Marquis Care At Shasta
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 3550 Churn Creek Rd., Redding, California 96002
- CMS Provider Number
- 056222
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Marquis Care At Shasta during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was not treated with respect and dignity during personal care when a CNA held the resident's hands down to prevent hitting during a linen change. The incident was witnessed and reported by another CNA, and facility leadership confirmed that the resident's rights were violated by this action.
A resident experienced significant delays in call light responses, with 54 instances exceeding 20 minutes and the longest wait being one hour. Despite the facility's policy to treat residents with dignity, the resident felt unfairly treated due to these delays. The resident, with multiple health conditions, was capable of making her own decisions, highlighting the importance of timely assistance.
A resident experienced a significant weight loss of 5% in one month, but the facility failed to update the care plan accordingly. Despite the resident's desire to regain weight and the facility's policy requiring re-weighing and dietitian consultation, the care plan was not revised. The resident consumed less than 25% of meals most of the time, and the Registered Dietitian had not addressed the issue with the resident. The facility's protocol did not account for the resident's refusal to be re-weighed.
The facility failed to ensure staff competency in assessing and documenting a surgical site, leading to a delayed infection diagnosis. A CNA incorrectly documented a resident's shower, and multiple residents experienced long call light wait times. Competency checklists relied on self-assessment without validation.
The facility did not adhere to pureed food recipes, affecting 11 residents on pureed diets. Staff used incorrect ingredient amounts and did not measure liquids accurately, leading to unappetizing food that potentially did not meet nutritional needs. The RD confirmed that recipes must be followed exactly.
The facility failed to provide appetizing and palatable meals to residents, with 14 residents expressing dissatisfaction with the food quality. Complaints included cold meals, hard meat, spoiled fruit, and incorrect meal orders. The Registered Dietician confirmed weight loss in a resident without a Nutritional at Risk Assessment, highlighting issues in the facility's food service.
The facility failed to honor the food preferences of several residents, leading to dissatisfaction and potential nutritional issues. A resident with foot wounds did not receive the ordered meals, affecting protein intake. Another resident with fractures received a different meal than ordered, which was too spicy. A cognitively impaired resident reported not receiving ordered meals, while another faced unavailable items and cold food. A resident with moderate cognitive impairment and her daughter noted frequent meal substitutions, particularly on Sundays.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illness for 115 residents. Issues included unmonitored cool down processes, improper dish machine temperatures, lack of hair restraints, and unclean kitchen equipment. Observations showed worn can openers, chipped spatulas, and improper storage of food and cleaning supplies. Non-functioning equipment was not discarded, highlighting significant lapses in maintaining a safe food preparation environment.
A LTC facility failed to update care plans for four residents, leading to deficiencies in addressing their medical and personal needs. One resident's significant weight loss was not reflected in their care plan, while another's care plan lacked updates for a room change and weight loss. Additionally, a resident's end-of-life care was not updated after choosing Hospice services, and another's care plan did not include a new UTI diagnosis.
The facility failed to provide adequate ADL care for three dependent residents, leading to deficiencies in personal hygiene and grooming. A resident with contractures and diabetes had long, jagged fingernails, while another resident with multiple health issues also had untrimmed nails. Additionally, a resident with severe cognitive deficits did not receive scheduled showers, with no refusals documented. The DON confirmed the facility's failure to follow its policies.
Expired medications and an expired E-Kit were found in a unit's medication room, indicating a failure in the facility's pharmaceutical services. The DON admitted that while reviews for expired medications should occur monthly, there was no strict schedule, leading to the oversight.
A LTC facility reported a medication error rate of 14.81%, exceeding the acceptable threshold. Errors included a nurse administering an iron supplement with milk, improper use of a Breo Ellipta Inhaler by two residents, and a nurse crushing enteric-coated and delayed-release medications. These actions could potentially affect medication efficacy and safety.
The facility failed to maintain a pest-free environment, with multiple observations of flies in the kitchen and dining areas. The air curtain, meant to prevent flying insects, was found inoperative, and staff were unclear about its operation. The CDM did not report the fly issue to the POM or pest control company, contributing to the deficiency.
A resident with anxiety and depression was left in a soiled brief due to delayed toileting assistance, despite being able to verbalize her needs. The facility's staff failed to promptly respond, leading to increased anxiety and a violation of her dignity and rights, as confirmed by interviews with the resident and staff.
A resident in an LTC facility was unable to see his wife's pictures due to clutter on his dresser, leading to frustration and a violation of his right to a homelike environment. The facility's policy emphasizes a clean and personalized setting, but staff confirmed the clutter, including hygiene products, obstructed the resident's view. The resident, with a history of anxiety and other medical conditions, expressed a preference for orderliness, which was not maintained.
A resident experienced significant unplanned weight loss due to the facility's failure to conduct a timely nutritional assessment and address the issue in NAR meetings. The RD was not notified of the resident's weight loss, and there was no documentation of IDT meetings or a care plan to manage the resident's nutritional needs. Additionally, the resident's admission weight was not obtained in a timely manner, delaying necessary interventions.
The facility did not ensure that the dietary manager met the educational qualifications as per California regulations. The Certified Dietary Manager (CDM) confirmed he had not received specific California dietary service training before assuming his role, potentially impacting meal distribution accuracy and food safety.
A resident was served pork pieces larger than the specified size for a chopped meat diet, contrary to the facility's diet manual. The resident, who was on an Easy to Chew diet, expressed dislike for the meat after chewing and spitting it out. The CDM was unaware of the specific size requirements for chopped meats, leading to this dietary oversight.
The facility failed to properly dispose of garbage, with broken down cardboard boxes left in the kitchen and various items cluttering the area outside the kitchen door. The CDM confirmed the boxes were only removed at the end of shifts, and the ADM acknowledged no specific person was assigned to manage the area, leading to potential pest issues affecting all 116 residents.
A facility failed to coordinate care with a Hospice agency for a resident with severe cognitive deficits and multiple diagnoses, resulting in unmet personal care needs. Despite being under Hospice care, the facility did not update the care plan or communicate effectively with the Hospice agency, leading to potential negative outcomes.
A resident with hemiplegia, vascular dementia, and kidney cancer was physically abused by a registry staff member who aggressively grabbed the resident's wrists during care. The incident was witnessed by a CNA and confirmed by the facility's administration.
A resident with dementia was verbally abused by a CNA during care. The resident became combative, and the CNA responded with inappropriate language. The incident was reported, and the CNA was suspended and later terminated. The resident did not recall the incident.
Resident Dignity Violated During Personal Care by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to treat a resident with respect and dignity during direct personal care. The resident, who had severe cognitive impairment and multiple complex diagnoses including Alzheimer's disease, vascular dementia with agitation, delusional disorder, and other significant medical conditions, became agitated and combative during a linen change. During this episode, the CNA held the resident's hands down on his chest to prevent him from hitting staff, despite being told multiple times by another staff member to stop. The facility's policy requires that all residents, including those with cognitive impairments, be treated with dignity and sensitivity, and that staff address the root causes of behaviors rather than physically restraining or contradicting residents. The incident was witnessed by another CNA, who intervened and reported the misconduct immediately. Interviews with facility leadership and staff confirmed that the resident's rights and dignity were violated during the incident, and that holding a resident's hands or restraining them in this manner is unacceptable. The resident's medical record indicated a need for maximum assistance with personal care and a history of combative behaviors, but staff are expected to respond appropriately without compromising the resident's dignity.
Delayed Call Light Responses Impact Resident Dignity
Penalty
Summary
The facility failed to ensure timely responses to residents' requests for assistance, specifically for one resident who experienced significant delays in call light responses. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, yet this was not upheld as evidenced by the delayed response times. During an interview, the resident expressed feelings of unfair treatment due to the frequent long waits for assistance, which were documented in the call light logs. The resident, who was admitted with multiple diagnoses including depression, diabetes, and chronic obstructive pulmonary disease, was capable of making her own decisions as indicated by her BIMS score. Despite this, the call light logs revealed 54 instances where the response time exceeded 20 minutes, with the longest wait time being one hour on several occasions. The Director of Staff Development acknowledged that staff are expected to answer call lights promptly, yet the logs indicated a pattern of delayed responses, contributing to the resident's feelings of neglect.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 call lights will be responded to timely. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All residents could be affected by this practice. Facility QA committee to meet to review call light logs for any patterns/units/shifts where longer call light times may be occurring and conduct a Root Cause Analysis for overall improvement in meeting timely call light times. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? DSD inserviced all staff on answering call lights in a timely manner. Including turning off call light when responding to needs, reactivating call light if more assistance is required by resident. Often call lights are forgotten to be deactivated until after all cares are delivered. How the facility plans to monitor its performance to make sure that the solutions are sustained. DSD will run call light report to ensure lights are being answered in a timely manner weekly x4 weeks, then monthly x90 days.
Failure to Revise Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced a significant unintentional weight loss of 5% in one month. The resident, who was admitted with multiple diagnoses including depression, adult failure to thrive, diabetes, and COPD, expressed a desire to regain weight. Despite the facility's policy requiring re-weighing and dietitian consultation for significant weight changes, the resident's care plan was not updated to address the weight loss. Interviews and record reviews revealed that the resident consumed 25% or less of meals 63 times out of 86 meals monitored over a month. The Registered Dietitian acknowledged the significant weight loss but had not discussed it with the resident or revised the care plan. The Resident Care Manager noted that the resident refused to be re-weighed, and the facility's protocol did not account for such refusals. The facility Administrator confirmed that the care plan should have been updated to reflect the resident's weight loss.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 4's care plan was corrected to reflect the significant weight loss of 5% in one month. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All other residents with significant weight loss have the potential to be affected. RD will conduct 100% audit of all residents with significant weight loss to ensure interventions and/or revisions are reflected in the care plan. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? Resident Care Managers, RD, and LN were inserviced by DNS to ensure care plan is to be updated with significant weight loss. How the facility plans to monitor its performance to make sure that the solutions are sustained. RCMs will check each care plan to ensure significant weight loss is present if indicated weekly x4 weeks, then monthly x90 days. Results will be reviewed by QA Committee. Date corrective action will be completed: 4/3/2025
Deficiencies in Staff Competency and Resident Care
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated appropriate competencies in assessing and documenting the condition of a surgical site for a resident. Despite the facility's policy requiring documentation of wound assessments, two licensed nurses did not document the presence of a surgical incision in the resident's progress notes. This oversight led to a delay in identifying an infection at the surgical site, which was later found to be inflamed and draining purulent material, necessitating antibiotic treatment. Additionally, a certified nurse assistant incorrectly documented that a resident received a shower, although the resident reported not having received one since admission. This discrepancy was confirmed by the CNA, who admitted to mistakenly documenting the shower. The resident expressed frustration over not receiving proper hygiene care, which was corroborated by the facility's documentation schedule. The facility also failed to address long call light wait times experienced by multiple residents, with documented instances of wait times exceeding 30 minutes. Residents reported waiting for assistance with basic needs, such as using the bathroom, which led to discomfort and distress. The facility's policy required prompt response to call lights, but the electronic time logs confirmed prolonged wait times. Furthermore, the competency checklists for registry staff relied on self-assessment without external validation, raising concerns about the adequacy of staff competencies.
Failure to Follow Pureed Food Recipes
Penalty
Summary
The facility failed to ensure that pureed food recipes were followed, resulting in unappetizing food that potentially did not meet the nutritional needs of 11 residents on pureed diets. Observations revealed that the staff did not adhere to the specified quantities and procedures outlined in the recipes for various pureed foods, including spinach, cornbread, sweet potatoes, and roast turkey. For instance, the staff used incorrect amounts of ingredients and did not measure liquids accurately, which deviated from the recipes' instructions. During interviews, the Registered Dietitian confirmed that recipes should be followed exactly and cannot be altered without approval. The facility's policy also indicated that recipes must be adhered to for menu items. The failure to follow these recipes as prescribed could lead to the residents receiving diets that do not meet their nutritional needs, as the food prepared was not in accordance with the dietary guidelines set by the facility.
Facility Fails to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to ensure that the food provided to residents was appetizing, palatable, and served at a safe and appetizing temperature. Observations and interviews revealed that 14 out of 115 residents expressed dissatisfaction with the quality of the food. Specific complaints included food not being to the residents' taste, meals not being warm, and the quality of the food being poor. Residents reported issues such as hard meat, spoiled fruit, overcooked vegetables, and incorrect meal orders. Several residents, including those with intact cognition and those with cognitive impairments, voiced their dissatisfaction during interviews. For instance, one resident mentioned that the food was not to their taste, while another stated that the food was not always warm and not very good. Another resident reported that the meat was very hard, and the vegetables were overcooked. Additionally, some residents noted that they did not receive the meals they ordered, and items were often missing from their trays. The Registered Dietician confirmed that one resident had experienced weight loss, and a Nutritional at Risk Assessment had not been completed. The Certified Dietary Manager stated that they had a good relationship with the residents and conducted monthly food satisfaction surveys. However, the dissatisfaction expressed by the residents indicates a failure in the facility's food service, potentially impacting the residents' nutritional intake and overall satisfaction with their meals.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of seven residents, leading to dissatisfaction with meals and potential nutritional issues. Resident 577, who was cognitively intact, reported not receiving the meals ordered and receiving food items like ham, which they disliked. This resident also expressed difficulty eating hard meat, which was necessary for protein intake to aid in healing foot wounds. Resident 61, who had multiple fractures, selected a pork chop but received a different meal, which she did not eat due to its spiciness. The Certified Dietary Manager could not explain the discrepancy in meal orders. Resident 579, who was severely cognitively impaired, also reported not receiving the meals ordered. Resident 580, who was cognitively intact, experienced issues with unavailable food items and cold meals. Resident 69, with moderate cognitive impairment, and her daughter noted frequent meal substitutions, particularly on Sundays. The daughter expressed discomfort in complaining to staff, understanding that the kitchen had run out of requested items. These incidents highlight a pattern of unmet food preferences and meal discrepancies for several residents.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, which posed a risk of foodborne illness to 115 of 116 residents who consumed food prepared in the facility's kitchen. The cool down process for time and temperature control of safety foods was not monitored, as confirmed by the Certified Dietary Manager (CDM), who admitted to not using a cool down log for ambient food items like tuna or chicken salad. Additionally, the dish machine's wash and rinse temperatures did not meet the manufacturer's guidelines, and the facility lacked chlorine test strips to ensure proper sanitization. Observations revealed that staff did not wear appropriate hair restraints, and food preparation equipment was not in proper working order. The can opener blade was worn, and rubber spatulas were chipped and discolored, yet they were still used in food preparation. The facility's kitchen was also found to be unclean, with dirty knife holders, floors, walls, and various kitchen equipment. The CDM confirmed these observations, acknowledging that the equipment and surfaces were not maintained according to the facility's policies. Furthermore, food and kitchen cleaning supplies were not stored properly, with items like cooking oil and brooms being placed on the floor. Non-functioning kitchen equipment, such as broken Robot Coupes, were not discarded and remained in the kitchen. These deficiencies highlight a significant lapse in maintaining a safe and sanitary environment for food preparation, which could potentially lead to foodborne illnesses among the residents.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their medical and personal needs. Resident 19 experienced a significant unplanned weight loss of 23 pounds, which was not reflected in their care plan. The Registered Dietitian confirmed that the care plan should have been updated to address this weight change, but it was not. Resident 36 also experienced unplanned weight loss and a room change, neither of which were updated in their care plan. The Resident Care Manager acknowledged that the care plan should have included the resident's preference for bathroom assistance and addressed the weight loss with a Nutritional at Risk Assessment, which was not completed. Resident 112's care plan lacked updates for end-of-life care after choosing Hospice services, and there was a lack of communication between the facility and the Hospice agency. Similarly, Resident 121's care plan was not revised to include a new UTI diagnosis, despite an active order for antibiotics. The Director of Nursing confirmed that the care plans for these residents were not developed, reviewed, or revised as required.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for three dependent residents, leading to deficiencies in personal hygiene and grooming. Resident 2, who has contractures, diabetes, quadriplegia, and a cognitive deficit, was observed with long, jagged fingernails that were pressing into his hand due to contractures. This was confirmed by both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN), who acknowledged the need for nail trimming, especially given the resident's diabetes and risk of skin problems. Resident 29, with diagnoses including anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, was also found with long, jagged fingernails. The resident expressed a desire for nail trimming, which was confirmed by multiple CNAs and the Director of Nursing (DON), who admitted that the facility's nail care policy was not followed. Resident 29 was totally dependent on staff for all ADLs and unable to participate in interviews due to a moderate cognitive deficit. Resident 112, with severe cognitive deficits and multiple health issues such as adult failure to thrive, heart disease, and diabetes, did not receive scheduled showers as per the facility's policy. Records showed that out of eight scheduled showers in August and September, only a few were completed, with no refusals documented. The DON confirmed that the facility failed to ensure Resident 112 received the required showers, and any refusals should have been documented and followed up by the LNs.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the presence of expired medications and an expired Emergency Drug Kit (E-Kit) in the [NAME] Unit medication room. During an observation, it was found that two bottles of unopened Acetaminophen, a nasal decongestant spray, and an E-Kit containing various antibiotics and intravenous solutions had expired. These expired medications were still available for resident use, which could potentially compromise the safety and effectiveness of treatments provided to residents. The Director of Nursing (DON) acknowledged that a medication review for expired medications should be conducted monthly. However, despite this schedule, expired medications were still present. The DON admitted uncertainty about why these medications were not removed and stated that nurses should ideally check for expired medications every 2 to 4 weeks, with the consultant pharmacist expected to perform a similar review every 3 months. It was noted that there was no strictly established schedule for these reviews, contributing to the oversight.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 14.81% during a medication pass. This was observed over two days, involving four medication errors out of twenty-seven opportunities for four residents. The errors included improper administration of medications and failure to follow manufacturer instructions, which could potentially affect the efficacy and safety of the medications administered. One of the errors involved a licensed nurse administering an iron supplement to a resident with milk, which is known to reduce the absorption of iron. The nurse was unaware of this interaction, which is contrary to medical guidelines that advise against consuming iron supplements with calcium-rich foods. Another error involved the improper use of a Breo Ellipta Inhaler for a resident, where the resident covered the vent and did not hold their breath as required, potentially leading to inadequate dosing. Additionally, a registered nurse crushed medications with special coatings for another resident, which is against the facility's policy. The medications included enteric-coated aspirin and delayed-release metoprolol, both of which should not be crushed as it compromises their intended release and absorption. The nurse acknowledged the error and the need to consult with the attending physician for alternative medications that can be safely crushed.
Pest Control Deficiency Due to Inoperative Air Curtain and Staff Oversight
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations of flies in various areas, including the kitchen, dining room, and conference room. The facility's policy on vermin control, dated April 2018, mandates that the Food and Nutrition Services Department must be free from pests at all times, with arrangements made by the Administrator for an effective pest control program. Despite this, flies were observed in the kitchen near the food preparation sink, in the dish room, and on meal trays, indicating a lapse in pest control measures. Interviews with facility staff revealed a lack of clarity and responsibility regarding the operation of the air curtain, a device intended to prevent flying insects from entering the kitchen. The air curtain was found to be non-operational during the initial observation, and staff members, including the Certified Dietary Manager (CDM) and various dietary aides, were either unaware of their responsibility to operate it or had never done so. The Plant Operations Manager (POM) confirmed that the air curtain should be turned on at all times, but it was not functioning until manually activated during the survey. The CDM also failed to report the fly issue to the POM or the pest control company, further contributing to the deficiency.
Resident Dignity Compromised Due to Delayed Toileting Assistance
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident 36, by not providing timely assistance with toileting needs. Resident 36, who was admitted with multiple diagnoses including anxiety and depression, was found to be totally dependent on staff for toileting and transfers. Despite having no cognitive deficits and being able to verbalize her needs, Resident 36 reported that staff often delayed responding to her requests for toileting assistance, sometimes making her wait up to an hour. This delay resulted in her being left in a soiled brief, which increased her anxiety and made her feel neglected. Interviews with Resident 36 and facility staff, including the Director of Social Services and the Resident Care Manager, confirmed the resident's feelings of anxiety and the violation of her rights. The Director of Nursing acknowledged that the staff's actions were a violation of the resident's rights and dignity. The facility's policies on dignity and resident rights emphasize the importance of treating residents with respect and promptly responding to their needs, which was not adhered to in this case.
Cluttered Dresser Obstructs Resident's View of Personal Pictures
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for one of its residents, identified as Resident 29, who was unable to see his wife's pictures due to clutter on his dresser. This deficiency was observed during a survey, where Resident 29 expressed frustration about the clutter, stating that he was accustomed to having things in order. The facility's policy, dated May 2011, emphasizes providing a safe, clean, and homelike environment, encouraging the use of personal belongings. However, the clutter on Resident 29's dresser, which included hygiene products left out in the open, violated this policy and the resident's right to a homelike setting. Interviews with facility staff, including two Certified Nursing Assistants (CNAs) and the Director of Social Services (DSS), confirmed the presence of clutter and acknowledged that Resident 29 was unable to view his personal pictures. The DSS noted that Resident 29, due to his background, preferred orderliness and should be able to see his personal pictures. The Director of Nursing also confirmed that the resident should have a homelike environment, and the clutter should be removed to allow the resident to view his family pictures. Resident 29's medical history includes anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, which may contribute to his need for a personalized and orderly environment.
Failure to Provide Adequate Nutritional Services
Penalty
Summary
The facility failed to provide adequate nutritional services to Resident 19, as evidenced by the lack of a timely nutritional assessment by the Registered Dietitian (RD) upon the resident's readmission. Despite the facility's policy requiring a nutritional assessment within seven to 21 days of admission, Resident 19's nutritional status was not assessed after readmission. The RD confirmed that there was no system in place to prevent missed nutritional assessments, and the RD was not notified of new admissions in a timely manner. Resident 19 experienced significant unplanned weight loss, which was not addressed by the RD or the Interdisciplinary Team (IDT). The resident's weight decreased from 215.4 lbs. to 192.4 lbs., a 10.6% loss over six months, which was not documented or addressed in the Nutrition at Risk (NAR) meetings. The RD and Licensed Nurse (LN) 8 confirmed that the weight loss was not communicated or documented properly, and there was no evidence of IDT meetings to address the issue. Additionally, the facility did not obtain Resident 19's admission weight in a timely manner, as required by their policy. The resident was not weighed until four days after readmission, which delayed the identification and intervention for the resident's weight loss. The RD and LN 8 confirmed that there was no documentation of a care plan to address the severe unplanned weight loss, and the resident's nutritional needs were not adequately monitored or managed.
Non-compliance with Dietary Manager Qualifications
Penalty
Summary
The facility failed to comply with federal regulations regarding the educational qualifications of the dietary manager, as specified in the California Code, Health and Safety Code (HSC 1265.4). This deficiency was identified during an interview with the Certified Dietary Manager (CDM), who stated that he received his CDM certificate from the University of Florida. However, he confirmed that he had not received the specific California dietary service requirements contained in Title 22 of the California Code of Regulations before assuming full-time duties as a dietetic services supervisor at the health facility. This oversight had the potential to result in inadequate oversight of the food and nutrition services department, which could affect meal distribution accuracy, safe food handling, and adherence to sanitation guidelines.
Inappropriate Diet Texture Provided to Resident
Penalty
Summary
The facility failed to provide the appropriate textured diet for one resident, identified as Resident 48, who was supposed to receive chopped meat as part of an Easy to Chew diet. During a lunch meal observation, Resident 48 was served pork pieces that were approximately one to one and a half inches in size, which did not meet the facility's diet manual specifications for chopped meat, defined as 1/4 inch to 1/2 inch pieces. This discrepancy was noted when Resident 48 was observed to have chewed and spit out a piece of pork, expressing dislike for the meat. The Certified Dietary Manager (CDM) was interviewed and confirmed that a Regular chopped meat diet was not listed on the therapeutic spreadsheet, which outlines the specifics of each diet type. Furthermore, the CDM admitted to not knowing the specific size requirements for chopped meats and indicated a need to refer to the diet manual for this information. This lack of knowledge and adherence to the diet manual's guidelines contributed to the failure in providing the appropriate diet texture for Resident 48.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, which had the potential to attract insects and rodents, affecting all 116 residents. During an initial tour of the kitchen, more than ten broken down cardboard boxes were observed on a kitchen cart and two additional boxes were found next to a food preparation table. The Certified Dietary Manager (CDM) confirmed that these boxes were collected in the kitchen and only taken outside at the end of the shift. Additionally, outside the kitchen door, various items such as dietary carts, linen carts, mattresses, and wheelchair parts were found near a portable storage container next to the kitchen loading dock. The Plant Operations Manager (POM) stated that no one was assigned to pick up trash in this area. The Administrator (ADM) confirmed that there was no specific person in charge of the area outside the kitchen door, and acknowledged that trash should not be present there. The ADM mentioned that the POM was responsible for taking items that needed to be discarded to the dump.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate care needs with a Hospice agency for a resident receiving end-of-life care. The resident, who had severe cognitive deficits and was dependent on staff for all activities of daily living, was admitted to the facility with multiple diagnoses, including adult failure to thrive, heart disease, and diabetes. Despite being under Hospice care, there was a lack of communication between the facility and the Hospice agency, resulting in the resident not receiving necessary personal care, such as showers or baths, as required by the facility's policy. Interviews with facility staff and the Hospice agency revealed that the facility did not update the resident's care plan to reflect current needs, nor did they coordinate with the Hospice agency to ensure the resident's comfort and symptom management. The Director of Patient Care from the Hospice agency confirmed that the plan for end-of-life care had been sent to the facility, but the facility failed to communicate any changes or coordinate care effectively. This lack of coordination and communication led to a delay in personal care and had the potential to cause emotional stress and negative clinical outcomes for the resident.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by a registry staff member. The incident involved a resident with a medical history that includes hemiplegia and hemiparesis following a cerebral infarct, vascular dementia, and kidney cancer. During care, a registry staff member aggressively grabbed the resident's wrists, which was confirmed by both the resident and a Certified Nursing Assistant (CNA) who witnessed the event. The facility's policy on abuse prevention, dated December 2020, explicitly states that residents have the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff from other agencies. Interviews conducted with the resident, CNA B, and CNA C revealed that the registry staff member grabbed the resident's wrists and pushed them down to the resident's chest while speaking in an aggressive tone. The registry staff member admitted to grabbing the resident's wrists to avoid the resident's attacks. The facility's administration confirmed that the incident occurred and was substantiated through their investigation.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a Certified Nursing Assistant (CNA) cursed at her while providing care. The incident involved a resident with diagnoses including intracranial hemorrhage, anxiety, and dementia. The California Department of Public Health received a report of possible verbal abuse by CNA 1 towards the resident. Another staff member witnessed CNA 1 calling the resident a derogatory term. CNA 1 was immediately suspended and later terminated. The resident had no recollection of the incident due to her dementia. During the investigation, it was revealed that the resident became combative during care, leading CNA 2 to request assistance from CNA 1. The resident's aggression escalated, and CNA 1 responded by making an inappropriate comment. CNA 1 admitted to the verbal abuse, citing personal stress as a contributing factor. The Director of Staff Development confirmed that CNA 1 was remorseful and acknowledged her wrongdoing.
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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