Lodi Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lodi, California.
- Location
- 321 West Turner Road, Lodi, California 95240
- CMS Provider Number
- 055289
- Inspections on file
- 35
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Lodi Creek Post Acute during CMS and state inspections, most recent first.
A resident with diabetes, hemiplegia, and generalized muscle weakness was scheduled for twice-weekly PM showers, but EMR review showed almost all bathing entries coded as "response not required," with only two bed baths documented for the month. The resident reported routinely refusing showers and preferring bed baths, and CNAs stated they provided bed baths, notified an LN of refusals, and were responsible for documenting showers, bed baths, and refusals. However, staff frequently used incorrect EMR codes instead of documenting refusals or accurately recording provided bed baths, resulting in records that did not match the shower schedule or reported care. Nursing leadership and the DSD confirmed the inconsistency and stated that documentation should reflect actual showers, refusals, and reasons, in accordance with facility policy requiring date, time, and refusal details for bathing care.
A resident with chronic pain and depression did not receive scheduled pain and depression medications within the required time frame, with administration occurring one hour and 45 minutes late. The delay was not documented or explained, and a family member reported that this caused the resident distress and unmanaged pain. Facility policy requires medications to be given within one hour of the scheduled time.
A resident was discharged without receiving a 30-day advance written notice, and the required Notice of Transfer or Discharge was not sent to the Ombudsman on the same day. Additionally, the discharge location listed on the notice did not match the physician's order, and staff confirmed these inconsistencies and failures to follow policy.
A resident with dementia and muscle weakness was not repositioned or assisted with care needs in a timely manner, despite being at risk for pressure injuries and skin breakdown. Observations and interviews revealed that the resident was not repositioned or taken to the bathroom during a family member's visit, and documentation for care was incomplete. Staff interviews indicated inconsistencies in care provision, and the Director of Nursing acknowledged the risk of skin breakdown and discomfort due to unmet care needs.
A resident with anoxic brain injury and bipolar disorder was physically abused by another resident with Alzheimer's disease in a shared bathroom. The aggressor, who believed she owned the facility, grabbed the other resident's arm, causing a scratch. The incident was unwitnessed, and staff interviews revealed the aggressor's history of territorial behavior. The facility's policies on abuse prevention were not effectively implemented to prevent this altercation.
The facility failed to log the use of two opened emergency kits (E-Kits) containing injectable medications, as confirmed by a licensed nurse and the ADON. The missing documentation and communication with the pharmacy were not completed, contrary to the facility's policy, increasing the risk of not having necessary medications during emergencies.
The facility failed to properly label, store, and dispose of medications, leading to several deficiencies. Expired medications were found in the medication cart and storage room, and several pharmaceutical products lacked opened or discard dates. Medications with torn labels were also found, violating labeling policies. Additionally, loose medications were found in a cart, and a powdered medication was left unattended at a resident's bedside, risking medication errors and resident safety.
The facility failed to accurately test sanitizing solutions in the kitchen, potentially exposing residents to foodborne illnesses. The dishwasher's sanitizing solution was not properly checked, with faded test strips and an unknown operational temperature. Additionally, the QAC solution used for dish and surface sanitation was tested at an incorrect temperature, below the manufacturer's recommendation, compromising the accuracy of the readings.
The facility failed to follow infection control practices, including improper hand hygiene by a laundry aide, delayed enhanced barrier precautions for a resident with medical devices, and lack of hand hygiene for a resident before meals. Additionally, the ice machine was found to be improperly cleaned, with blackish growth present.
The facility failed to ensure that call lights were within easy reach and operable for six residents, including those with Alzheimer's, dementia, and other conditions. Observations revealed broken or inaccessible call lights, confirmed by CNAs and the Maintenance Director. The Director of Nursing emphasized the importance of functional call lights, as per facility policy.
The facility failed to obtain and update informed consent for antipsychotic medications for two residents. One resident's consent was not updated every six months, while another was prescribed medication without any consent. Facility policy and regulations require informed consent before administering such medications, which was not followed in these cases.
A resident admitted with an indwelling urinary catheter (IUC) did not have the IUC included in their baseline care plan within 48 hours of admission, as required by facility policy. Staff interviews confirmed the expectation that the IUC should have been documented to guide care. The omission potentially placed the resident at risk for unmet care needs.
A resident with dementia, schizophrenia, and apraxia, who did not speak English, was not provided with an effective communication care plan. Staff relied on gestures and an unofficial interpreter, despite the availability of translation services and communication boards. The resident's care plan, last revised in 2020, failed to include these resources, contrary to facility policies.
The facility failed to adhere to professional standards for two residents. One resident's PICC IV flushes were improperly documented, with nurses not recording the procedure as required. Another resident's urinary drainage bag was improperly managed, being positioned higher than the bladder, not enclosed in a privacy bag, and with kinked tubing, obstructing urine flow. These deficiencies were confirmed by staff and did not align with facility policies.
A resident with a language barrier was not provided with adequate communication support, as staff failed to use a communication board or translator service, relying instead on gestures and the resident's son for translation. This was contrary to the facility's policy, which requires the use of communication aids for residents with limited English proficiency.
The facility failed to monitor VADs for two residents, risking infection. One resident with a Midline catheter for cellulitis treatment had nine out of 23 shifts without documented assessments. Another resident with a PICC line for multiple conditions had several shifts without documented assessments. Staff interviews confirmed the lack of documentation, increasing infection risk. Facility policies required consistent monitoring, which was not followed.
A facility failed to accurately measure and record the output of a resident with ESRD receiving hemodialysis, as required by physician orders. Instead of recording the output in milliliters, staff noted the number of times the resident urinated, despite the resident being continent. This oversight was confirmed by the DON, highlighting a deviation from the facility's policy and recognized standards of care.
A resident with depression and bipolar disorder was prescribed buspirone without proper documentation of diagnosis, manifestation, or side effect monitoring. The facility's policy requires these elements for psychotropic medication management, but they were not followed, as confirmed by interviews with the Medical Record Director and nursing staff.
The facility failed to maintain freezer number six in good working order, with an observed internal temperature of 10 degrees Fahrenheit and loose door seals causing frost buildup. The Certified Dietary Manager confirmed the freezer should be at 0 degrees Fahrenheit or lower, as per facility policy and FDA guidelines. This deficiency posed a risk of foodborne illnesses due to improper food storage conditions.
A resident in an LTC facility was hit in the face with a television remote control by another resident, resulting in a scratch and bruise. The incident was witnessed by a staff member who intervened after the first strike. The victim, who has a history of cerebrovascular accident, was sent to a hospital for evaluation and diagnosed with a subconjunctival hemorrhage. The facility's policy on abuse prevention was not followed, leading to this deficiency.
A resident with dementia and a history of aggression punched another resident in the memory care unit, causing injury. The altercation occurred after the second resident accidentally ran over the first resident's foot with a wheelchair. Staff interviews revealed that both residents have severe memory problems and behavioral issues, requiring close monitoring. However, there was a lack of supervision in the hallway at the time of the incident, leading to a failure in protecting residents from abuse.
A medication cart was left open and unattended in a hallway, with LN 1 unaware of its unlocked state while sitting at the nursing station. The DON confirmed that staff are expected to lock medication carts when not in use, as per the facility's policy. This incident posed a risk for medication misuse and drug diversion.
Inaccurate EMR Documentation of Resident Bathing and Shower Refusals
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for a resident whose bathing care was not properly recorded in the electronic medical record (EMR). The resident, admitted in 2022 with type 2 diabetes, right-sided hemiplegia/hemiparesis, and generalized muscle weakness, was scheduled to receive showers on Sunday and Wednesday during the PM shift. Review of the EMR bathing record for the month of January showed that "response not required" was documented for all shifts except for three entries: one notation of "resident not available" and two entries indicating bed baths on specific dates. This documentation did not align with the facility’s shower schedule or with staff reports of the resident’s actual bathing routine. Interviews with the resident and multiple CNAs revealed that the resident routinely refused showers and preferred bed baths, which staff reported were being provided, often on the morning shift instead of the scheduled PM shift. CNAs stated that they were responsible for completing shower sheets, obtaining nurse signatures, and documenting showers, bed baths, and refusals in the resident’s chart. They also stated that when a resident refused a scheduled shower, they would notify a licensed nurse and offer the shower multiple times during the shift, then document the refusal. However, review of the EMR showed that CNAs frequently used the code "response not required" instead of documenting refusals or accurately recording when bed baths were provided. Licensed nurses and facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the EMR documentation for the resident’s showers and bed baths in January was inconsistent with expectations and the facility’s shower schedule. The DSD verified that only two bed baths were documented for the month, whereas at least eight showers should have been documented if the resident was receiving bathing twice weekly as scheduled. Both the DSD and DON stated that staff were expected to use correct coding, such as documenting refusals and appropriate reasons when showers did not occur, and confirmed that the existing charting did not meet these expectations. Review of the facility’s bath/shower policy indicated that staff were required to document the date and time of showers/tub baths and, if refused, the reasons and interventions taken, which was not consistently done for this resident.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), major depressive disorder, and osteoarthritis was admitted with a care plan identifying a risk for pain, depression, anxiety, and sleep problems related to unrelieved pain. The care plan included interventions such as administering medication as ordered. The resident was prescribed meloxicam for osteoarthritis pain, scheduled to be administered daily at 8:00 AM. On one occasion, the medication was administered at 9:46 AM, one hour and 45 minutes after the scheduled time, as confirmed by the medication administration record and interviews with facility staff. There was no documentation explaining the delay in administration. A family member reported that the late administration of the pain medication caused the resident distress and unmanaged pain. The Assistant Director of Nurses confirmed that medications are required to be administered within one hour before or after the scheduled time and that any delays should be communicated to the physician. The facility's policy also states that medications must be administered in a safe and timely manner, within one hour of the prescribed time, and based on resident need rather than staff convenience.
Failure to Provide Proper Discharge Notice and Notification to Ombudsman
Penalty
Summary
The facility failed to provide a 30-day advance written notice of discharge to a resident, as required by both federal and state regulations. The resident, who had diagnoses including acute respiratory failure, influenza, and pneumonia, was verbally informed of the discharge on the same day the facility attempted to discharge him and received the discharge paperwork at that time. There was no evidence that the resident received any prior written notification about the impending discharge before that day, despite the facility's policy and regulatory requirements for advance notice. Additionally, the facility did not send a copy of the Notice of Transfer or Discharge to the Ombudsman's office on the same day the resident was served the notice. The resident contacted the Ombudsman independently and was informed that their office had not received the required notice from the facility. Interviews with facility staff confirmed that the notice was not sent to the Ombudsman, and there was a misunderstanding among staff regarding the timing and necessity of this notification, particularly for residents with Medi-Cal coverage. Furthermore, there was a discrepancy between the discharge location listed on the resident's Notice of Transfer or Discharge and the location specified in the physician's discharge order. The notice indicated one homeless shelter, while the physician's order specified a different shelter. Facility staff, including the Social Services Director, Case Manager, and ADON, acknowledged that the discharge locations should have matched and confirmed the inconsistency. The facility's own policy requires that the specific discharge location be accurately documented and communicated.
Failure to Reposition and Assist Resident Timely
Penalty
Summary
The facility failed to meet professional standards of care for a resident who was not repositioned or assisted with care needs in a timely manner. The resident, who was admitted with diagnoses including dementia and muscle weakness, was at risk for pressure injury development and skin breakdown due to immobility and incontinence. The care plan required turning and repositioning every two hours and as needed. However, observations and interviews revealed that the resident was not repositioned or taken to the bathroom during the family member's visit from 9:30 AM to 2:30 PM. The family member reported that the resident was never repositioned or provided incontinence care during these times, which was corroborated by the lack of documentation for turning, repositioning, and incontinence care after 6 AM on the day in question. Interviews with staff indicated inconsistencies in the care provided to the resident. CNA 2 stated that care was provided between 9 AM and 9:30 AM, but could not recall subsequent care times, while CNA 3 reported that care was last provided at 1 PM. The Health Information Manager confirmed that documentation for turning and repositioning was blank after 6 AM, and there was no documentation of incontinence care after 1:18 AM. The Director of Nursing stated that it was expected for residents to be repositioned every two hours and have their toileting needs met, acknowledging the risk of skin breakdown and discomfort if care was not provided. The facility's policy on Activities of Daily Living indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including mobility and toileting support.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident grabbed her arm, resulting in a scratch. The incident occurred in an adjoining bathroom shared by the two residents. The resident who was scratched had a history of anoxic brain injury and bipolar disorder but was cognitively intact, while the aggressor had Alzheimer's disease and moderate cognitive impairment. The altercation was unwitnessed by staff, and the residents were separated immediately after the incident. The resident who was scratched reported feeling unsafe in her room following the incident. She described the aggressor entering the bathroom, grabbing her arm, and claiming ownership of the bathroom. The aggressor, who believed she owned the facility, expressed fear of harm and did not recall grabbing the other resident's arm. Staff interviews revealed that the aggressor often believed the facility was her home and did not like others in her space, which may have contributed to the altercation. The facility's policies on abuse prevention and resident-to-resident altercations were reviewed, indicating a commitment to protecting residents from abuse and investigating all altercations. However, the incident highlighted a failure to prevent resident-to-resident abuse, as the aggressor's behavior was not adequately managed to prevent the altercation. The facility's policy required reporting and investigating such incidents, but the deficiency occurred due to the lack of effective measures to prevent the altercation.
Failure to Log Emergency Kit Usage
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of its residents by not properly logging the use of emergency kits (E-Kits). During an observation and interview, it was found that two out of three E-Kits with injectable medications were opened but not logged in the E-Kit log. Licensed Nurse 3 (LN 3) confirmed the oversight and stated that the yellow forms, which should have been filled out and faxed to the pharmacy, were missing from the binder. This indicates that the necessary documentation and communication with the pharmacy were not completed as required. The Assistant Director of Nursing (ADON) verified the lack of logging for the two opened E-Kits, and the Director of Nursing (DON) expressed that staff were expected to fill out the E-Kit log form immediately upon medication removal. The facility's policy from 2007 outlines that upon removal of any medication from the E-Kit, the nurse must document the usage on an emergency kit log and fax a copy to the pharmacy. The failure to adhere to this policy increased the potential risk of not having the necessary medications available during emergencies, which could jeopardize residents' health and safety.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications, leading to several deficiencies. Expired medications, such as pantoprazole suspension and regular insulin, were found in the medication cart and storage room, despite being past their discard dates. Licensed nurses confirmed these medications should have been discarded, as per the facility's policy, which mandates that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. Additionally, several pharmaceutical products were found without opened or discard dates, including a vial of tuberculin purified protein derivative, an umeclidinium inhaler, a fluticasone furoate/vilanterol inhaler, a bottle of valproic acid oral solution, and a bottle of lactulose solution. The facility's policy requires that the date of opening be recorded on multi-dose containers, which was not adhered to in these instances. Furthermore, medications with torn and unclear labels, such as an albuterol sulfate inhaler and a budesonide and formoterol fumarate dihydrate inhaler, were found, violating the policy that requires clear labeling consistent with federal and state requirements. The facility also failed to maintain safe medication storage practices. Loose medications were found in a medication cup within a cart, and a white powdered medication was left unattended at a resident's bedside. The Director of Nursing confirmed that loose pills should be disposed of immediately and that medications should be stored in locked compartments to prevent access by wandering residents. These lapses in medication management could potentially lead to medication administration errors and jeopardize residents' health and safety.
Inaccurate Sanitizing Solution Testing in Kitchen
Penalty
Summary
The facility failed to accurately check and test sanitizing solutions in the kitchen, which could potentially expose residents to foodborne illnesses. During an observation and interview, it was found that the dishwasher sanitizing solution was not accurately checked for effectiveness. The Dietary Aide (DA 1) was unaware of the minimum operational temperature for the low-temperature dishwashing machine, which was observed to be operating at 110 degrees Fahrenheit. The sanitizing solution used was Chlorine, and the test strips used to check its concentration were faded and hard to read, with an expiration date that was not visible. This made it difficult to verify the accuracy of the Chlorine test readings. Additionally, the Quatenary Ammonium Compound (QAC) used for sanitizing dishes and kitchen surfaces was not tested at the correct temperature. DA 1 demonstrated the testing process and found the QAC solution to be at 400 ppm, but the solution was tested in cold water at 63 degrees Fahrenheit, below the manufacturer's recommended temperature range of 65 to 75 degrees Fahrenheit. The Registered Dietitian confirmed that the QAC testing result was at 400 ppm and emphasized the importance of following the manufacturer's recommendations to ensure accurate readings. The FDA Food Code highlights the necessity of accurate chemical sanitizer concentration testing to ensure effective sanitization.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices in several instances, as observed during a survey. A laundry aide was seen handling clean and soiled linen without performing necessary hand hygiene before and after glove use, which could lead to cross-contamination. The facility's policy requires handwashing after handling soiled linen and before handling clean linen, but this was not followed, as confirmed by the laundry aide and the infection preventionist. In another instance, enhanced barrier precautions (EBP) were not initiated in a timely manner for a resident with indwelling medical devices, such as a urinary catheter and a PICC line. The resident had been in the facility for over two weeks before EBP was implemented, despite the facility's policy indicating that EBP should be used for residents with such devices. This delay in implementing EBP was acknowledged by the infection preventionist, who confirmed that the best practice is to initiate EBP as soon as possible to prevent the spread of infection. Additionally, staff failed to ensure a resident performed hand hygiene before being served lunch. The resident, who required assistance with personal hygiene, was not offered hand sanitizer upon returning to the dining room, contrary to the facility's policy. Staff members acknowledged the oversight and confirmed that residents should be offered hand hygiene before meals. Furthermore, the facility's ice machine was found to be improperly cleaned, with blackish growth observed on the machine, indicating a lack of adherence to the facility's cleaning procedures.
Inoperable Call Lights in Resident Rooms
Penalty
Summary
The facility failed to ensure that call lights were within easy reach and operable for six residents, which could prevent them from contacting nursing staff when needed. Resident 51, who was admitted with Alzheimer's disease and dementia, had a call light that was broken and out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who noted the button was missing. Resident 42, diagnosed with senile degeneration of the brain, had a call light cord wrapped around the bed rail and hanging close to the floor, making it inaccessible. The CNA confirmed the call light was not within reach. Resident 14, with hemiplegia and epilepsy, was unable to locate the call light due to contractures in the right hand. A CNA had to search under pillows to find it, acknowledging the need for the call light to be closer to the resident's left hand. Resident 38, with encephalopathy and COPD, did not have a call light available, which was confirmed by the Maintenance Director. The director stated that non-working call lights should be reported immediately. Resident 30, with COPD and diabetes mellitus type 2, had a broken and inoperable call light, confirmed by a CNA. Resident 26, diagnosed with Huntington's disease and schizophrenia, also had a broken call light, as confirmed by the Maintenance Director. The Director of Nursing stated that call lights are expected to be within easy reach and functional, as per the facility's policy. The facility's policy requires that call lights remain functional and accessible at all times, and any defects should be reported promptly.
Failure to Obtain Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure informed consent for the use of antipsychotic medications for two residents, Resident 11 and Resident 20. Resident 11, who was admitted in 2021 with diagnoses of depression and bipolar disorder, had an informed consent for antipsychotic medication aripiprazole that was not updated every six months as required. The Director of Nursing (DON) confirmed that the informed consents for Resident 11's psychotropic medications were last obtained in 2021 and acknowledged the need for updates every six months. Resident 20, admitted in October 2023 with dementia, psychotic disturbance, and schizophrenia, was prescribed quetiapine fumarate for schizophrenia without an informed consent being completed. Despite being on the medication since December 2023, there was no documentation of informed consent in Resident 20's medical records. Interviews with the DON and Licensed Nurse 5 (LN 5) revealed that the facility's practice required the physician to obtain informed consent before starting antipsychotic medications, which was not adhered to in this case. The facility's policy, revised in June 2021, mandates that informed consent must be obtained and verified before the administration of psychotherapeutic drugs. Additionally, an All Facilities Letter (AFL) effective January 2024, reinforced the requirement for informed written consent before prescribing psychotherapeutic drugs, with renewals every six months. The failure to obtain and verify informed consent for Residents 11 and 20 highlights a significant deficiency in the facility's adherence to these policies and regulations.
Failure to Include IUC in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for a resident who had an indwelling urinary catheter (IUC). The resident, admitted in August 2024 with diagnoses including urinary tract infection, sepsis, and chronic kidney disease, did not have the IUC included in their baseline care plan. This omission was observed during a room visit where the resident was seen using a walker with an IUC drainage bag attached. The resident's order summary confirmed the presence of an active order for the IUC, which was initiated on the day of admission. Interviews with facility staff, including a licensed nurse, the Director of Staff Development, and the Assistant Director of Nursing, revealed that the care plan should have included the IUC to ensure staff were aware of the necessary care requirements. The facility's policy on baseline care plans, dated March 2022, mandates that such plans include physician orders and are developed within 48 hours to meet immediate health and safety needs. The failure to include the IUC in the baseline care plan potentially placed the resident at risk for unmet care needs.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to revise and implement an effective communication care plan for a resident who did not speak English, increasing the potential for inadequate and inaccurate care. The resident, who was admitted with diagnoses of dementia, schizophrenia, and apraxia, communicated in a language not understood by the staff. Observations revealed that the resident was communicating in a different language without the aid of a communication board in her room. Interviews with staff, including a CNA and a licensed nurse, confirmed that they were unaware of the specific language spoken by the resident and relied on gestures for communication. They also mentioned the presence of a relative working in the dietary department who occasionally helped with interpretation, although this person was not an official interpreter. Further investigation revealed that the facility had language communication resources, such as a communication board and 24/7 phone translation services, which were not utilized for the resident. The resident's care plan, last revised in 2020, did not include these interpreter services as interventions. The Director of Nursing acknowledged the oversight and confirmed that the care plan should have included these services. The facility's policies on translation and care plans emphasized the importance of providing meaningful access to services for individuals with limited English proficiency, which was not adhered to in this case.
Deficiencies in Documentation and Catheter Management
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. For Resident 331, the deficiency involved improper documentation of PICC IV flushes. The resident was admitted with conditions including a urinary tract infection, sepsis, and chronic kidney disease, and had an order for PICC IV flushes every shift. However, the documentation for these flushes was not completed by the nurse who performed the procedure, as required by professional standards and facility policy. Instead, nurses documented that another nurse had performed or would perform the flush, which was confirmed by the Director of Staff Development and the Assistant Director of Nursing as not aligning with facility expectations. For Resident 135, the deficiency involved improper management of a urinary drainage bag. The resident, admitted with pneumonia, urinary retention, and a urine catheter, was observed with a drainage bag positioned higher than the bladder, preventing optimal urine flow. Additionally, the drainage bag was not enclosed in a privacy bag, and the collection tubing was kinked, further obstructing urine flow. These observations were confirmed by a Certified Nurse Assistant and the Director of Nursing, who stated that the drainage bag should be positioned lower than the bladder, free of kinks, and enclosed in a privacy bag, as per facility policy. These failures in documentation and catheter management decreased the facility's potential to prevent worsening of the residents' clinical conditions. The facility's policies on medication administration and catheter care were not adhered to, leading to these deficiencies in care for Residents 331 and 135.
Failure to Provide Adequate Communication Support for Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident with a language barrier, which hindered the resident's ability to communicate basic needs. The resident, who was admitted in 2022 with a diagnosis of depression, primarily spoke Portuguese. The care plan for the resident included interventions such as providing a communication board and utilizing a translator or interpreter. However, these interventions were not implemented by the staff. During observations and interviews, it was confirmed that the staff, including a Certified Nursing Assistant and a Licensed Nurse, did not use the communication board or a translator service. Instead, they relied on body language, gestures, and the resident's son for translation, which was against the facility's policy. The Director of Nursing acknowledged that the staff should have used the communication board or phone translator as per the facility's policy, which aims to ensure meaningful access to information and services for individuals with limited English proficiency.
Failure to Monitor Vascular Access Devices
Penalty
Summary
The facility failed to ensure proper monitoring of Vascular Access Devices (VADs) for two residents, leading to potential risks of infection. Resident 282, who was admitted with cellulitis of the left lower limb, had a Midline catheter for IV antibiotics. The facility's records indicated that the midline site was to be assessed for signs of infection every shift. However, out of 23 shifts, nine shifts were not signed off as completed, indicating a lack of monitoring. Interviews with the Licensed Nurse and Director of Nursing confirmed the absence of documentation, and the Infection Preventionist emphasized the importance of monitoring to prevent infections. Similarly, Resident 331, admitted with diagnoses including urinary tract infection, sepsis, and chronic kidney disease, had a peripherally inserted central catheter (PICC) line. The order summary required the PICC line to be assessed for infection signs every shift. However, the August Medication Administration Record (MAR) showed multiple instances where the assessments were not documented, suggesting they were not performed. Interviews with nursing staff and the Director of Staff Development confirmed the lack of documentation, and the Assistant Director of Nursing acknowledged the increased infection risk due to missed assessments. The facility's policies on care plans and central venous catheter care emphasized the need for consistent monitoring and documentation to prevent complications such as infections. Despite these policies, the facility did not adhere to the required procedures, as evidenced by the missing documentation and interviews with staff. This oversight placed both residents at risk for VAD-related infections, highlighting a significant deficiency in the facility's care practices.
Failure to Accurately Measure Dialysis Patient's Output
Penalty
Summary
The facility failed to provide the necessary care and services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, identified as Resident 281, was admitted with multiple diagnoses, including ESRD and fluid overload. The facility was required to monitor and record the resident's intake and output (I&O) in milliliters every shift as part of a fluid restriction order. However, the resident's output was inaccurately recorded as the number of times urinated rather than the actual amount in milliliters, as specified in the order. During interviews and record reviews, it was revealed that Licensed Nurse 6 (LN 6) recorded the number of times the resident used the toilet instead of measuring the output in milliliters, despite the resident being continent. The Director of Nursing (DON) confirmed that the staff should have recorded the output amount in milliliters according to the order. The facility's policy on measuring and recording output, as well as the care of residents with ESRD, required adherence to physician orders and recognized standards of care, which were not followed in this instance.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medication for one resident, identified as Resident 11, out of a sample of 20 residents. Resident 11 was admitted to the facility in 2021 with diagnoses of depression and bipolar disorder. A review of the resident's Minimum Data Set (MDS) indicated mild cognitive impairment. The Order Summary Report showed that Resident 11 was prescribed buspirone, an antianxiety medication, without a documented diagnosis, manifestation, or side effect monitoring. This lack of documentation was confirmed during an interview with the Medical Record Director, who noted the absence of side effect monitoring in the Medication Administration Record. Further interviews with the Director of Nursing (DON) and Assistant DON (ADON) revealed that the psychotropic medication order was incomplete due to the missing diagnosis, manifested by, and informed consent. The ADON emphasized that without these elements, the resident or their family would not understand the reason for the medication. The facility's policy on psychotropic medication use, dated July 2022, requires indications for use and monitoring of behavior, as well as adequate monitoring for efficacy and adverse consequences, which were not adhered to in this case.
Freezer Temperature and Seal Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good working order, specifically freezer number six, which was observed to have an internal temperature of 10 degrees Fahrenheit. This was noted during an observation and interview with the Certified Dietary Manager (CDM) in the kitchen dry storage area. The CDM confirmed that the freezer's temperature should be kept at zero degrees Fahrenheit or lower. It was also noted that the freezer's door seals were not forming a tight seal, leading to an accumulation of frost inside the top part of the freezer. The CDM stated that a latch was needed to ensure the freezer door could be closed and locked properly to maintain a tight seal. The facility's policy on food storage, dated January 1, 2017, indicated that frozen foods should be stored in their frozen state unless being thawed according to the current Food Code. Additionally, a Food and Drug Administration article dated March 5, 2024, emphasized the importance of keeping freezer temperatures at 0 degrees Fahrenheit. The CDM acknowledged the loose seals and frost buildup, stating that she regularly removed the frost and that a new freezer was needed. This deficiency had the potential to cause foodborne illnesses among the residents due to improper food storage conditions.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit them in the face with a television remote control, resulting in a scratch on the nose and a bruise on the left eye. The incident occurred when the victim was resting in bed, and a staff member witnessed the perpetrator standing over the victim with the remote control in hand. The staff member intervened after the first strike but was unable to prevent the initial assault. The victim was subsequently sent to a local hospital for further evaluation, where they were diagnosed with a subconjunctival hemorrhage and a history of cerebrovascular accident with residual deficit. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse, was not adhered to in this case. Interviews with various staff members, including the Director of Nursing and the Social Services Director, confirmed that the incident was recognized as inappropriate and that the victim was more agitated and traumatized following the event. The perpetrator admitted to hitting the victim due to noise caused by the victim shaking the bed siderail. The facility's failure to prevent this altercation highlights a deficiency in ensuring resident safety and protection from abuse.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents in the memory care unit. Resident 1, who has a history of dementia and traumatic brain injury, punched Resident 2 in the face, causing a bruise and a skin tear on Resident 2's right eye. This incident was witnessed by a Licensed Nurse (LN 1) who was nearby but not directly supervising the residents at the time. The altercation began when Resident 2, who also has dementia and delusional disorders, accidentally ran over Resident 1's foot with a wheelchair, prompting Resident 1 to react aggressively. The report highlights that both residents involved in the incident have severe memory problems and behavioral issues, necessitating close monitoring and supervision. Resident 1's care plan included interventions for comfort and safety, such as checking on him every two hours, but it appears that these measures were insufficient to prevent the altercation. Staff interviews revealed that Resident 1 is known to become agitated and aggressive, while Resident 2 can be verbally aggressive, indicating a need for heightened supervision in the memory care unit. The facility's policies on resident rights and abuse prevention emphasize the need for residents to be free from abuse and the importance of adequate staffing and oversight. However, during the incident, there was a lack of supervision in the hallway where the altercation took place. Staff members, including CNAs and the Director of Nursing, acknowledged that the incident could have been prevented with closer monitoring, underscoring a deficiency in the facility's ability to protect residents from abuse by other residents.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by a medication cart being left open and unattended in the hallway. This incident was observed during a survey when Licensed Nurse 1 (LN 1) was found sitting at the nursing station, on the phone, and unaware that Medication Cart 2 was unlocked. The cart was left open in a hallway where other residents in wheelchairs and staff were present, creating a potential risk for medication misuse and drug diversion. The Director of Nursing (DON) confirmed that the expectation is for staff to lock the medication cart when not in use or when they are not in close proximity to it. The facility's policy on Medication Labeling and Storage, dated February 2023, clearly states that all medications and biologicals must be stored in locked compartments when not in use. The Administrator (ADM) indicated that LN 1 would be asked to write a statement acknowledging awareness of the unlocked cart. This deficiency highlights a lapse in adherence to the facility's medication storage policy.
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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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