Lodi Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lodi, California.
- Location
- 1334 S. Ham Lane, Lodi, California 95242
- CMS Provider Number
- 555049
- Inspections on file
- 23
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lodi Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident was not given the required SNF ABN notification after their Medicare Part A skilled services ended and they remained in the facility as an LTC resident. Staff confirmed that the notice, which should inform the resident of changes in coverage and potential financial liability, was not provided as required by facility policy.
A resident with severe mobility impairments and high fall risk was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat, as recommended by therapy. The care plan was not updated with these critical rehabilitation instructions, and staff relied on verbal communication rather than documented interventions. This led to the resident falling from the wheelchair and sustaining a head injury.
The facility failed to maintain food safety and sanitation standards, with issues including an unclean ice machine, improper food handling without gloves, expired coffee machine water filter, damaged utensils, and unclean equipment. These deficiencies posed a risk of foodborne illness to residents.
The facility failed to ensure functional and accessible call lights for residents, affecting their ability to contact staff for assistance. Residents with various medical conditions were given ineffective alternatives like hand bells, leading to longer wait times. Observations revealed nonfunctional call lights and inadequate systems for notifying staff, with issues escalated but not resolved due to cost. Staff confirmed the importance of call lights being within reach, but this was not consistently practiced, resulting in deficiencies in resident care.
The facility failed to ensure proper food safety practices, as staff were observed handling food without gloves, posing a cross-contamination risk. Additionally, weekly thermometer calibrations were not completed as required, potentially affecting food safety. These deficiencies could expose residents to bacterial contamination and foodborne illnesses.
The facility failed to ensure pureed food was of acceptable texture and palatability for residents on a pureed diet. Observations revealed that the cook did not follow the recipe for dilled zucchini and carrots, resulting in discoloration due to overcooking. Additionally, a puree beef entree was too thin, posing a choking hazard. These issues affected six residents, potentially impacting their nutritional status.
The facility failed to provide snacks that met residents' preferences, as revealed by resident council meetings and interviews. Two residents reported not receiving preferred snacks, such as cheese and meat sandwiches, due to shortages. Staff interviews highlighted inconsistencies in snack availability, and the facility's policies on food preferences were not followed, potentially impacting residents' nutrition and health.
The facility failed to implement proper infection control measures, as a used urinal in a shared bathroom was not labeled, and shared medical devices like glucometers and blood pressure devices were not adequately cleaned between uses. Staff confirmed these lapses, which contradicted facility policies and CDC guidelines.
The facility failed to maintain the low-temperature dishwashing machine at the required 120 degrees Fahrenheit, operating instead at 90-100 degrees. The booster equipment was non-functional for a week, and staff confirmed the temperature should be higher to ensure sanitation. This failure posed a potential health risk to residents.
A resident with dysphagia and muscle weakness was not treated with dignity during meal assistance. A CNA stood over the resident while feeding him, contrary to policy requiring staff to be at eye level. The CNA also referred to residents needing meal assistance as 'feeders,' which violates the facility's dignity policy. The DON confirmed these actions were dignity issues.
A resident experienced a lack of privacy due to a non-functioning curtain in their room, which staff were unaware of. The resident, admitted with muscle weakness, expressed concerns about privacy, and interviews with a CNA and the Director of Maintenance confirmed the issue. The DON highlighted the importance of functioning curtains for resident dignity.
A resident with a history of neoplasm, anxiety, and heart failure was not provided with adequate nail care, resulting in long, thick, and discolored toenails causing discomfort. Despite being on a podiatry list, staff failed to trim the resident's nails, citing a lack of appropriate tools and misunderstanding of policy. Facility policies emphasize the importance of grooming and foot care, yet staff did not address the issue, impacting the resident's quality of life.
A resident with a history of femur fracture and mobility issues did not receive restorative nursing services after physical therapy was discontinued due to insurance limitations. Despite recommendations for a restorative nursing program to maintain the resident's functional status, these services were not provided, as confirmed by facility staff. The facility's policies indicate that such care should be provided to promote safety and independence.
A resident with an indwelling catheter was observed multiple times with their urinary collection bag positioned above bladder level, contrary to facility policy and professional standards. Staff confirmed the bag should be below the bladder to prevent infection. The resident's care plan highlighted the risk of complications, including UTIs, due to catheter use, yet the deficiency persisted.
The facility failed to ensure safe medication storage practices, as staff's personal belongings were found in a medication storage room, and loose pills were discovered on the floor and in a cabinet. The DON acknowledged these practices were unacceptable due to risks of cross-contamination and drug diversion.
A resident with dysphagia and no teeth was not provided with the recommended mechanical soft texture diet, receiving instead a regular texture meal that was difficult to chew. Despite the Registered Dietitian's recommendation, the facility failed to implement the appropriate diet, potentially impacting the resident's nutrition and leading to weight loss.
The facility failed to provide adequate hydration for two residents, as observed when one resident's water pitcher was empty and another resident had no water pitcher available, despite expressing thirst. A CNA confirmed the risk of dehydration due to the lack of water availability. Interviews with the RD and DON indicated that water should be readily available unless there are fluid restrictions, aligning with the facility's hydration policy.
Failure to Provide SNF ABN Notification After End of Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident after the end of their Medicare Part A skilled services coverage. According to interviews and record reviews, the resident's Medicare Part A coverage ended, but the resident continued to stay in the facility as a long-term care resident. The Admissions Coordinator confirmed that the SNF ABN notice, which informs residents of changes to their Medicare coverage and potential financial liability, was not issued when the skilled services ended. The Social Services Director and Director of Nursing also confirmed that there was no documentation in the resident's medical record indicating that the SNF ABN was provided. Facility policy requires that Medicare beneficiaries be informed of their potential liability for payment and that the SNF ABN (Form CMS-10055) be issued before providing items or services not covered by Medicare. Staff interviews revealed that the SNF ABN should have been given three days before the last covered day to ensure the resident was aware of their rights and had the opportunity to appeal. The failure to provide this notice was acknowledged by facility staff, and it was confirmed that the resident did not receive the required notification.
Failure to Update Care Plan and Ensure Safe Wheelchair Use Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure an accident-free environment and provide adequate supervision to prevent accidents for a resident with significant mobility impairments. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, paraplegia, and contractures, was assessed as having a high risk for falls and was totally dependent on staff for transfers and mobility. The care plan did not include updated or specific instructions from the rehabilitation department regarding the use of a recliner wheelchair and a non-slip mat (Dycem), which were necessary to safely position the resident and prevent falls. On the day of the incident, nursing staff placed the resident in a regular upright wheelchair instead of the recommended recliner wheelchair with a Dycem. The staff relied on verbal communication and did not have access to therapy notes or updated care plan interventions. The resident was left in a 90-degree upright position in the wheelchair, became agitated, and attempted to push himself forward, resulting in a fall and a minor head laceration. Interviews with staff revealed that the specific rehabilitation instructions were not documented in the care plan, and staff were unaware of the need for a recliner wheelchair and Dycem for this resident. The facility's policies required that care plans be updated as residents' conditions changed and that interventions be clearly documented to prevent accidents. However, the care plan for this resident lacked the necessary details about the type of wheelchair, positioning, and supervision required, leading to a breakdown in communication between the rehabilitation and nursing departments. This omission directly contributed to the resident being placed in an unsafe position, resulting in a fall and injury.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and facility policy for food service, resulting in multiple deficiencies. The ice machine was not cleaned according to the manufacturer's guidelines and facility policy, with visible black and brown substances and debris found inside the machine. The Maintenance Director and Dietary Services Manager acknowledged the internal areas with debris, and the Registered Dietitian emphasized the risk of food-borne illnesses from dirty ice. The facility's policy required monthly cleaning of the ice machine, which was not followed. During a trayline observation, food handling practices were found to be unsanitary. Cooks and dietary aides were observed preparing and serving food without wearing gloves, and one cook placed a bare thumb inside a disposable dish. The Dietary Services Manager and Registered Dietitian both stated that gloves should be worn to prevent cross-contamination, aligning with the FDA Food Code that prohibits bare hand contact with ready-to-eat food. Additional deficiencies included an expired coffee machine water filter, damaged serving utensils, and unclean equipment. The coffee machine's water filter was expired by 18 months, contrary to the manufacturer's recommendation for annual replacement. Serving ladles and scoops had melted handles with grime, posing a risk of contamination. A griddle top collection tray was found with grime and food residue, and expired curry powder and discolored parsley were noted in storage. These issues collectively had the potential to cause widespread foodborne illness among the 61 residents consuming facility-prepared meals.
Deficiency in Call Light Functionality and Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of eight residents by not ensuring that their call lights were functional or within reach. Residents with various medical conditions, including ataxic gait, acute respiratory failure, epilepsy, and muscle weakness, were affected. The call lights for several residents were nonfunctional, and alternative means such as hand bells were provided, which were not effective in alerting staff promptly. This led to longer wait times for assistance, particularly for residents experiencing pain or needing to use the restroom. During observations, it was noted that call lights in multiple rooms were not working, and only one resident per room was given a hand bell to notify staff on behalf of others. This system was inadequate, especially when the resident with the hand bell had no visibility of their roommates. Staff confirmed that the call system had been down for 6-12 months, and the issue had been escalated to corporate, but repairs were denied due to costs. The facility's policies emphasized the importance of maintaining adaptive devices for residents, but these were not adhered to. Additionally, a resident's call light was found underneath the bed and out of reach, preventing them from contacting staff when needed. Staff interviews confirmed that call lights should be within reach to ensure residents can ask for help, and failure to do so increases the risk of unmet needs and falls. The facility's policy required call lights to be placed within reach before staff left the room, but this was not consistently practiced, leading to deficiencies in resident care.
Food Safety and Thermometer Calibration Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen staff adhered to proper food safety and sanitation practices, as observed during a tray line inspection. Two cooks and two dietary aides were seen handling food without wearing gloves, which is against the facility's policy and the FDA Food Code 2022. One cook was observed placing her bare thumb inside a foam container while serving meatloaf, and another was preparing dessert plates without washing her hands or wearing gloves. The dietary aides were also seen placing food trays onto carts without gloves. Interviews with the Dietary Services Manager and a Registered Dietitian confirmed that these practices posed a cross-contamination risk. Additionally, the facility did not complete weekly thermometer calibrations as required by their policy. A review of the WEEKLY THERMOMETER CALIBRATION CHART showed that calibrations were not performed weekly, with gaps of several weeks between calibrations. This was confirmed during an interview with a cook, who stated that calibrations depended on the cooks' schedules. The Dietary Services Manager acknowledged the failure to adhere to the weekly calibration schedule, which could result in food items not being at the correct temperatures. The facility's failure to follow proper food handling and thermometer calibration procedures had the potential to expose residents to bacterial contamination and foodborne illnesses. The facility's policies and the FDA Food Code emphasize the importance of wearing gloves during food preparation and maintaining accurate thermometer readings to ensure food safety. The census at the time of the survey was 61 residents, all of whom could be affected by these deficiencies.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that food served to residents on a pureed diet was of acceptable texture and palatability. During an observation, it was noted that the cook did not follow the pureed recipe as written for the preparation of dilled zucchini and carrots. The puree mixture was observed to have a dark brownish color, which was attributed to being kept in the oven for too long. The Dietary Services Manager (DSM) and Registered Dietitian (RD) confirmed that the oven's high temperature led to discoloration and potential loss of nutritional value. The facility's recipe for dilled carrots and zucchini specified simmering and steaming the vegetables until tender, which was not adhered to. Additionally, during a test tray observation, the puree of a beef entree was found to be too thin and not of the desired mashed potato consistency. The DSM confirmed that extra gravy was added, making the puree too watery, which could pose a choking hazard and aspiration risk. The facility's policy on food preparation emphasized using approved recipes and preparing foods close to serving time to preserve nutrition and prevent overcooking. These failures affected six residents on a pureed diet, potentially impacting their meal intake and nutritional status.
Failure to Meet Residents' Snack Preferences
Penalty
Summary
The facility failed to ensure that residents received snacks that met their preferences, as evidenced by observations, interviews, and record reviews. The resident council meeting minutes from April 2024 to October 2024 revealed ongoing concerns about the lack of regular snacks and nourishments. During a resident council meeting, residents expressed dissatisfaction with the availability and variety of snacks, noting that dietary preferences were not being met. This issue was further highlighted by the experiences of two unsampled residents, who reported not receiving snacks or alternative meals that aligned with their preferences. Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation, reported not receiving alternative meals and foods she liked, such as cottage cheese, oatmeal, and yogurt. Despite having an intact cognitive status, she had not communicated her food preferences to the Registered Dietitian. Similarly, Resident 63, with diagnoses including cellulitis, hyperlipidemia, hypertension, and constipation, expressed a preference for cheese and meat sandwiches and crisp rice cereal treats, but noted that the facility consistently ran out of these items. Interviews with staff members revealed inconsistencies in the availability and distribution of snacks, with some staff unaware of the residents' unmet needs. The facility's policies on food preferences and nourishment indicated that residents' food preferences should be adhered to and that suitable, nourishing alternative meals and snacks should be provided. However, interviews with the Administrator, Director of Nursing, Dietary Services Manager, and Registered Dietitian revealed a lack of awareness and communication regarding the residents' snack preferences and the facility's failure to consistently offer a variety of snacks. This deficiency had the potential to impact the residents' nutrition and health status, as the facility did not adhere to its policies and procedures regarding food preferences and nourishment.
Infection Control Lapses in Shared Equipment and Facilities
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, as observed during a survey. In one instance, a used urinal in a shared bathroom was not labeled with a resident identifier, which was confirmed by a Certified Nursing Assistant (CNA). The CNA acknowledged that the urinal should have been cleaned after use and labeled with a resident identifier to prevent cross-contamination among the three residents sharing the bathroom. The Infection Preventionist and the Director of Nursing also confirmed that the urinal should have been labeled to prevent potential cross-contamination. Additionally, the facility did not adhere to proper cleaning protocols for shared medical devices. Observations revealed that a Licensed Nurse (LN) used a glucometer and blood pressure device on multiple residents without adequately cleaning and disinfecting them between uses. The LN used a single wipe to quickly clean the glucometer's outer surface, contrary to the facility's policy and manufacturer's instructions, which require thorough cleaning and disinfection. The Director of Staff Development confirmed that the glucometer should be cleaned with a specific type of wipe and allowed to remain wet for a specified time to ensure proper disinfection. The facility's policies and procedures, as well as CDC guidelines, were not followed, leading to potential risks of infection spread among residents. The facility's policy required cleaning and disinfecting reusable items between residents, and the CDC guidelines emphasized the importance of cleaning and disinfecting glucometers between uses to prevent the spread of infectious agents. The failure to adhere to these protocols was acknowledged by the facility staff during interviews.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the kitchen equipment in a safe and operable manner, specifically the low-temperature dishwashing machine, which was not reaching the required wash temperature of 120 degrees Fahrenheit. During an observation, the dishwashing machine was found to be operating at temperatures between 90-100 degrees Fahrenheit. Dietary Aide 1 confirmed that the booster equipment, which is responsible for heating the water to the correct temperature, had been non-functional for a week. This issue was corroborated by the Maintenance Director and the Dish Machine Vendor Technician, both of whom stated that the wash temperature should be at least 120 degrees Fahrenheit. The Dietary Services Manager initially misunderstood the temperature requirements but later acknowledged the mistake, recognizing the potential health risks to residents if proper temperatures were not maintained. The Registered Dietitian also confirmed that the inadequate temperature could result in bacteria not being killed, posing a risk of illness to residents. The facility's policy and the FDA Food Code both specify the necessity of maintaining the dishwashing machine at the correct temperature to ensure sanitation and safety, which was not adhered to in this instance.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of Resident 10. Resident 10, who was admitted with diagnoses including dysphagia and muscle weakness, required supervision and assistance with eating. During an observation, CNA 1 was seen standing over Resident 10 while assisting him with his meal, which is contrary to the facility's policy that requires staff to be at eye level with residents during meal assistance. CNA 1 acknowledged that standing over a resident could make them feel uncomfortable and confirmed that she should have been sitting while assisting Resident 10. Additionally, CNA 1 referred to residents who needed assistance with meals as 'feeders,' which is against the facility's policy of addressing residents by their name of choice and not labeling them by their care needs. This was confirmed during an interview with the Director of Nursing, who stated that such terminology and actions were dignity issues. The facility's policies on assistance with meals and quality of life emphasize the importance of treating residents with dignity and respect, which was not adhered to in this instance.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to protect the privacy of a resident, identified as Resident 45, due to the absence of functioning privacy curtains in their room. Resident 45, who was admitted in the fall of 2023 with a diagnosis of muscle weakness, pointed out that the curtain in their room was unable to close completely, resulting in a lack of privacy since their admission. This issue was confirmed during an observation and interview with the resident, who expressed concerns about the lack of privacy. Further interviews with facility staff, including a CNA and the Director of Maintenance, revealed that the staff was unaware of the missing curtain. The CNA acknowledged that without the curtain, providing privacy during care would be challenging. The Director of Maintenance stated that residents could request curtain replacements, but was not aware of the issue in Resident 45's room. The Director of Nursing emphasized the expectation for complete and functioning curtains to maintain resident dignity and prevent embarrassment. The facility's policy on dignity and privacy was reviewed, indicating staff should promote and protect resident privacy during personal care and treatment procedures.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 43, who was admitted with diagnoses including neoplasm of the bladder, anxiety, and heart failure. The resident's Minimum Data Set indicated the need for supervision or assistance with personal hygiene. Despite this, the resident's toenails were observed to be long, thick, curved, and discolored, causing discomfort and pain. The resident reported that staff had not trimmed his toenails for months, despite multiple requests and being informed that he was on a podiatry list. Interviews with facility staff, including the Social Services Director, Licensed Nurse, and Director of Nursing, confirmed the resident's toenails were not trimmed and that he was not diabetic or suffering from vascular disease, which would necessitate podiatric intervention. The facility's policies on foot care and quality of life emphasize the importance of maintaining residents' mobility and dignity through proper grooming, including nail care. However, the staff acknowledged that the resident's toenails were not trimmed due to the lack of appropriate tools and the assumption that only a podiatrist could perform the task, despite the facility's policy allowing trained staff to provide routine foot care.
Failure to Provide Restorative Services Post-Physical Therapy
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as Resident 35, after the discontinuation of physical therapy. Resident 35 was admitted to the facility with diagnoses including a fracture of the lower end of the right femur, abnormalities of gait and mobility, and muscle weakness. The resident's care plan indicated a self-care deficit requiring extensive assistance with bed mobility, toileting, and personal hygiene. Despite recommendations for continued restorative nursing services following the end of physical therapy, these services were not provided. Resident 35's physical therapy was discontinued on December 21, 2023, due to insurance limitations, although the resident still required moderate assistance for mobility and self-care activities. The physical therapy discharge summary recommended a restorative nursing program to maintain the resident's current level of performance and prevent decline. However, the resident did not receive these services, as confirmed by interviews with the Restorative Nursing Assistant and the Director of Nursing. The facility's policies on restorative nursing and rehabilitation services indicate that residents should receive restorative care as needed to promote safety and independence, especially after discharge from rehabilitative care. Despite these policies, Resident 35 did not receive the recommended restorative nursing services, which could have helped maintain or improve her functional status. This oversight was acknowledged by the facility's Director of Nursing during the investigation.
Improper Positioning of Urinary Collection Bag for Resident with Catheter
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, as the urinary collection bag was repeatedly observed positioned above the resident's bladder level. This improper positioning was confirmed by multiple staff members, including CNAs and LNs, who acknowledged that the urinary collection bag should be kept below the bladder to ensure proper urine drainage and prevent infection. Despite the facility's policy and professional standards indicating the necessity of keeping the collection bag below the bladder, observations on multiple occasions showed the bag placed on the upper bed rail, above the bladder level. The resident involved had a history of obstructive uropathy and was at high risk for complications, including urinary tract infections, due to the use of a Foley catheter. The resident's care plan specifically noted the need to keep the drainage bag below the bladder level to mitigate these risks. Interviews with the Infection Preventionist and the Director of Nursing further confirmed the potential risks associated with improper catheter bag positioning, such as urinary retention and infection. Despite these guidelines and the resident's care plan, the deficiency persisted, as evidenced by repeated observations of the improper placement of the urinary collection bag.
Unsafe Medication Storage Practices Identified
Penalty
Summary
The facility failed to ensure safe medication storage practices for its residents, as observed during a survey. In one instance, staff's personal belongings, including a personal bag and an insulated water bottle, were found stored in the Station 2 medication storage room. The Licensed Nurse (LN) confirmed these items belonged to her and acknowledged that personal items should not be stored in the medication room. The Director of Nursing (DON) also confirmed that storing personal items in the medication storage room was unacceptable due to the risk of cross-contamination and drug diversion. In another instance, loose pills were found on the floor and at the bottom of the base cabinet in the Station 1 medication storage room. A total of five loose pills and one capsule were observed, and the LN confirmed their presence, stating they needed to be disposed of. The DON acknowledged that loose pills should not be on the floor or in the cabinet and should have been destroyed properly. The facility's policy on medication storage, revised in April 2007, indicates that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Provide Correct Diet Texture for Resident
Penalty
Summary
The facility failed to provide a diet in the correct texture to meet the needs of Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation. The resident's Nutrition Care Plan indicated impaired nutrition and hydration status related to osteoporosis and dysphagia, with a goal to maintain safe swallowing. Despite this, the active Physician Diet Order prescribed a regular consistency diet with thin liquids, which was inconsistent with the Registered Dietitian's recommendation for a dysphagia mechanical soft texture diet. Observations and interviews revealed that Resident 19, who is edentulous and rarely wears dentures, received a regular texture lunch meal that was difficult to chew. The resident expressed difficulty eating the hard noodles and vegetables and preferred soft and semi-soft foods. The Licensed Nurse confirmed that the resident was on a regular diet but preferred softer foods, and the Registered Dietitian acknowledged that the recommended diet texture was not implemented. The facility's policy required diet orders to be provided as prescribed by the physician, with any discrepancies clarified by the Food & Nutrition Services Director. However, the Registered Dietitian and Dietary Services Manager were unaware that the resident was not receiving the recommended mechanical soft texture diet. This oversight had the potential to negatively impact the resident's food intake, nutrition status, and lead to weight loss, as the resident had already lost weight over a short period.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, Resident 3 and Resident 36, as observed during a survey. On one occasion, Resident 36's water pitcher was found empty on the bedside table, and on another occasion, Resident 3 was observed without a water pitcher and expressed thirst. These observations were confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the absence of water pitchers could put residents at risk for dehydration. Interviews with facility staff, including a Registered Dietitian (RD) and the Director of Nursing (DON), revealed that it was the facility's expectation for water to be readily available to residents unless there were fluid restrictions. The facility's policy on Resident Hydration and Prevention of Dehydration, revised in October 2017, indicated that nurses' aides should provide and encourage fluid intake as part of daily care. The lack of water availability for Resident 3 and Resident 36 was contrary to these expectations and policies, potentially leading to health issues such as dehydration and urinary tract infections.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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