Leisure Court Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 1135 Leisure Court, Anaheim, California 92801
- CMS Provider Number
- 555520
- Inspections on file
- 16
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Leisure Court Nursing Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were involved in an altercation when one resident attempted to enter another resident’s room, leading the room’s occupant to push the other in the chest, causing a fall and subsequent hip and pelvic fractures. Prior to the incident, the injured resident ambulated with supervision and required only set-up or minimal assistance for bed mobility and transfers, but afterward required partial to maximal assistance, used a two-wheeled walker, and experienced significant pain with frequent crying, screaming, and yelling. Staff, including CNAs and LPNs, reported that the resident became largely bedbound and dependent for ADLs following the event. The facility had an abuse prevention and reporting policy defining abuse as willful infliction of injury or intimidation resulting in harm, yet the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Two residents were involved in an altercation when one cognitively impaired resident pushed another who was attempting to enter her room, causing the second resident to fall, cry, and complain of left hip pain, later associated with pubic rami fractures. Staff, including an LVN and an RN, were informed of the push on the same day, and the pushing resident admitted to giving a shove. Facility policy required that allegations of physical abuse and resident-to-resident altercations with actual harm be reported to CDPH, the ombudsman, and local law enforcement within 2 hours, but the RN did not make these notifications within the required timeframe. Instead, the SOC 341 abuse report naming one resident as the victim and the other as the alleged abuser was submitted the next day, outside the mandated reporting window.
A resident with impaired decision-making capacity experienced an unwitnessed fall, cried and pointed to the hip, and reported moderate pain. An x‑ray later showed fractures of the left superior and inferior pubic rami, but nursing staff only faxed the abnormal radiology report and did not call the MD as required by facility policy. The resident had PRN acetaminophen ordered for mild pain and a Lidoderm patch ordered for hip pain, yet acetaminophen was repeatedly administered for pain scores above the mild range without notifying the MD. Required pain documentation, including a pain flow sheet and consistent recording of responses and non‑pharmacologic interventions, was missing from the record, and staff could not recall whether pain medication was given immediately after the fall.
The facility failed to maintain sanitary conditions in the kitchen, including improper use of cutting boards for raw poultry, inadequate sanitizing solution concentration, and unclean kitchen equipment. Additionally, utensils were not air-dried, and maintenance tools were improperly stored, posing contamination risks. These issues were confirmed by staff and management.
A resident was found to be self-administering Flax Seed Oil and Omegas + Tumeric supplements without a physician's order or an assessment by the IDT. Despite being cognitively intact, the resident's medical records lacked documentation of an assessment or care plan for self-administration. The facility's policy required such assessments and physician approval, which were not conducted.
A resident with a positive Level I PASRR screening for serious mental illness did not receive a required Level II mental health evaluation after being admitted to the facility. The facility failed to notify the California Department of Health Care Services Level II evaluators of the resident's admission, and no documentation was found to indicate awareness of the resident's status.
The facility failed to ensure proper PASRR screenings for two residents, as the Business Office Manager, not a qualified staff member, completed the screenings. Additionally, the facility did not follow up with DHCS when one resident's screening was closed due to unresponsiveness, risking inadequate services for the residents' mental disorders.
A resident with a forearm wound did not receive a scheduled dermatology consult due to a transportation error. The facility failed to reschedule the appointment or document follow-up actions, resulting in a deficiency in providing necessary services as ordered by the physician.
A resident with severe cognitive impairment and mobility issues did not receive the necessary restorative nursing services as ordered. The facility failed to apply carrot splints to the resident's hands and AFOs to the feet for the required duration, as per physician's orders. Observations showed the resident with contracted hands and rolled towels instead of splints, and documentation lacked evidence of the required application time.
A facility failed to document and address the elopement risk for a resident who exhibited wandering and exit-seeking behaviors. Despite staff observations of the resident's desire to leave and standing by the locked front door, the resident was not assessed as high risk for elopement, and there was no documentation of these behaviors or interventions in the medical record. Additionally, the resident was not provided with an ID bracelet as per the elopement assessment plan, and there was no care plan for the resident's non-compliance with wearing the bracelet.
A facility failed to update a resident's gastrostomy tube (GT) feeding rate and care plan according to the physician's orders. The resident's GT feeding was observed running at 60 ml/hr, despite an order to increase it to 65 ml/hr. This discrepancy was confirmed by an LVN, who acknowledged the incorrect rate and conflicting orders. The care plan also did not reflect the updated feeding rate, posing a risk to the resident's care.
A facility failed to monitor a resident's vital signs and weight after dialysis sessions on multiple occasions, as required by their policies. This oversight was confirmed through medical record reviews and an interview with an RN, highlighting a lack of documentation and follow-up with the dialysis facility.
A resident with morbid obesity was using side rails without a physician's order or informed consent, and the facility did not attempt less restrictive alternatives or develop a care plan. Staff confirmed the lack of necessary documentation and procedures, which was acknowledged by the DON.
The facility failed to administer medications as ordered and accurately document them for two residents. One resident did not receive a prescribed medication, and the MAR was inaccurately completed. Another resident's controlled medication was not documented in the MAR after administration. Additionally, narcotic inventory checks were not properly conducted, with missing signatures on the Narcotic Check Sheet.
The facility failed to ensure two residents were free from unnecessary drugs, leading to potential adverse effects. One resident was given metoprolol and clonidine despite low blood pressure readings, while another was administered metoprolol below the prescribed threshold. These actions were confirmed by RNs during interviews and medical record reviews.
The facility failed to ensure seven residents were free from unnecessary psychotropic drugs, with deficiencies in monitoring, informed consent, and documentation. Inconsistent meal intake monitoring, lack of renewed informed consents, and failure to monitor side effects were noted. These issues could lead to adverse complications and inadequate data for prescribers.
A resident did not receive their prescribed Zyprexa medication for several days due to a delay in pharmacy order transmission and delivery. The MAR was inaccurately signed, indicating administration when the medication was not available. The facility's policies for medication administration and order transmission were not followed, leading to a significant medication error.
The facility failed to ensure proper medication storage in two instances. Medication Cart A contained both orally and externally administered medications in the same compartment, confirmed by an LVN. Additionally, Medication Cart B was left unlocked and unattended in a hallway, as verified by the DON and an LVN. These lapses could negatively impact residents' well-being and increase the risk of drug diversion or misuse.
The facility failed to ensure kitchen staff competency in food safety practices, including testing sanitizing solutions and using correct cutting boards. Two dietary aides were unable to correctly test sanitizing solutions, and a cook used the wrong cutting board for raw poultry. The CDM admitted to not providing necessary in-service training, posing a risk of unsafe food handling for 94 residents.
The facility failed to provide adequate protein in vegetarian meals for two residents, one with vitamin D deficiency and hypocalcemia, and another with severe protein-calorie malnutrition and pulmonary disease. The residents received grilled cheese sandwiches with insufficient protein compared to the regular menu. The facility lacked a structured vegetarian menu and portion guidelines, leading to this nutritional deficiency.
The facility failed to ensure proper storage, preparation, and safe food handling for food brought in by visitors, risking foodborne illness for 94 residents. Staff interviews revealed inconsistencies in policy implementation, with food being stored and reheated contrary to guidelines. No recent staff training or visitor education on safe food handling was evident, contributing to the deficiency.
A facility failed to provide necessary hospice care for a resident with senile degeneration of the brain, as required by physician orders. The resident did not receive the prescribed number of visits from a Certified Home Health Aide and a Skilled Nurse over several weeks. Additionally, the facility lacked a designated hospice coordinator, leading to communication delays between the hospice provider and the facility, potentially affecting the resident's care.
The facility failed to maintain infection control in the laundry room and medication carts. Personal belongings were found in the clean folding area, risking contamination of linens. Additionally, spoon containers on Medication Carts B and C were dirty and damaged, compromising infection control during medication administration.
The facility failed to maintain essential equipment, including improper cleaning of the ice machine, a charred microwave, and ice buildup in medication and specimen refrigerators. The Maintenance Director admitted to not following manufacturer's guidelines for the ice machine, and the unsafe microwave was removed after being reported. These deficiencies were confirmed by staff, including the DON and Infection Preventionist.
The facility failed to complete entrapment assessments and record measurements during bed inspections for residents using side rails, impacting four residents. The facility's policies required regular inspections to prevent risks, but these were not followed. For example, a resident using side rails for mobility had no documented entrapment assessment, and another resident's assessment was incomplete. The Environmental Services Director confirmed these findings, acknowledging incomplete documentation and assessments.
The facility failed to maintain a homelike environment for two residents due to scratches and unpainted areas on the walls adjacent to their beds. One resident expressed a desire for the wall to be repaired and painted, while another resident, who spent most of her time in her room, also requested repairs. These observations were communicated to the Administrator.
A facility failed to notify the Ombudsman of a resident's discharge, as required by policy. The resident, admitted for short-term respite care, was discharged after one day due to aggressive behavior. Despite attempts by RN 2 to fax the notice, it was not found in the medical record, and the Ombudsman did not receive it, risking the resident's awareness of appeal rights.
A facility failed to maintain complete and accurate medical records for a resident, as documentation regarding the formulation of an advance directive was missing. The absence of this information was confirmed during a review of the resident's POLST and Advance Directive Acknowledgement form.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, as required by its abuse prevention and reporting policy. The facility’s policy, revised in 4/2024, defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm or mental anguish and emphasized protection of resident rights and investigation/reporting of alleged violations. Despite this policy, an incident occurred in which one cognitively impaired resident (Resident 2) pushed another cognitively impaired resident (Resident 1) when Resident 1 attempted to enter Resident 2’s room. On the date of the incident, the facility’s SOC 341 documented that Resident 1 tried to get into Resident 2’s room, and Resident 2 pushed Resident 1 in the chest, causing Resident 1 to back off, lose balance, and fall. Resident 2’s medical record and MDS showed severe cognitive impairment, and progress notes documented that Resident 2 stated she was trying to stop Resident 1 from entering her room and admitted to pushing her. A nurse (LVN 3) found Resident 1 on the floor near a room, crying and complaining of hip pain, with Resident 2 standing by the door and stating she had given Resident 1 “a little shove” to stop her from going into the room. Another nurse (LVN 1) confirmed that Resident 2 admitted to pushing Resident 1. Resident 1’s medical record showed that she lacked capacity to understand and make decisions and, prior to the incident, required only set-up or clean-up assistance for bed mobility and transfers and could walk 150 feet with supervision or touching assistance without an assistive device. Following the fall, Resident 1 complained of left hip pain, and radiology on the date of the incident showed fractures of the left superior and inferior pubic rami, with a subsequent CT scan at the acute care hospital confirming recent fractures of the left lateral superior pubic ramus and left inferior pubic ramus. After the incident, therapy documentation reflected a decline in functional status, with Resident 1 requiring partial to maximal assistance for bed mobility, transfers, and ambulation with a two-wheeled walker, and nursing and CNA interviews described increased pain, frequent screaming and yelling due to pain, and dependence on staff for activities of daily living. These findings support that the facility failed to protect Resident 1 from physical abuse by another resident in accordance with its abuse prevention policy.
Failure to Timely Report Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Reporting and Prevention policy and the requirements of section 1150B of the Act and state law for timely reporting of a reasonable suspicion of a crime. Facility policy required that alleged abuse resulting in serious bodily injury, including physical abuse and resident-to-resident altercations with actual harm, be reported to CDPH, the ombudsman, and local law enforcement immediately, but no later than two hours after forming the suspicion. On the date of the incident, two residents were involved in an altercation at approximately 1620–1700 hours when one resident, who had severe cognitive impairment per MDS, pushed another resident who was attempting to enter her room. Multiple staff interviews confirmed that the pushing incident was reported to nursing staff on the same day, and that the pushing resident admitted to giving the other resident a “little shove” to stop her from entering the room. The pushed resident, who lacked capacity to understand and make decisions per H&P, was found on the floor near the room, crying and complaining of left hip pain rated five out of ten. Progress notes documented the event as an unwitnessed fall, and subsequent radiology showed fractures of the left superior and inferior pubic rami, with the age of the fracture indeterminate. Despite the facility’s policy that any allegation of physical abuse and resident-to-resident altercations with actual harm be reported within two hours, the RN did not notify CDPH, the ombudsman, or local law enforcement within that timeframe. Instead, the SOC 341 report identifying one resident as the alleged victim and the other as the alleged abuser was submitted the following day at 0906 hours, outside the required two-hour reporting window. The DON later acknowledged that the incident should have been reported within two hours and that incorrect information about injury status had been relayed to him.
Failure to Notify MD of Abnormal X‑ray and Inadequate Pain Management After Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide required skilled nursing services to a cognitively impaired resident who lacked capacity to understand and make decisions. The resident was admitted in June and had an H&P documenting lack of decision-making capacity. On a later date, the physician ordered bilateral hip and pelvis x‑rays. The radiology report showed fractures of the left superior and inferior pubic rami with indeterminate age. Facility policy on Laboratory and Radiology Documentation required licensed nurses to promptly call the physician with abnormal radiology results. Nursing documentation showed the x‑ray result was faxed to the primary physician, but there was no evidence the physician was called about the abnormal finding. RN 1 confirmed the record lacked documentation of a call, and RN 2 stated he only faxed the report and did not notify the physician because the fracture age was indeterminate. The DON stated the expectation was immediate reporting of abnormal radiology results to prevent delay in treatment. The facility also failed to follow its Pain Management Protocol after the resident experienced an unwitnessed fall. On the date of the fall, documentation on the SBAR Communication Form and Progress Notes showed the resident was found on the floor, crying, pointing to the left hip, and reporting pain at 5/10. The subsequent radiology report confirmed fractures of the left superior and inferior pubic rami. Existing physician orders included PRN acetaminophen 325 mg, two tablets every six hours as needed for mild pain (1–3), and a later order for a Lidoderm 5% patch to the left hip for seven days. LVN 3, who found the resident on the floor, stated the resident was crying and complaining of hip pain but did not recall whether acetaminophen was administered after the fall. RN 1 also stated he did not know if LVN 3 gave acetaminophen at that time. Medication administration records for January showed acetaminophen was repeatedly given for pain scores that exceeded the ordered “mild pain” range, including pain levels of 4–8, and the Lidoderm patch was applied daily for seven days. Nursing progress notes and the medical record did not show that the physician was notified when the resident’s pain exceeded the mild range on multiple documented occasions. The record also lacked a pain documentation flow sheet required by the facility’s Pain Management Protocol to record each PRN dose, the resident’s response, and any non‑pharmacological interventions. RN 1 verified that pain scores of 4 and above were not reported to the physician until a later physician visit and confirmed the absence of required pain flow sheet documentation and monitoring details in the MAR.
Sanitary Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as evidenced by several observations during an inspection. The facility did not use the correct cutting board for raw poultry, which could lead to cross-contamination. Specifically, a dietary aide was observed using a red cutting board for raw chicken instead of the designated yellow one. Additionally, the sanitizing solution used for cleaning food preparation surfaces was found to be below the required concentration, with a test showing it at 150 ppm instead of the necessary 200 ppm. This was confirmed by the dietary aide and the Certified Dietary Manager (CDM), who stated that the solution should be changed every four hours or as needed. Further observations revealed that kitchen equipment and utensils were not properly cleaned or air-dried. A blender, microwave, toaster, and robocoupe were found with residues and build-up, indicating they were not clean to sight and touch. Moreover, items such as steam table pans and a blender were stored wet, which is against the requirement for air-drying to prevent microorganism growth. Maintenance tools like brooms were also improperly stored on the floor, posing a risk of contamination. These deficiencies were verified by the dietary aide and confirmed in interviews with the facility's administration and dietary management.
Failure to Assess and Plan for Resident's Self-Administration of Supplements
Penalty
Summary
The facility failed to assess and develop a plan of care for a resident who was self-administering supplements, specifically Flax Seed Oil and Omegas + Tumeric, without a physician's order or an assessment by the interdisciplinary team (IDT). The resident, who was cognitively intact with a BIMS score of 15, had been self-administering these supplements since admission. However, there was no documentation in the medical records, including the Order Summary Report and Plan of Care, to indicate that the resident had been assessed for the safety of self-administration or that a care plan had been developed. During observations and interviews, it was confirmed that the resident had the supplements at the bedside and had been taking them twice daily. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) verified the absence of a physician's order and the lack of an assessment or care plan addressing the self-administration of these medications. The facility's policy required that residents be assessed by the IDT and approved by a physician for self-administration, which was not followed in this case.
Failure to Conduct Level II Mental Health Evaluation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 106, received a Level II mental health evaluation after a positive Level I PASRR screening for serious mental illness. Resident 106 was discharged from an acute care hospital and admitted to the facility without the necessary follow-up for a Level II evaluation. The initial Level I screening, completed at the acute care hospital, indicated the need for a Level II evaluation, but this was not scheduled because the resident was discharged from the hospital, and the case was closed. Upon review, it was found that the facility did not notify the California Department of Health Care Services Level II evaluators of Resident 106's admission. RN 1 confirmed there was no documentation indicating that the evaluators were aware of the resident's current status. The facility should have conducted another PASRR Level I screening upon the resident's admission to ensure the necessary Level II evaluation was completed, which could have determined the need for specialized services for the resident.
Inadequate PASRR Screening and Follow-Up
Penalty
Summary
The facility failed to ensure that PASRR screenings for two residents were completed by the appropriate staff member. The Business Office Manager, who was not qualified according to the facility's policy, completed the PASRR Level 1 screenings for both residents. This was contrary to the requirement that a qualified staff member with knowledge of medical terminology and the residents' medical and behavioral history should complete the screenings. Additionally, the facility did not verify with the Department of Health Care Services (DHCS) when one resident's PASRR Level 1 screening was closed due to the facility staff's lack of response to multiple communication attempts by DHCS. The medical records for one resident showed that the PASRR Level 1 screening resulted in a Categorical Review, but the facility staff did not follow up with DHCS or submit a new Level 1 screening after the case was closed. An interview with a registered nurse confirmed that the Business Office Manager's computer was used to access the PASRR website, and there was no documented evidence of follow-up actions for the closed case. This lack of proper screening and follow-up posed a risk for the residents not receiving adequate services and assessments related to their mental disorders.
Failure to Provide Dermatology Consult as Ordered
Penalty
Summary
The facility failed to provide a dermatology consult for a resident as ordered by the physician. The resident, who was unable to make decisions, had a wound on the left forearm that required a dermatology consult scheduled for a specific date. However, due to an error in arranging the appropriate transportation, the resident missed the appointment. The facility did not reschedule the dermatology consult, and there was no documented follow-up to ensure the resident received the necessary care. Interviews with facility staff revealed that the licensed nurses were responsible for scheduling physician appointments and coordinating transportation if needed. Despite this protocol, the dermatology consult was not rescheduled after the missed appointment, and there was no documentation of any follow-up actions. The Director of Nursing acknowledged the findings, confirming the deficiency in providing the necessary services as ordered by the physician.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to provide necessary restorative nursing services for a resident, identified as Resident 53, who was reviewed for positioning and mobility. The deficiency was observed when Resident 53 was not applied with carrot splints to both hands and AFOs to both feet for the required duration of four hours as per the physician's order. During an initial tour, Resident 53 was observed in bed with contracted hands and no splints on the hands, although splints were present on the feet. Subsequent observations showed rolled towels on the resident's hands instead of the prescribed splints. The medical record review revealed that Resident 53 had severe cognitive impairment and was dependent on staff assistance for self-care and mobility, with impairments in both upper and lower extremities. The physician's orders specified the application of splints for five days a week for four hours as tolerated. However, the Restorative Nursing form documented only two minutes of splint application daily, lacking evidence of the required duration. Interviews with the RNA and DON confirmed the findings, indicating a failure to document the hours the splints were applied, which was necessary to assess the resident's tolerance to the splints.
Failure to Document and Address Elopement Risk for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, was free from accident hazards related to elopement risks. Despite observations and staff reports indicating that Resident 28 exhibited wandering and exit-seeking behaviors, such as verbalizing a desire to leave the facility and standing by the locked front door, the facility did not accurately assess the resident's risk for elopement. The resident was not documented as a high risk for elopement, and there was a lack of documentation regarding the resident's wandering behaviors and the interventions used. Additionally, the facility did not provide Resident 28 with an ID bracelet as per the elopement assessment plan, and there was no documentation of the resident refusing or removing the ID bracelet. Interviews with facility staff, including CNAs and the DSD, confirmed that Resident 28 had a history of expressing a desire to leave the facility and had been observed packing belongings and waiting by the door for someone to pick her up. However, there was no care plan developed to address the resident's non-compliance with wearing an ID bracelet, nor was there documentation of the resident's behaviors in the medical record. The lack of proper documentation and failure to implement the elopement protocol for Resident 28 posed a risk of delayed identification and response in the event of an elopement incident.
Failure to Update GT Feeding Rate and Care Plan
Penalty
Summary
The facility failed to ensure that the gastrostomy tube (GT) feeding rate for Resident 62 was updated according to the physician's orders and did not revise the resident's care plans to reflect the new orders. Resident 62 was observed with a GT feeding formula running at 60 ml/hr, despite a physician's order dated 9/14/24 to increase the rate to 65 ml/hr. This discrepancy was confirmed during an observation and interview with LVN 6, who acknowledged the incorrect rate and the presence of conflicting GT feeding orders. Additionally, the facility's Plan of Care for Resident 62, initiated on 4/7/24, did not reflect the updated GT feeding rate as per the physician's order on 9/14/24. The care plan continued to list the previous rate of 60 ml/hr, which was based on an earlier recommendation from the registered dietitian on 8/27/24. These failures posed a risk of not providing the necessary GT care and interventions to Resident 62, as the care plans were not aligned with the current medical orders.
Failure to Monitor Post-Dialysis Vital Signs and Weight
Penalty
Summary
The facility failed to provide necessary post-dialysis care for a resident requiring dialysis services. Specifically, the facility did not monitor the resident's vital signs and weight after returning from dialysis sessions on multiple occasions, including 12/21, 1/2, 1/4, 1/9, 1/14, 1/16, and 1/18. This lack of monitoring was confirmed through a review of the resident's medical records, which showed no documentation of vital signs or post-dialysis weight checks on these dates. Additionally, the facility's policies and procedures for dialysis care, which require the completion of a post-dialysis checklist including vital signs, were not followed. An interview with RN 1 confirmed the absence of documentation for the resident's vital signs and post-dialysis weight checks on the specified dates. The RN also verified that the resident's post-dialysis weight on 1/18 was not followed up with the dialysis facility. This oversight in monitoring vital signs and weight post-dialysis had the potential to delay care for any complications arising from the dialysis treatment.
Failure to Obtain Consent and Assess Alternatives for Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 13, remained free from accident hazards due to the use of side rails. The facility did not obtain a physician's order or informed consent for the use of side rails, nor did they review the risks and benefits with the resident or their representative. Additionally, the facility did not attempt the least restrictive alternatives before resorting to side rails, and there was no care plan developed to address the use of side rails for Resident 13. This oversight was observed during a facility tour and through interviews with the resident and staff, as well as a review of the resident's medical records. Resident 13, who had a significant diagnosis of morbid obesity and required partial to moderate assistance for bed mobility, was observed using side rails for turning and getting out of bed. Despite the resident's capacity to understand and make decisions, there was no documented evidence of a comprehensive care assessment or any attempts to use alternatives such as two-person assistance, pillows, or an overhead trapeze. Interviews with facility staff, including a CNA and an LVN, confirmed the lack of necessary documentation and procedures for the use of side rails, which was acknowledged by the Director of Nursing.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to two residents, leading to medication administration errors and documentation issues. For one resident, the facility did not administer docusate sodium as ordered by the physician, and the medication administration record (MAR) was inaccurately documented. The Licensed Vocational Nurse (LVN) responsible for administering the medication stated that she did not give the dose after clarifying the order with the physician. Additionally, the LVN admitted to documenting the administration of medications on the MAR before actually administering them, contrary to the facility's policy. For another resident, the facility failed to accurately document the administration of a controlled medication, tramadol, which was signed out but not recorded in the MAR. The LVN acknowledged that she administered the medication but forgot to document it. This oversight in documentation could lead to potential medication errors and issues with tracking controlled substances. Furthermore, the facility did not properly conduct narcotic inventory checks as required by their policy. The Narcotic Check Sheet for Medication Cart B had multiple missing nurses' signatures during shift changes, indicating that the physical inventory of controlled medications was not consistently verified by two licensed nurses. This lapse in procedure could increase the risk of medication diversion and errors in medication management.
Failure to Adhere to Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, leading to potential adverse effects. Resident 37 was administered metoprolol and clonidine despite having blood pressure readings below the parameters prescribed by the physician. Specifically, metoprolol was given on three occasions with systolic blood pressure (SBP) readings of 109, 104, and 101 mmHg, and clonidine was administered once with an SBP of 99 mmHg, all below the prescribed threshold of 110 mmHg. These actions were verified by RN 1 during an interview and medical record review. Similarly, Resident 53 was administered metoprolol on four occasions with SBP readings of 116, 116, 115, and 114 mmHg, which were below the physician's prescribed parameter of 120 mmHg. This was confirmed by RN 3 during an interview and medical record review. The failure to adhere to the prescribed parameters for medication administration had the potential to cause significant side effects such as hypotension, thereby negatively affecting the residents' health and well-being.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that seven residents were free from unnecessary psychotropic drugs, as evidenced by several deficiencies in monitoring, informed consent, and documentation. For one resident, the facility did not accurately monitor meal intake related to the use of Remeron, an antidepressant medication. The documentation of meal intake was inconsistent and did not match the CNA's Documentation Survey Report, leading to discrepancies in the monthly behavior summary. Another resident's informed consent for multiple medications, including Depakene, Remeron, and risperidone, was not renewed after six months, and the facility failed to monitor blood pressure for orthostatic hypotension as ordered by the physician. The facility also failed to monitor another resident for side effects related to the use of lorazepam, an antianxiety medication. Additionally, informed consent was not obtained prior to the administration of risperidone for another resident, and the facility did not have documentation of informed consent from the resident or their responsible party. Furthermore, informed consents for several medications, including trazodone, Zyprexa, and bupropion, were not renewed after six months for another resident, despite the facility's policy requiring such renewals. In another case, informed consents for Seroquel and Depakote were not renewed after six months for a resident, and the facility failed to renew informed consents for Depakote ER, fluvoxamine maleate, olanzapine, and risperidone for another resident. These failures had the potential to result in adverse complications from the medications and hindered the ability to provide accurate data to prescribers for dose adjustments. Additionally, these deficiencies could lead to residents and their responsible parties not being informed about their medications and potential side effects.
Failure to Administer Zyprexa as Ordered
Penalty
Summary
The facility failed to ensure that Resident 20 was free from significant medication errors, specifically regarding the administration of Zyprexa, an antipsychotic medication. The physician had ordered Zyprexa 10 mg to be administered at bedtime for the resident's schizoaffective disorder, but the medication was not administered from January 17 to January 19, 2025, as the Medication Administration Record (MAR) was left blank for these dates. The medication was only documented as administered on January 20 and 21, 2025, despite the medication not being available until January 22, 2025. This discrepancy was confirmed through interviews with LVN 1 and LVN 2, who acknowledged the medication was not on hand and that the MAR was inaccurately signed. The facility's policies and procedures for medication administration and physician orders were not followed, as the order for Zyprexa was not transmitted to the pharmacy in a timely manner, resulting in a delay in receiving the medication. The pharmacy confirmed that the order was received on January 20, 2025, but the medication was not delivered until January 22, 2025. The Director of Nursing (DON) acknowledged that the charge nurses should have followed up with the pharmacy and that it was unacceptable to document medication administration when the medication was not available. The failure to administer the medication as ordered placed Resident 20 at risk for medical complications.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in two instances involving Medication Carts A and B. In the first instance, during an inspection of Medication Cart A, it was observed that orally administered medications were stored together with externally used medications and supplies. Specifically, a box of loperamide HCL tablets, a bottle of sodium chloride tablets, Salonpas patches, and a tube of Refresh Celluvisc were found in the same compartment. LVN 1 confirmed these findings and acknowledged that these medications should not be stored together due to their different routes of administration. In the second instance, Medication Cart B was found unlocked and unattended in the hallway, with facility staff and residents passing by. This was verified by the DON and LVN 1, who admitted that the cart was left unlocked after LVN 1 had taken narcotic medications from it and forgot to lock it. These lapses in medication storage practices had the potential to negatively impact residents' well-being and increase the risk of drug diversion or misuse.
Deficiencies in Kitchen Staff Competency and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their duties, specifically in testing sanitizing solutions and using the correct cutting boards. Two dietary aides were unable to correctly test the sanitizing solution used for food preparation surfaces and equipment. One dietary aide held the test strip in the solution for an incorrect duration, resulting in an inaccurate reading of 150 ppm, which was confirmed to be incorrect. The Certified Dietary Manager (CDM) admitted that no in-service training on testing the sanitizing solution had been provided to the kitchen staff. Additionally, another dietary aide was unable to demonstrate or describe the manual dishwashing procedure, including testing the concentration of the sanitizing solution. Although the CDM provided in-service training and written instructions, there was no return demonstration required to evaluate the employee's competency. This lack of competency evaluation posed a risk of improper sanitization of dishes, potentially leading to foodborne illnesses among the 94 residents receiving food from the kitchen. Furthermore, a cook was observed using the wrong cutting board for raw poultry, using a red board instead of the designated yellow board. The CDM confirmed that no in-service training on the proper use of cutting boards had been conducted in 2024. These deficiencies in staff training and competency evaluation in food safety practices posed a risk of exposure to unsafe food handling practices for the residents.
Nutritional Deficiency in Vegetarian Diets
Penalty
Summary
The facility failed to meet the nutritional needs of two residents who were on vegetarian diets. During a lunch meal service, these residents received a grilled cheese sandwich that provided only nine grams of protein, compared to the 28 grams of protein provided by the regular menu's meatloaf entree. This discrepancy was observed during a review of the facility's meal service and dietary documentation. The facility's documentation did not include a specific vegetarian menu or portion sizes, which contributed to the inadequate protein provision for these residents. Resident 11, who had a medical history of vitamin D deficiency and hypocalcemia, was observed receiving a lunch tray with a grilled cheese sandwich, peas, and juices. Resident 70, diagnosed with severe protein-calorie malnutrition and pulmonary disease, received a similar meal. Interviews with facility staff revealed that there was no established vegetarian menu or portion guidelines, and the Registered Dietitian confirmed that vegetarian meals should be nutritionally equivalent to regular menu entrees. The lack of a structured vegetarian menu and portion sizes led to the nutritional deficiency observed in these residents' meals.
Deficiency in Safe Food Handling Practices for Visitor-Brought Food
Penalty
Summary
The facility failed to ensure proper storage, preparation, and safe food handling practices for food brought in by family members or visitors, which could potentially lead to foodborne illness among the 94 residents receiving an oral diet. The facility's policy, revised in July 2019, discourages visitors from bringing potentially hazardous foods and mandates that such foods be consumed immediately or discarded, without reheating or storage. However, interviews with staff revealed inconsistencies in the implementation of this policy. RN 1 stated that food could be stored for 24 hours, and RN 4 confirmed that food could be reheated in a microwave at Nursing Station 1, which was observed to be unclean. Additionally, there was no evidence of recent training on safe food handling for staff, and no information was provided to visitors regarding safe food handling practices. The Director of Nursing (DON) and Infection Preventionist (IP) were unaware of any written information provided to visitors about safe food handling, and the IP confirmed that no education on safe food handling had been provided to staff. The facility's failure to adhere to its own policy and lack of staff training and visitor education on safe food handling practices contributed to the deficiency. This oversight had the potential to compromise the health and safety of residents by increasing the risk of foodborne illnesses.
Failure to Provide Required Hospice Services
Penalty
Summary
The facility failed to provide necessary hospice care services for a resident, identified as Resident 49, who was under hospice care for senile degeneration of the brain. The facility did not ensure that the resident received the required hospice care visits, which included three weekly visits by a Certified Home Health Aide (CHHA) and one to three weekly visits by a Skilled Nurse (SN). Over several weeks, there were multiple instances where the CHHA visits were fewer than ordered, and there was no documented evidence of SN visits. This lack of adherence to the prescribed hospice care schedule was confirmed through a review of the resident's medical records and hospice visit logs. Additionally, the facility did not assign a designated hospice coordinator to oversee and coordinate the hospice services for Resident 49. This absence of a hospice coordinator led to delays in communication between the hospice provider and the facility, potentially affecting the resident's care. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the visitation logs had not been reviewed, and the facility acknowledged the need for a hospice coordinator to ensure the hospice care plan was followed as intended.
Infection Control Lapses in Laundry and Medication Cart Areas
Penalty
Summary
The facility failed to implement appropriate infection control practices in two key areas, as observed during a survey. In the laundry room's clean folding area, personal belongings of employees and residents were found, including a large pink purse, a cellphone charger, lotion, eye goggles, bottled water, a remote control, and reading glasses. The Environmental Services Director (ESD) confirmed these findings and acknowledged that the items should not be present in the clean area as they could contaminate clean clothes and linens. The ESD was unable to confirm if the items from the soiled linens, such as the reading glasses and remote control, were sanitized. The Infection Preventionist (IP) also confirmed that the clean folding area should be free of personal belongings to prevent contamination. Additionally, the facility failed to maintain cleanliness and integrity of the spoon containers on Medication Carts B and C. The spoon container on Medication Cart B had broken plastic pieces, while the container on Medication Cart C was cracked and taped. Both containers were observed to have dirt and a brown dry substance on them. The IP verified these observations and stated that the spoon containers should be clean to prevent the spread of infection, as they are used for medication administration.
Deficiencies in Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain essential equipment in proper working order, as evidenced by several deficiencies. The ice machine was not cleaned and sanitized according to the manufacturer's guidelines. The Maintenance Director admitted to using incorrect proportions of descaler and water for cleaning and sanitizing, which did not align with the manufacturer's instructions. This discrepancy was confirmed during an interview with the Maintenance Director, who stated that the ice machine was cleaned monthly by the facility's staff and annually by an external company. Additionally, the microwave at Station 1 was found to be in an unsafe condition, with a charred and burnt interior. This was confirmed by RN 1, who stated that the microwave was used to heat food brought in for residents. The Maintenance Director was notified and removed the microwave. Furthermore, ice buildup was observed in two medication refrigerators and one specimen refrigerator, which was verified by the DON and the Infection Preventionist during inspections. These issues indicate a failure to maintain equipment in a safe and sanitary condition, potentially affecting the well-being of residents.
Deficiency in Bed Entrapment Assessments and Inspections
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using side rails. This deficiency was observed in four residents who were reviewed for side rail use. The facility also did not conduct regular inspections of all beds, which could potentially lead to resident entrapment, serious injury, or death. The facility's policies and procedures required regular inspections and assessments to prevent such risks, but these were not adequately followed. For Resident 13, there was no documented evidence of an entrapment assessment prior to the installation of side rails, despite the resident's use of the rails for mobility assistance. The maintenance department was responsible for installing the side rails and measuring gaps, but the necessary assessments were not completed. Similarly, Resident 29's records showed that while the resident requested grab bars and understood the risks, the entrapment assessment was incomplete, with certain zones not evaluated. The maintenance staff was responsible for these evaluations, but the documentation was inconsistent and incomplete. Resident 37's records indicated that while the resident was cognitively intact and used grab bars for mobility, the entrapment assessment was not fully conducted, with some zones marked as not applicable without proper justification. Additionally, Resident 5's records showed that the entrapment assessment did not include Zone 2, which was necessary for a complete evaluation. The Environmental Services Director confirmed these findings, acknowledging that the assessments were not conducted with the resident in bed and that documentation was lacking for beds without grab bars.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, identified as Resident 72 and Resident 4, due to the presence of scratches and unpainted areas on the walls adjacent to their beds. During an observation and interview, Resident 72, who was lying in her bed in Room A, expressed that having the wall repaired and painted would be nice. Similarly, Resident 4, who was observed lying in her bed watching television in Room B, stated that she spent most of her time in her room and would like the wall to be repaired. These conditions were noted during observations conducted on January 22, 2025, and the findings were communicated to the Administrator on January 27, 2025.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a notice of transfer or discharge to the Ombudsman for a resident, identified as Resident 109, who was reviewed for closed records. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in January 2017, mandates that a copy of the notice of transfer or discharge be sent to a representative of the Office of the State Long-Term Care Ombudsman and that the reasons for the transfer or discharge be recorded in the resident's medical record. However, during the review, it was found that the Ombudsman did not receive the notification of discharge for Resident 109, which was confirmed by the Ombudsman herself. Resident 109 was admitted to the facility for short-term respite care but was discharged after one day due to aggressive and combative behaviors. The Social Services Director (SSD) confirmed that the notification of discharge was supposed to be provided to the responsible party, the Ombudsman, and the VA hospital in this case. Despite attempts by RN 2 to fax the notice of discharge to the Ombudsman on the day of the resident's discharge, the notice was not found in Resident 109's medical record, and the Ombudsman did not receive it. This oversight posed a risk of Resident 109 and their representative not being aware of their appeal rights, potentially jeopardizing the appeal process if they felt the discharge was inappropriate or involuntary.
Incomplete Documentation of Advance Directive for a Resident
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately maintained. Specifically, the medical record for Resident 8 lacked documentation regarding the formulation of an advance directive. During a review of Resident 8's POLST, Section D, dated 10/14/20, and the Advance Directive Acknowledgement form dated 8/22/24, it was found that there was no documentation indicating whether Resident 8 had formulated an advance directive. This deficiency was confirmed during an interview and concurrent medical record review with the SSD on 1/22/25.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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