a head bump. On the day of the incident, only four CNAs were present instead of the scheduled seven, resulting in reduced direct care hours. The assigned CNA was assisting another resident at the time, and documentation did not specify how long the resident was on the floor before being found. The DON acknowledged that the staffing shortage could have delayed the response to the resident's needs.
Staff failed to follow food safety protocols by not wearing masks while plating food, not changing gloves after touching non-food items, and storing expired food products in the kitchen. These actions were observed during meal preparation and confirmed in staff interviews, with facility policies indicating that such practices were required for infection control and food safety.
A CNA was observed entering a resident care area wearing an N95 respirator mask incorrectly, with the string hanging in front, which did not provide a proper seal as required by facility policy. The CNA acknowledged the improper use and described the correct method, but failed to follow it, resulting in noncompliance with the Respiratory Protection Program and potentially affecting all residents and staff.
A resident with a history of lack of coordination and muscle weakness, identified as high fall risk, did not receive a complete fall risk assessment after a fall. The Fall Risk Evaluation omitted documentation of the fall, the resident's level of consciousness, gait, balance, medications, and did not provide a fall risk score, contrary to facility policy. The DON confirmed the assessment was not properly completed.
Three residents did not have timely or appropriate care plans developed or implemented for their specific needs, including restorative nursing services, antipsychotic medication management, and nail care. Staff and record reviews confirmed that care plans were either missing or delayed, resulting in inconsistent care and unmet resident needs.
A resident with multiple medical conditions, including diabetes and cognitive impairment, who was dependent on staff for ADLs, was found with long fingernails that had not been trimmed. The resident stated that no one had offered nail care, and staff acknowledged the nails were excessively long and should have been addressed according to facility policy, but the need was not reported or acted upon.
Two residents with severe cognitive and physical impairments did not consistently receive physician-ordered passive range of motion (PROM) therapy five times a week, and required documentation was missing for multiple days and weeks. Staff interviews confirmed lapses in both the provision and documentation of restorative nursing services, in violation of facility policy and physician orders.
A staff member prepared a pureed breakfast meal with French toast that was served in a liquid consistency, rather than the required smooth, pudding-like texture. The staff member did not follow the established recipe, and both the Kitchen Supervisor and DON confirmed that proper consistency is essential for residents with swallowing difficulties. Facility policy requires pureed foods to be smooth and hold their shape, which was not met during this meal service.
A resident with significant physical and cognitive needs was left without access to a functioning call light for several days due to a broken clip, resulting in the resident repeatedly having to scream for help. Staff and maintenance were unaware of the issue until it was brought to their attention, despite facility policy requiring prompt repair and alternative alert systems when call devices are defective.
A resident with severe cognitive impairment, legal blindness, and poor mobility was assessed as needing bilateral side rails to promote independence and assist with bed mobility. Although the need for side rails was identified and ordered, the care plan addressing their use was not created until after the resident experienced a fall. Nursing staff and the DON confirmed the care plan was delayed, resulting in the resident not having the appropriate interventions in place as required by facility policy.
A resident with severe cognitive and physical impairments, including legal blindness and poor bed mobility, did not have side rails installed as ordered and recommended by assessment. Despite documented need and physician orders, the side rails were not in place at the time the resident experienced a fall, as confirmed by nursing staff and the DON.
A resident with schizophrenia and bipolar disorder was prescribed Risperidone and Depakote for mood disorders. The facility failed to monitor and document the resident's aggressive behaviors and the indication for an increased dose of Depakote. Staff interviews revealed inconsistent behavior monitoring, and the facility did not follow its policy for documenting behavior occurrences and medication effectiveness.
A resident with schizoaffective disorder and impaired cognitive skills slapped another resident with Parkinson's disease in the face. The aggressive resident had a history of outbursts and was not adequately monitored or managed, leading to the incident. The facility's abuse prevention policy was not effectively implemented.
A resident with cognitive impairments and a history of wandering was not monitored hourly as required by their care plan, leading to multiple incidents of the resident entering other residents' rooms. Despite staff attempts to redirect the resident, the facility did not adhere to the care plan's directive for hourly visual monitoring, placing the resident at risk for altercations.
A resident in an LTC facility was unable to reach her call light while in bed, as it was found behind the bedside table and later on the floor. The resident, with diagnoses including dementia and polyneuropathy, required assistance for daily activities and was dependent on staff for mobility. The facility's policy required call lights to be within reach, but this was not followed, leading the resident to yell for help.
A facility failed to implement a comprehensive care plan for the safe storage of smoking materials for three residents. Observations showed residents had unsupervised access to lighters, despite policies requiring safe storage and supervision. Care plans lacked details on storing smoking materials, posing a fire risk to all residents, staff, and visitors.
Three residents with varying medical conditions were found with cigarette lighters and smoking unsupervised, despite requiring supervision according to their care plans. The facility failed to ensure safe storage of smoking materials, leading to potential safety hazards.
The facility failed to report a resident-to-resident altercation within the required timeframe, as per its abuse policy. A resident with cerebral infarction and fluctuating cognitive capacity reported being physically assaulted by another resident with dementia and schizoaffective disorder. The DON was unaware of the incident, which was not reported to the appropriate agencies, placing residents at risk for further abuse.
The facility staff failed to notify the physician when a resident continued to refuse her medications, leading to delayed medical intervention and unnecessary hostile behavior. Despite the care plan indicating the need to administer psychotropic medications, the resident refused multiple times, and the licensed nursing staff did not complete a Change of Condition (COC) or notify the physician as required by the facility's policies and procedures.
The facility failed to prevent verbal abuse between two residents. One resident, with multiple diagnoses including depression and anxiety, reported being verbally abused by another resident with fluctuating capacity due to schizophrenia and bipolar disorder. Despite being aware of the situation, staff did not immediately separate the residents, leading to further incidents of verbal abuse.
The facility failed to provide a written report of findings for an investigation of verbal abuse within the mandated five working days. A resident verbally abused another resident using racial slurs and profanity. The incident was reported via email, but the required written report was not submitted on time, as confirmed by the Administrator.
The facility failed to implement the baseline care plan for a resident with multiple mental health diagnoses by not monitoring psychotropic medication side effects, mental status, or signs of distress as required. Interviews and record reviews confirmed the lack of documentation and adherence to the care plan, putting the resident at risk for delayed care.
A resident with multiple health conditions reported being verbally threatened and cursed at by a housekeeper. The incident, which occurred on the morning of 4/3/2024, was not immediately reported or documented as required by the facility's policies. The housekeeper was suspended, and the Social Services Designee resigned following an investigation initiated two days later.
A resident was verbally threatened and cursed at by a housekeeper, but the incident was not reported to the Administrator or other required authorities immediately as per facility policy. Multiple staff members were aware of the altercation, but the delay in reporting meant the incident was not investigated in a timely manner.
Failure to Care Plan and Monitor Resident With Known Sexual and Physical Aggression Resulting in Abuse of Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not developing and implementing care plans and abuse-prevention measures for a resident with known sexually inappropriate and aggressive behaviors. Resident 2 was admitted with diagnoses including muscle weakness and schizoaffective disorder, bipolar type, and a documented history from an acute care hospital of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. Despite this history, the facility did not create a care plan upon admission to address Resident 2’s sexual misconduct risk. Progress notes dated 12/13/2025 documented that Resident 2 made sexually explicit and inappropriate verbal comments toward a CNA on two occasions, and on 12/15/2025 he was seen touching a CNA inappropriately and telling her he wanted to go to bed with her. These behaviors were only redirected in the moment, and no corresponding care plan interventions were developed to manage or monitor his sexually inappropriate behavior. Resident 1, who had dementia and was documented as lacking capacity to consent due to dementia, required moderate to total assistance with most ADLs and had a care plan for cognitive impairment that included visual monitoring for safety. Her MDS indicated she was usually able to understand and be understood. On 12/19/2025, an SBAR documented that she was exposed to inappropriate behavior by Resident 2, that she was assessed with no injuries and no immediate distress, and that she would be monitored for emotional distress and kept separated from Resident 2. However, her clinical record did not contain any indication of consent to sexual activity with Resident 2. A police incident report documented that Resident 1 stated Resident 2 entered her room, sat on her bed, shook her shoulders aggressively, kissed her cheeks multiple times, pulled his pants down to his thighs, reached into his shorts to touch his penis (though she did not see it exposed), then put his hands inside her shorts, past her diaper, and penetrated her vagina with his fingers while she called for help. Staff interviews corroborated that Resident 1 reported that Resident 2 kissed her, touched her, and put his fingers inside her vagina, and that staff observed Resident 2 pulling his pants up when they entered the room. Resident 1 later stated she was traumatized by the incident, had to sleep with the lights on for two weeks, and was afraid Resident 2 would enter her room again. Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs, had capacity to understand and make decisions and was able to communicate effectively. On 12/19/2025, his progress notes and a change-of-condition form documented that he reported being struck three times on his legs by Resident 2 and that Resident 2 was removed from his room. A police incident report further documented that Resident 6 reported Resident 2, his roommate, entered the room, repeatedly requested to perform oral sex on him, advanced toward him despite being told to leave, attempted to pull down his blanket to potentially expose his penis, and, when resisted, punched his right knee approximately three times with a balled fist before leaving. Resident 6 confirmed in interview that Resident 2 asked to suck his penis, tried again after being told no, attempted to pull down his blanket, and then hit his right leg three times. A CNA reported hearing Resident 6 screaming for help and that he alleged Resident 2 had asked to suck his penis. Resident 6’s record contained no indication of consent to sexual activity with Resident 2. Despite Resident 2’s known history of sexual misconduct and the documented sexually inappropriate behaviors toward staff shortly after admission, the facility did not develop or revise a comprehensive, person-centered care plan to address his sexual behaviors, monitor his whereabouts, or implement specific safety interventions for other residents. The existing care plan for Resident 2 addressed risk for wandering/elopement but did not address his sexually inappropriate behavior. After the sexually abusive and physically aggressive incidents toward Residents 1 and 6 on 12/19/2025 and Resident 2’s transfer and readmission from an acute care hospital for management of aggression and sexually inappropriate behavior, his care plan still did not include interventions related to his sexually inappropriate behavior toward other residents or monitoring for behavioral changes and safety concerns. The DON acknowledged that no care plan was created at admission or after the documented incidents on 12/13/2025 and 12/15/2025, and stated that if care plans had been created, they might have protected Residents 1 and 6 from Resident 2’s sexually inappropriate behavior and physical aggression. The facility’s own policies on Comprehensive Person-Centered Care Planning and Abuse Prevention and Management required review and revision of care plans with new problems or behavior changes and required identification, correction, and intervention in situations where abuse is more likely to occur, but these were not implemented in relation to Resident 2’s behaviors.
Failure to Report Allegations of Sexual and Physical Abuse to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of sexual and physical abuse to the California Department of Public Health (CDPH) as required by policy and regulation. On 12/19/2025, a resident with dementia, hemiplegia/hemiparesis, depression, and anxiety, who lacked capacity to consent but was usually able to understand and be understood, reported that another resident entered her room, removed his pants, removed her pants, kissed her face, and touched her vagina. An SBAR dated 12/19/2025 documented that this resident was exposed to inappropriate behavior by the alleged perpetrator. A CNA observed the alleged perpetrator in the resident’s room lowering his pants, and the resident reported to the CNA and RN Supervisor that her vagina had been touched. The RN Supervisor reported the incident to the DON. The same day, another resident, who had muscle weakness and low back pain and had capacity to understand and make decisions, reported that the same alleged perpetrator entered his room, stated he wanted to suck the resident’s penis, attempted to pull off his blankets to expose him, and, when unsuccessful, hit him on the right leg three times. A Change in Condition Evaluation dated 12/19/2025 documented that this resident reported being struck on his legs three times by the other resident. CNA 3 stated that the resident told her about the sexual statement and being hit, and she reported this to LVN 1. LVN 1 confirmed that the resident reported being hit on the leg and being asked if the alleged perpetrator could suck his private part. The facility’s records for the alleged perpetrator showed schizoaffective disorder, behavioral symptoms including public sexual acts and disrobing, and an SBAR documenting that he entered the first resident’s room, lowered his pants, and exhibited sexually inappropriate behavior. Despite these documented allegations and staff reports, the DON stated she did not report the incidents to CDPH because she believed that the described behaviors (exposing private parts and hitting on the leg) were not considered abuse. The Administrator stated he was informed of both incidents on 12/19/2025 and did not report them to CDPH. Facility policies titled “Abuse Prevention and Management” and “Abuse-Reporting and Investigations” defined abuse to include physical and sexual abuse and required that all allegations of abuse and criminal activity be promptly reported, with the Administrator or designee submitting a written SOC 341 report to CDPH Licensing and Certification within two hours. The failure of the DON and Administrator to report these allegations to CDPH constituted the cited deficiency.
Failure to Investigate Multiple Alleged Sexual and Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple alleged incidents of sexual and physical abuse by one resident against other residents, as required by its Abuse Prevention and Management policy. Resident 1, who had dementia and was documented as not having capacity to consent, was assessed as usually able to understand and be understood, and required varying levels of assistance with ADLs and mobility. An SBAR dated 12/19/2025 documented that Resident 1 was exposed to “inappropriate behavior,” was promptly assessed with no injuries or distress noted, and that she would be monitored and kept separated from Resident 2. However, the clinical record contained no documentation that an abuse investigation was conducted regarding Resident 2’s sexually abusive behavior toward Resident 1 on that date. Resident 2 had diagnoses including muscle weakness and schizoaffective disorder, bipolar type, with a history of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. An SBAR for Resident 2 dated 12/19/2025 documented that he entered Resident 1’s bedroom, lowered his pants, and exhibited sexually inappropriate behavior toward her, after which staff redirected him, administered medication, and planned transfer to an acute care hospital for further evaluation and behavior management. Despite these documented behaviors and his known history, Resident 2’s clinical record contained no documentation that an investigation was conducted into the incidents of sexually assaulting two residents and physically assaulting one of them on 12/19/2025. Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs and mobility, reported that Resident 2 entered his room, repeatedly requested to perform oral sex, attempted to pull down his blanket to expose his penis, and, when resisted, punched his right leg three times. A police crime/incident report corroborated that Resident 6, who was bedridden, described Resident 2’s repeated sexual requests, attempts to pull down his blanket near his genital area, and punching of his right knee with a balled fist. Resident 6’s clinical record, however, contained no documentation that an investigation was conducted into the sexual abuse and physical assault by Resident 2 on that date. In an interview, the Administrator acknowledged being informed that day about Resident 2 sexually assaulting two residents and hitting one resident, and stated that no investigation was done because the events occurred on a Friday afternoon, despite the facility’s policy requiring the Administrator or designee to interview residents, witnesses, family, and others who may have relevant information. The facility’s Abuse Prevention and Management policy, dated 6/12/2024, specified that the Administrator or designated representative conducting an investigation should interview individuals who may have information relevant to the allegation or suspected crime, including the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, and visitors. The absence of any documented investigations in the clinical records of Residents 1, 2, and 6, combined with the Administrator’s admission that no investigation was initiated after being informed of the alleged sexual and physical assaults, demonstrates that the facility did not follow its own policy and procedures for responding to and investigating alleged abuse incidents involving Resident 2 and the affected residents.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living and incontinence care to keep a resident clean, dry, and comfortable in accordance with the resident’s needs and the facility’s own policy. The resident had diagnoses including muscle weakness and hypertension, fluctuating capacity to understand and make decisions, and required varying levels of assistance for ADLs, including dependence for toileting hygiene and lower body dressing. The resident’s care plan indicated assistance with ADLs as needed. On the survey date, the resident reported not being cleaned all morning and sitting in urine for hours, despite repeatedly calling staff for help. Observations showed the resident using the call light while a CNA walked past the room without responding. The resident stated that staff did not respond to call lights and ignored her. During subsequent observations and interviews, CNA 1 stated she was too busy to assist the resident, citing responsibility for nine residents and indicating she had already responded several times to requests to adjust the bed. CNA 1 left the room while the resident verbally expressed discomfort and a need for help. When CNA 2 entered, the resident again requested to be cleaned, but CNA 2 stated she could not clean the resident because she was about to pass meal trays and asserted that residents had to wait during tray pass per facility rules. CNAs stated they could not clean residents during tray pass and that all residents had to wait. Later, CNA 2 told the Infection Prevention Nurse that the resident had refused care that morning, while the resident stated CNA 2 had never asked to clean her. The facility’s bowel and bladder policy required that incontinent residents be kept clean, dry, and comfortable, and the DON acknowledged residents should not be left in urine for a long period of time because it could lead to skin breakdown and make residents feel neglected or ignored.
Failure to Follow Hand Hygiene and Glove Use Protocol During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement infection prevention and control measures during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, fluctuating capacity to understand and make decisions, and required substantial to maximal assistance for bed mobility and was dependent for toileting hygiene, lower body dressing, and transfers. During an observation in the resident’s room, a CNA wearing gloves opened the resident’s soiled incontinence brief, cleaned the pubic area, then used the bed remote control to reposition the bed without changing gloves or performing hand hygiene. The CNA then turned the resident to the left side, cleaned the buttocks and buttocks fold, removed the soiled brief, and applied a clean brief, again without changing gloves or performing hand hygiene. After completing the incontinence care, the CNA left the resident’s room still wearing the same soiled gloves and without performing hand hygiene in order to obtain a clean gown for the resident. In an interview, the CNA stated she did not realize she had not changed her gloves because she was trying to finish the incontinence care quickly. The Infection Prevention Nurse stated that staff should change gloves and perform hand hygiene when moving from dirty to clean areas, and that failure to do so could lead to the spread of germs and place residents at risk for infections. Review of the facility’s PPE policy indicated gloves are to be used once, discarded in the appropriate receptacle in the room, and that hands are to be washed before and after removing gloves. The facility’s hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections and required hand hygiene after contact with body fluids and before donning and after doffing PPE, as well as upon entering and exiting a resident room.
Failure to Provide Written Notice for Room Change After Hospital Transfer
Penalty
Summary
The facility failed to provide written notice with a reason for a room change for one resident. The resident, who had diagnoses including metabolic encephalopathy, pneumonia, type 2 diabetes mellitus, and schizophrenia, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The resident was transferred to a general acute care hospital due to a change in condition, specifically a persistent cough and increased secretions despite IV antibiotics for pneumonia. Upon review of the facility's census, it was found that the resident's bed was assigned to another individual the day after the hospital transfer, resulting in the resident losing their bed. The DON confirmed that a room change occurred without knowledge of the reason and acknowledged that written notice was not provided as required by facility policy. The facility's policy mandates timely advance written notice with reasons for any room or roommate change, which was not followed in this instance.
Failure to Honor Bed Hold and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident who was transferred to a general acute care hospital (GACH) for treatment of pneumonia and other medical conditions. The resident, who had severe cognitive impairment, was dependent on staff for activities of daily living and lacked decision-making capacity. After being transferred to the hospital, the facility did not honor the required 7-day bed hold, and the resident's bed was reassigned to another individual within one day of transfer. Confusion and miscommunication occurred between facility staff, the hospital, and the resident's public guardian (PG). The facility's Regional Marketer (RM) and Admission Coordinator (AC) both reported being told by hospital staff or the PG that the resident would not be returning, but the PG denied ever making such a statement. The hospital social worker reported that the facility stopped answering calls and stated the resident would not be readmitted, despite discharge orders being in place for the resident to return. The RM and AC did not verify the information with the PG or the hospital, leading to further delays and the resident remaining in the hospital beyond the necessary period. The Director of Nursing (DON) was not informed of the situation and only became aware after reviewing the census, which showed the resident's bed had been reassigned. The facility's policy required honoring a 7-day bed hold for residents transferred to the hospital, but this was not followed. The failure to coordinate and communicate effectively among facility staff, the hospital, and the PG resulted in the resident not being readmitted as required by policy, prolonging the hospital stay.
Failure to Readmit Hospitalized Resident Despite Available Bed
Penalty
Summary
A resident with diagnoses including metabolic encephalopathy, spinal stenosis, type 2 diabetes, and COPD was admitted to the facility and was noted to have intact cognitive skills but required substantial assistance with activities of daily living. The resident was transferred to a general acute care hospital due to increased confusion and at the family's request. Following the hospitalization, the facility failed to readmit the resident, despite available female beds during the relevant period, resulting in the resident remaining in the hospital for 30 days. The admissions coordinator, responsible for facilitating returns after hospitalization, stated that the resident was denied readmission due to a change in insurance, a decision made by the regional marketer. The director of nursing was not informed of the denial and indicated that the regional marketer did not have the authority to deny readmission. Facility policy required that previously admitted residents be allowed to return, but this was not followed in this case.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to implement its grievance policy and procedure for one resident who reported an issue with her roommate repeatedly touching the privacy curtain, which caused her distress. The resident, who had no cognitive impairment and was able to make her own decisions, stated that she reported the issue to a staff member, but no action was taken. The facility's grievance log did not contain any record of this concern, and there was no documentation of any investigation or follow-up regarding the resident's complaint. Interviews with the Social Services Director and the Director of Nursing confirmed that the grievance should have been documented and addressed according to facility policy, which requires grievances to be logged and investigated with appropriate follow-up. The Social Services Director acknowledged that a room change was offered but declined by the resident, yet this was not documented. The lack of documentation and follow-up meant the resident's grievance was not formally acknowledged or resolved as required by the facility's policy.
Failure to Provide Effective Pain Management and Documentation
Penalty
Summary
Facility staff failed to provide effective pain management for a resident who reported pain levels of 4 out of 10 on two consecutive days. Despite physician orders to administer acetaminophen for mild pain and to use non-pharmacological interventions such as heat, repositioning, relaxation breathing, food/fluids, massage, exercise, and immobilization, there was no documentation that these interventions were provided. Additionally, the resident's pain was not thoroughly assessed or reassessed after the initial complaint, as required by both physician orders and facility policy. The resident involved had diagnoses including lack of coordination and hypertensive heart disease, and required substantial assistance with activities of daily living. The resident was cognitively intact and able to communicate pain. Facility records, including the Medication Administration Record and Medication Administration Notes, did not show evidence of pain assessments, administration of pain medication, or implementation of non-pharmacological interventions on the dates in question. Interviews with the DON confirmed the lack of documentation and intervention following the resident's pain reports.
Failure to Provide Functional Call Devices for Residents
Penalty
Summary
The facility failed to provide functional call devices for two out of three sampled residents, resulting in the absence of a means for these residents to communicate their needs to staff. Both residents had no cognitive impairment and required substantial to maximal assistance with activities of daily living, including toileting, transfers, and mobility. Observations revealed that the call lights in their rooms did not activate when pressed, and no alternative call bells or devices were available at their bedsides. One resident reported that her call light had not worked for two weeks, requiring her to go to the nurse’s station for assistance. A review of the facility’s maintenance log confirmed that the call light issues for these residents began several days prior and had not been resolved. The facility’s policy required that if the call alert system could not be repaired immediately, an alternative process such as tap bells or auxiliary aids should be implemented, but this was not done. Staff interviews acknowledged the lack of functional call lights and the absence of alternative alert systems for the affected residents.
Insufficient Staffing Led to Delayed Response After Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care and safety needs of a resident with significant cognitive and physical impairments. On the date in question, only four CNAs were present for the morning shift when seven were scheduled, resulting in a lower than planned direct care hours per patient day. The resident involved had diagnoses including muscle weakness, glaucoma, legal blindness, and severe cognitive impairment, and was dependent on staff for all activities of daily living and mobility. The resident experienced a fall and was found sitting on the floor with a bump on the forehead, but the documentation did not specify how long the resident was on the floor before being discovered. The assigned CNA was attending to another resident at the time of the fall, and another CNA found the resident on the floor. The Director of Nursing acknowledged that the reduced staffing could have led to a delayed response in providing care to the resident after the fall. Facility policy required resident checks at least every two hours, but the staffing shortage may have impacted the ability to meet this standard. The incident resulted in the resident being sent to the hospital for evaluation, though no injuries were found.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation practices in the kitchen. During breakfast tray line service, both the cook and a dietary aide were observed plating food without wearing masks, contrary to facility policy and infection control standards. Additionally, the dietary aide was seen returning to the tray line and handling food after touching non-food items in dry storage, without changing gloves or washing hands. The dietary aide acknowledged the importance of changing gloves and hand hygiene to prevent cross contamination but did not follow these procedures during the observed event. Further observations revealed expired food items stored in the kitchen, including bread, marshmallows, spices, and cartons of chocolate milk, some of which were unlabeled or past their expiration dates. Staff interviews confirmed that expired products were not always removed promptly and that proper procedures for checking expiration dates were not consistently followed. Facility policies reviewed indicated clear requirements for mask use, glove changes, and monitoring of food expiration dates, but these were not adhered to during the survey.
Improper Use of N95 Respirator Mask by Staff
Penalty
Summary
The facility failed to implement proper infection control interventions in accordance with its Respiratory Protection Program policy and procedure. During an observation, a Certified Nurse Assistant (CNA) was seen entering a resident care area wearing an N95 respirator mask incorrectly, with the string hanging in front of the mask. The CNA acknowledged during an interview that the mask was not worn properly, which did not provide a proper seal and could allow germs to enter or escape, potentially contributing to the spread of COVID-19. The CNA also described the correct method for donning the N95 mask, which was not followed at the time of the observation. A review of the facility's Respiratory Protection Program policy indicated that respirators must be used as certified by NIOSH or the manufacturer, and that employees are required to perform positive and negative pressure user seal checks each time they wear a respirator. The improper use of the N95 mask by the CNA was not in compliance with these established procedures, impacting all residents and staff in the facility.
Incomplete Fall Assessment Following Resident Fall
Penalty
Summary
The facility failed to perform an accurate fall assessment for one resident following a fall incident. The resident, who was admitted with diagnoses of lack of coordination and muscle weakness, was identified as high risk for falls and had a care plan in place indicating the need to follow the facility's fall protocol. Despite this, after the resident experienced a fall, the Fall Risk Evaluation completed did not document the fall event, nor did it include critical assessment elements such as the resident's level of consciousness, gait and balance, or medications. Additionally, the evaluation did not provide a fall risk score. During an interview and record review, the DON confirmed that the Fall Risk Evaluation was not completed properly and acknowledged the omission of essential information, including the recent fall and relevant assessment details. The facility's policy required a new fall risk evaluation to be conducted post-fall, but this was not done in accordance with the policy, resulting in an incomplete assessment for the resident.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies related to individualized care. For one resident with diagnoses including cerebral infarction, hemiplegia, and quadriplegia, there was an order for Restorative Nursing Assistance (RNA) involving passive range of motion exercises. Despite the resident's cognitive impairment and dependence on staff for activities of daily living, no care plan for RNA services was created until after the issue was identified during the survey. Staff interviews confirmed that a care plan should have been in place to guide interventions and evaluate the effectiveness of the RNA program. Another resident, diagnosed with muscle wasting, degenerative nervous system disease, and quadriplegia, was prescribed Risperdal, an antipsychotic medication, for schizophrenia. The medical record review revealed that there was no care plan addressing the use of antipsychotic medication. Staff acknowledged that a care plan is required for any resident receiving such medications to ensure appropriate monitoring and care. The absence of a care plan meant that staff lacked guidance on managing the resident's medication regimen and monitoring its effects. A third resident, with metabolic encephalopathy, spinal stenosis, and type 2 diabetes, was observed to have long fingernails and reported that no one had offered to trim them, despite being dependent on staff for personal care. Although a care plan was eventually created to address the risk of infection and injury related to long nails, it was not initiated at the time the problem was identified. Staff interviews and care plan history confirmed the delay in care plan development, resulting in the resident's needs not being promptly addressed.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including grooming and personal hygiene, was not provided with necessary nail care. The resident, who had diagnoses including metabolic encephalopathy, spinal stenosis, and type 2 diabetes mellitus, was observed to have long fingernails. The resident reported that no one had offered to trim her nails and expressed a desire for them to be trimmed. Multiple staff members, including a CNA, LVN, and the DON, observed and acknowledged that the resident's fingernails were excessively long and could harbor dirt and germs. The facility's policy required that residents with diabetes have their nails trimmed by a licensed nurse, but this was not done for the resident in question. Interviews with staff revealed that the long fingernails had not been reported or addressed, despite being noticeable during daily care. The DON stated that CNAs should have identified the need for nail care and reported it to the charge nurse, but this did not occur. The failure to provide appropriate nail care was confirmed through observation, interviews, and record review, resulting in the resident not receiving care and services necessary to maintain good grooming and personal hygiene.
Failure to Provide and Document Ordered Restorative Nursing Care for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative nursing program (RNA) care as ordered by physicians for two residents with limited range of motion (ROM). Both residents had significant neurological and musculoskeletal diagnoses, including cerebral infarction, hemiplegia, quadriplegia, muscle wasting, and degenerative nervous system disease, resulting in severe cognitive and physical impairments. Physician orders specified that each resident was to receive passive range of motion (PROM) exercises to both upper and lower extremities five times a week, as tolerated. Record reviews revealed multiple days in February and March when RNA services were not provided to either resident, despite the standing orders. Additionally, weekly interdisciplinary team (IDT) progress notes documenting the residents' response to therapy and progress were missing for several weeks. Staff interviews confirmed that RNA services were not always documented, and in some cases, the therapy may not have been performed. The RNA staff acknowledged that documentation was required each time therapy was provided and that missing documentation indicated the therapy was not done. Facility policies required daily and weekly documentation of RNA services and adherence to physician orders. The Director of Nursing (DON) confirmed the importance of daily and weekly documentation to monitor residents' progress and determine if further interventions were needed. The lack of consistent RNA services and documentation for these two residents constituted a failure to follow physician orders and facility policy, resulting in a deficiency.
Failure to Follow Pureed Diet Recipe Results in Improper Food Consistency
Penalty
Summary
During a breakfast meal service, a staff member was observed preparing a pureed diet for a resident, which included pureed French toast and pureed eggs. The French toast was served in a cup and had a liquid consistency, rather than the required smooth, pudding-like texture. The staff member acknowledged that the consistency was incorrect and attempted to correct it by adding more bread and blending it further, but did not follow or review the established pureed recipe. The staff member stated the importance of proper preparation for resident safety and to prevent choking. Interviews with the Kitchen Supervisor and the Director of Nursing confirmed that recipes for pureed diets are to be strictly followed to ensure appropriate consistency and nutritional value. Both emphasized that pureed foods must be smooth, hold their shape, and not be watery or liquid, as improper consistency could make swallowing difficult for residents, especially those with a history of stroke. Review of the facility's policy indicated that pureed items should be smooth, free of lumps, and not weep, which was not adhered to during the observed meal preparation.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required substantial assistance for daily activities and was at high risk for falls did not have access to a functioning call light in their room. The resident, who had a history of muscle weakness and major depressive disorder, was observed on multiple occasions screaming for help because the call light was not within reach. The call light's clip was broken, causing it to fall to the floor and remain inaccessible for at least three days. The resident reported having to scream for help daily, which made them feel angry and forgotten. On two separate occasions, the resident's roommate had to use their own call light to summon staff assistance for the resident. Staff interviews confirmed that the call light was supposed to be on the bed but kept falling due to the broken clip. Certified Nurse Assistants acknowledged that not having the call light within reach could lead to accidents or the resident feeling neglected. The Maintenance Director stated that he had not been informed about the broken call light until the morning of the second observation, despite having replacement clips available. Facility policy required that call lights be kept within reach and that defective devices be reported for immediate repair, with alternative alert systems provided if immediate repair was not possible.
Failure to Timely Develop Care Plan for Side Rail Use
Penalty
Summary
The facility failed to develop a timely care plan for the use of side rails for one resident. The resident, who was admitted with diagnoses including muscle weakness, glaucoma, and legal blindness, was assessed as having severe cognitive impairment and was dependent on staff for activities of daily living and mobility. Documentation showed that a bed rail assessment conducted on 3/4/2025 recommended bilateral side rails to promote independence and assist with bed mobility due to poor trunk control. However, although the need for side rails was identified in the assessment and supported by physician orders, the corresponding care plan addressing the use of side rails was not created until 3/18/2025, which was after the resident experienced a fall on 3/15/2025. Interviews with nursing staff and the DON confirmed that the care plan for side rails should have been implemented at the time of the assessment, but was delayed. The facility's policies required that care plans be updated based on assessed needs and specifically addressed the development of a care plan for bed rail use. The delay in care planning resulted in the resident not having the appropriate interventions in place at the time of the fall, as the side rails were not in use despite being indicated by assessment and requested by the resident's family.
Failure to Provide Ordered Side Rails Resulting in Resident Fall
Penalty
Summary
The facility failed to provide side rails as ordered for a resident with significant physical and cognitive impairments. The resident, who was legally blind, had muscle weakness, poor bed mobility, poor trunk control, and was dependent on staff for most activities of daily living. Documentation showed that a bed rail assessment recommended bilateral side rails to promote independence and provide safety, and physician orders were in place for side rails due to the resident's poor mobility. Despite these orders and assessments, side rails were not installed on the resident's bed at the time of a fall incident. On the date of the incident, the resident was found sitting on the floor with a small red lump on the forehead but no bleeding or reported pain. Interviews with nursing staff and the Director of Nursing confirmed that side rails had been recommended and ordered since earlier in the month, but were not in place at the time of the fall. The facility's policies required completion of a bed rail evaluation and installation by maintenance, but these procedures were not followed, resulting in the resident not having the necessary side rails as part of their fall prevention plan.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of a resident who was prescribed Risperidone, a psychotropic medication, for mood disorder. The resident, who had a history of schizophrenia, schizoaffective disorder, bipolar disorder, psychosis, and anxiety, exhibited aggressive behaviors such as destroying property and entering other residents' rooms. Despite these behaviors, there was no documented evidence of the number of outbursts, which was necessary to assess the effectiveness of the medication and prevent further incidents. Interviews with staff revealed that the resident had moments of aggression, but these were not consistently recorded, and the facility did not contact the doctor to reassess the medication. Additionally, the facility did not document the indication for an increased dose of Depakote, another medication prescribed to the resident for mood disorder. The dose was increased from 500 mg to 750 mg twice a day without proper documentation on the Situation, Background, Assessment, and Recommendation (SBAR) form. The Nurse Practitioner indicated that the increase was due to heightened behaviors, but this was not recorded as per the facility's standard practice. The facility's policy required monthly documentation of behavior occurrences and any adverse reactions, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in one resident slapping another on the face. Resident 1, who has Parkinson's disease, polyosteoarthritis, and major depressive disorder, was admitted to the facility in 2017 and readmitted in 2025. His cognitive skills for daily decision-making were moderately impaired. Resident 2, admitted in 2024, has schizoaffective disorder, psychosis, and anxiety disorder, with similarly impaired cognitive skills. Prior to the incident, Resident 2 exhibited aggressive behavior, including throwing objects and having outbursts. On the day of the incident, Resident 2 accused Resident 1 of stealing his girlfriend, an accusation that was unfounded and not based in reality. Despite previous aggressive behavior, there was no documented evidence of monitoring or intervention to prevent such altercations. A Registered Nurse witnessed Resident 2 slap Resident 1 while assisting him to the bathroom. The facility's policy on abuse prevention and management, which prohibits any form of resident abuse, was not effectively implemented, as staff failed to monitor and address Resident 2's behavior adequately.
Failure to Implement Hourly Monitoring for Wandering Resident
Penalty
Summary
The facility failed to implement a critical intervention in a resident's care plan, which required hourly visual monitoring for a resident at risk of wandering and elopement. This deficiency was identified during a review of the care plan and order summary report, which indicated that the intervention for the resident's risk of wandering and elopement included visual hourly monitoring. However, the Director of Nursing confirmed that no visual hourly monitoring was conducted for the resident from July 6, 2024, through August 5, 2024. The resident in question, identified as Resident 2, was admitted with diagnoses including polyneuropathy, paranoid schizophrenia, and cognitive communication deficit. The resident's Minimum Data Set (MDS) indicated a need for partial to substantial assistance with activities of daily living and supervision for mobility. Despite these needs, the facility did not adhere to the care plan's requirement for hourly visual monitoring, which was crucial given the resident's tendency to wander into other residents' rooms, as observed on multiple occasions. Interviews with staff, including registered nurses and licensed vocational nurses, revealed that the resident frequently wandered into other residents' rooms, sometimes causing distress. Staff attempted to redirect the resident but did not consistently follow the care plan's directive for hourly monitoring. This lack of adherence to the care plan placed the resident at risk for altercations with other residents, as evidenced by an incident where another resident reported being attacked by the wandering resident.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident while she was in bed. This deficiency was identified during a survey where it was observed that the call light was behind the bedside table and later found on the floor behind the resident's bed. The Director of Nursing (DON) confirmed that the call light was supposed to be within reach of the residents, acknowledging that the current placement would prevent the resident from getting help if needed. The resident involved in this deficiency had been admitted and readmitted to the facility with diagnoses including polyneuropathy, dementia, and paranoid personality disorder. The resident's history and physical indicated she did not have the capacity to understand and make decisions. Despite this, the Minimum Data Set (MDS) assessment showed that the resident was usually understood and able to understand others, requiring varying levels of assistance from staff for daily activities and being dependent on staff for mobility. The facility's policy and procedure on the call system, dated 2012, stated that call cords should be placed within the resident's reach to allow prompt communication with nursing staff. However, the failure to adhere to this policy resulted in the resident having to yell to get help, as she did not have a phone or accessible call light. This oversight had the potential to delay the resident's ability to receive timely assistance from the staff.
Failure to Implement Safe Smoking Practices
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for the safe storage of smoking materials for three residents who were smokers. Observations revealed that Resident 1 had a cigarette lighter in her purse, Resident 2 had a lighter on his wheelchair seat, and Resident 3 was holding a lighter while coming out of his room. These incidents occurred despite the facility's policy requiring the interdisciplinary team to create individualized plans for the safe storage and supervision of smoking materials. Resident 1's care plan and smoking safety form were inconsistent, leading to confusion among staff about the necessary interventions for safe smoking practices. The care plan indicated that Resident 1 required supervision while smoking, but it did not specify how her smoking materials should be stored. Similarly, Resident 2's care plan failed to address the storage of smoking materials, even though the resident was supposed to be supervised during smoking. Resident 3's care plan also lacked details on the storage of smoking materials, despite the resident's need for supervision during smoking times. The facility's failure to ensure the safe storage of smoking materials posed a significant risk to the health and safety of all residents, staff, and visitors. The lack of proper storage and supervision could potentially lead to fires, as residents had unsupervised access to lighters and cigarettes. The facility's nursing manual outlined the need for assessments and individualized care plans for smoking residents, but these were not effectively implemented, resulting in the identified deficiencies.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents who were smokers. Resident 1, diagnosed with schizoaffective disorder and nicotine dependence, was found with a cigarette lighter in her purse, unsupervised during some cigarette breaks, and without a clear plan for the safe storage of smoking materials. The care plan and smoking safety form for Resident 1 were inconsistent, leading to confusion about the necessary supervision and storage of smoking materials. Resident 2, with a diagnosis of metabolic encephalopathy and unsteadiness on feet, was observed with a cigarette lighter on his wheelchair seat. Despite requiring assistance and supervision when smoking, Resident 2 kept his smoking materials and smoked without staff supervision. The care plan did not specify how his smoking materials should be stored, and the facility's protocol for storing smoking materials was not followed. Resident 3, with severe cognitive impairment and a history of schizoaffective disorder, was seen holding a lighter and smoking unsupervised. The facility's smoking safety evaluation indicated that Resident 3 required supervision, but the smoking materials were stored in an unsecured tacklebox, raising concerns about safety. The facility's manual stated the need for a safe and hazard-free environment, which was not upheld in these cases.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the timely reporting of resident-to-resident altercations. Specifically, the facility did not report an altercation between two residents to the State Survey Agency and Ombudsman within the required two-hour timeframe. Resident 1, who has a history of cerebral infarction, atrial fibrillation, and celiac disease, reported an incident where Resident 2 blocked the door with his wheelchair and grabbed Resident 1's private parts, leading to a physical altercation. Resident 1's cognitive assessment indicated fluctuating capacity to understand and make decisions, while Resident 2, diagnosed with cardiomegaly, dementia, and schizoaffective disorder, was assessed as lacking the capacity to understand and make decisions. The Director of Nursing (DON) was unaware of the altercation, which occurred on 6/16/2024, and confirmed that the incident was not reported as per the facility's abuse policy. The facility's policy, dated 3/2018, mandates that all allegations of abuse be reported to the Administrator and appropriate agencies promptly, with serious bodily injury incidents requiring notification within two hours. The failure to report this incident placed Resident 1 and other residents at risk for further abuse, as the facility did not adhere to its established procedures for handling such situations.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility staff failed to notify the physician when a resident continued to refuse her medications, including Remeron, Buspirone, and Seroquel. This resulted in the physician being unaware of the resident's change of condition, leading to delayed medical intervention and the resident experiencing unnecessary hostile behavior. The resident, who had diagnoses including schizophrenia, bipolar disorder, metabolic encephalopathy, depression, and anxiety, was admitted with fluctuating capacity to understand and make decisions. Despite the care plan indicating the need to administer psychotropic medications as ordered, the resident refused the medications multiple times, and the licensed nursing staff did not complete a Change of Condition (COC) or notify the physician as required by the facility's policies and procedures. During interviews and record reviews, it was found that the licensed vocational nurse and the Director of Nursing acknowledged that the COC was not completed and the physician was not notified. The facility's policies and procedures clearly stated that the attending physician must be notified promptly in case of a significant change in the resident's condition, including refusal of treatment. The failure to notify the physician in a timely manner put the resident at risk for health complications and hospitalization, as evidenced by the resident's subsequent hospitalization for behavioral evaluation.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, specifically involving Resident 1 and Resident 2. Resident 1, who was admitted with diagnoses including diabetes, hypertension, dysphagia, depression, and anxiety, reported a verbal altercation with Resident 2. Resident 2, who had fluctuating capacity to understand and make decisions due to schizophrenia, bipolar disorder, depression, and anxiety, called Resident 1 derogatory names and used profanity. This incident was initially reported by Resident 1 to CNA1, who did not immediately report it to the charge nurse as required by the facility's policy. CNA1 later witnessed Resident 2 verbally abusing Resident 1 again and reported it to LVN1. Despite being aware of the situation, LVN1 did not transfer Resident 2 to a different room, believing Resident 2 did not appear aggressive or hostile at that time. This inaction led to another incident where Resident 2 became very agitated and verbally abusive towards Resident 1 and staff. The Director of Nursing (DON) was informed of the situation but was not aware that Resident 2 had not been transferred immediately. The facility's policies on abuse prevention and resident-to-resident altercations were not followed. The staff failed to separate the residents promptly and did not take appropriate actions to prevent further verbal abuse. The DON acknowledged that the staff should have transferred Resident 2 to a different room immediately to ensure Resident 1's safety and prevent further incidents of verbal abuse.
Failure to Report Verbal Abuse Incident Within Mandated Timeframe
Penalty
Summary
The facility failed to provide the State Survey Agency with a written report of findings for the investigation of an allegation of verbal abuse within five working days. This incident involved Resident 1, who was verbally abused by Resident 2. Resident 1 was admitted to the facility with diagnoses including diabetes, hypertension, dysphagia, depression, and anxiety, and was totally dependent on staff for oral, toileting, and personal hygiene. Resident 2, who had fluctuating capacity to understand and make decisions, was admitted with diagnoses including schizophrenia, bipolar disorder, depression, and anxiety. On the day of the incident, Resident 2 became very agitated and verbally abusive towards Resident 1, using racial slurs and profanity. The incident was reported to the State Survey Agency via email, but the required written report of findings was not submitted within the mandated five-day period. During an interview, the Licensed Vocational Nurse (LVN1) confirmed hearing the commotion and witnessing the verbal abuse. The progress notes indicated that Resident 2 was transferred to the hospital for a behavioral evaluation following the incident. The facility's Policy and Procedure on Reporting Abuse, revised in 2018, mandates that a written report of findings be provided to the appropriate agencies within five working days of the incident. However, the Administrator admitted that this report was not submitted to the Health Department, resulting in a failure to comply with federal and state regulations regarding the reporting of abuse incidents.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to implement the baseline care plan for a resident diagnosed with schizophrenia, bipolar disorder, metabolic encephalopathy, depression, and anxiety. Specifically, the facility did not monitor the resident's psychotropic medication side effects every shift, did not closely monitor the resident's mental status, and did not assess the resident for signs of distress or anxiety. These actions were required by the resident's care plan, which was initiated upon admission. The lack of documentation in the Medication Administration Record (MAR) and Electronic Medical Record (EMR) indicated that these interventions were not carried out by the licensed staff. During interviews, both an LVN and the Director of Nursing (DON) confirmed that there was no documented evidence of monitoring and recording the resident's medication side effects or behaviors. The DON acknowledged that the care plan was not implemented as required, which put the resident at risk for delayed care and treatment. The facility's policy and procedure for comprehensive person-centered care plans emphasized the importance of addressing resident-specific health and safety concerns to prevent decline or injury, but these guidelines were not followed in this case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents are free from verbal abuse, as evidenced by an incident involving a resident and a housekeeper. The resident, who has diagnoses including hypertension, muscle weakness, diabetes, and heart failure, reported being verbally threatened and cursed at by the housekeeper on the morning of 4/3/2024. The resident expressed feeling frustrated and scared following the altercation. This incident was corroborated by multiple staff members who either heard or witnessed the verbal exchange, although it was not immediately reported or documented as required by the facility's policies. The Licensed Vocational Nurse (LVN) on duty during the incident heard the altercation but did not witness it directly. The LVN confirmed that the housekeeper admitted to a verbal altercation with the resident but did not suspect abuse. The housekeeper involved in the incident admitted to using curse words and profanity during the altercation and reported the incident to a certified nursing assistant and his supervisor. However, the incident was not reported to the Administrator or Director of Nursing (DON) until two days later, which is against the facility's policy. The Director of Nursing (DON) and the Administrator (ADM) were made aware of the incident on 4/5/2024, and an investigation was initiated. The housekeeper was subsequently suspended, and the Social Services Designee (SSD) resigned. The facility's policies clearly state that all staff are mandatory reporters and must report any known or suspected instances of abuse immediately to the Administrator or their designee. The failure to follow these procedures resulted in a delay in addressing the verbal abuse incident, potentially causing psychological distress to the resident.
Failure to Timely Report Verbal Abuse
Penalty
Summary
The facility staff failed to timely report an allegation of verbal abuse involving a resident. The incident occurred on the morning of 4/3/2024 when the resident was verbally threatened and cursed at by a housekeeper. Despite multiple staff members being aware of the altercation, including a Licensed Vocational Nurse (LVN), the housekeeper involved, and another housekeeper who overheard the incident, the verbal abuse was not reported to the Administrator (ADM) or other required authorities immediately as per facility policy. The resident, who has a medical history including hypertension, muscle weakness, diabetes, and heart failure, reported the incident during a psychiatric evaluation on 4/6/2024. The Director of Nursing (DON) was informed of the incident on 4/5/2024, and the ADM was made aware by the resident on the same day. The ADM then reported the incident to the ombudsman and the California Department of Public Health (CDPH) within two hours of being informed. However, the delay in reporting by the staff members involved meant that the incident was not investigated in a timely manner. Interviews with the staff revealed that there was a lack of understanding and adherence to the facility's policy on reporting abuse. The LVN, housekeepers, and the DON all acknowledged that the incident should have been reported immediately to the ADM to ensure a timely investigation and to prevent further abuse. The facility's policy clearly states that all staff must report known or suspected instances of abuse to the ADM or their designee immediately, but this protocol was not followed in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
