Merced Nursing & Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Merced, California.
- Location
- 510 West 26th Street, Merced, California 95340
- CMS Provider Number
- 055249
- Inspections on file
- 20
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Merced Nursing & Rehabilitation Ctr during CMS and state inspections, most recent first.
Two residents were involved in a behavioral incident where one resident pushed another’s wheelchair and the other resident kicked the first resident’s wheelchair, leading to yelling and verbal aggression toward peers and staff. Although a nurse intervened, separated the residents, and reported performing an assessment on the second resident, no documentation of this assessment, no care plan updates, and no IDT notes were entered for that resident. For the first resident, documentation and care plan updates focused only on alleged false statements, without addressing the documented aggressive behaviors toward another resident and staff or the wheelchair‑kicking incident. These omissions violated facility policies requiring ongoing assessment and timely, person‑centered care plan revisions after significant changes in condition or behavior and were cited as placing both residents at risk for psychosocial distress and for not being comprehensively reassessed for appropriate individualized services.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that a registered dietician was available onsite to conduct required sanitation inspections and observe food safety practices, resulting in unaddressed residue and buildup on kitchen equipment and improper garbage disposal. The remote RD was unable to perform these tasks, and no monthly sanitation audits were conducted after the previous onsite RD left. Observations found unsanitary conditions in the kitchen and around dumpsters, and staff confirmed that facility policies and expectations for cleanliness were not met.
Surveyors found that the facility failed to maintain safe food storage and kitchen sanitation, with expired food items present in storage and food residue on equipment such as the stove, oven, and steam table. Staff interviews revealed inconsistent understanding and application of food labeling and disposal policies, and cleaning schedules were not consistently followed. The Registered Dietician was unable to conduct in-person inspections, and previous audits documented ongoing sanitation issues.
The facility failed to ensure proper disposal of garbage and refuse, as observed by uncovered and overflowing dumpsters, piles of cardboard on the ground, and littered areas outside the kitchen. Staff interviews confirmed ongoing issues with garbage accumulation after deliveries, and the inability of the remote RD to conduct required sanitation inspections. Facility policies and job descriptions required proper containment and cleanliness, but these were not followed, resulting in unsanitary conditions and potential cross-contamination risks for residents receiving food from the kitchen.
A resident with multiple medical conditions and a urinary catheter was observed with an uncovered catheter drainage bag, making their urine visible to anyone entering the room. Both a CNA and the Infection Preventionist confirmed that the catheter bag should have been covered to protect the resident's dignity, in accordance with facility policy. The resident was cognitively intact at the time of the incident.
A resident with insomnia, who was cognitively intact, repeatedly requested to receive melatonin later at night to improve sleep but continued to receive it earlier than preferred. Staff acknowledged the request but did not adjust the medication schedule, resulting in the resident's right to participate in healthcare decisions not being honored.
Two residents were unable to sleep and became irritable due to excessively loud televisions and staff shift changes at night. Staff and leadership acknowledged the noise issue, with one television measured at 100 dB in the hallway, but did not take effective action to reduce the noise. Residents affected had complex medical conditions and varying cognitive abilities, and the facility did not follow its own policy or resident council recommendations regarding noise control.
A resident with end stage renal disease, heart failure, and other conditions was placed on a physician-ordered fluid restriction, but the care plan was not updated in a timely manner to reflect the restriction or its distribution between nursing and dietary staff. Staff interviews and record reviews confirmed the omission, and facility policy required such updates within 72 hours of a change in treatment.
An unsecured, unlabeled pill was found on a resident's dresser, and two bottles of Erythromycin Ophthalmic Ointment in a medication cart were labeled with incorrect expiration dates. Staff interviews and policy reviews confirmed that medications should not be left unsecured or mislabeled, and that proper procedures for medication storage and administration were not followed.
A resident was served milk with a meal despite a documented dislike, leading to refusal to eat lunch. Multiple staff confirmed the resident's preference was listed and should have been followed, but the tray was not checked for accuracy. The facility's policy requires food preferences to be assessed and communicated, but this was not adhered to, resulting in the resident missing a meal.
Two rooms in the facility did not meet the minimum required living space of 80 square feet per resident, as observed during a survey. Each of these rooms housed four residents but measured less than the required square footage. Despite this, residents had adequate privacy, storage, and accessibility to care and facilities.
In a Memory Unit, inadequate supervision led to an altercation between two residents when a CNA left the dining room unattended to assist another resident. One resident, with a history of brain disorders, struck another resident with dementia. The facility's policy requires a licensed staff member to be present to ensure safety, but this was not adhered to, resulting in the incident.
The facility failed to follow its policy for garbage disposal, as two outside trash bins were found with open lids, attracting animals. Staff interviews confirmed that bins should be closed to prevent pest infestations, aligning with the facility's policy.
The facility failed to provide a homelike environment for several residents due to improperly hung curtains and chipped paint on walls. Staff acknowledged the issues, which compromised privacy and comfort. Residents involved had various medical conditions, including cognitive impairments and chronic illnesses.
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet needs and potential risks. Two residents lacked individualized care plans for ADLs, while three others did not have plans to ensure they were regularly out of bed, increasing the risk of pressure ulcers. Staff interviews revealed a lack of communication and planning, with no care plans in place to guide staff in addressing these issues.
The facility failed to meet professional standards by not having physician orders for oxygen for a resident with COPD and not following the prescribed oxygen delivery rate for another. Observations showed one resident receiving oxygen without orders and another receiving a higher rate than ordered. Staff interviews confirmed these discrepancies, which were against facility policies requiring physician orders for oxygen administration.
The facility failed to store and prepare food according to professional standards, affecting 71 residents. Issues included a plastic lid on a pantry shelf, incorrect labeling of food items, and the absence of an air gap under the food preparation sink. These deficiencies were acknowledged by the Certified Dietary Manager and Maintenance Supervisor, posing risks of expired food consumption and contamination.
The facility failed to maintain an effective infection control program, as three residents' oxygen concentrators were improperly maintained. One resident's concentrator operated without a filter, while two others had filters covered in lint and dust. This lack of maintenance was acknowledged by staff and could lead to respiratory infections.
A resident's dignity was compromised when her nephrostomy catheter bag was left uncovered, making the urine visible. The resident, who had a history of urinary tract infection and kidney issues, was observed with the uncovered bag on her lap. Staff, including a CNA, LVN, DSD, and DON, acknowledged the importance of covering catheter bags to maintain privacy and dignity, as per the facility's policy.
The facility did not meet the required square footage per resident in two rooms, with room 14 having 292 square feet for four residents and room 17 having 289 square feet for four residents. Despite this, the facility provided adequate privacy, storage, and accessibility, ensuring the waiver did not adversely affect resident health and safety.
Failure to Reassess and Revise Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to timely reassess and revise comprehensive, person‑centered care plans for two residents after a significant behavioral incident involving resident‑to‑resident aggression. On 3/13/26, one resident (Res 1), a female with chronic kidney disease stage 3, hypertension, heart failure, type 2 diabetes, atrial fibrillation, malignant pleural effusion, anxiety disorder, depression, hypothyroidism, generalized muscle weakness, and difficulty walking, was observed yelling at other residents and pushing another resident’s (Res 2’s) wheelchair near the nursing station. Res 2, a 61‑year‑old male with hemiplegia and hemiparesis following cerebral infarction affecting the left side, dysphagia, generalized muscle weakness, difficulty walking, a left rib fracture, benign neoplasm of the meninges, nicotine dependence, a cerebrospinal fluid drainage device, and a history of falling, became upset and kicked Res 1’s wheelchair. Staff, including LVN 1, intervened, separated the residents, and moved Res 2 to the patio area while Res 1 remained near the nurses’ station, continuing to yell at staff. Following the incident, LVN 1 documented in Res 1’s nursing note that Res 1 had an episode of behavior with another resident, pushed Res 2’s wheelchair, and that Res 2 kicked Res 1’s wheelchair. The note indicated that both residents were separated, no physical contact was made between their bodies, and that Res 1 continued yelling at staff and attempted to reach toward the nurse. LVN 1 reported performing a head‑to‑toe assessment and mental‑health check on Res 2 and attempting to assess Res 1, but acknowledged she did not document any assessment or notes in Res 2’s medical record. Interviews with the Social Services Director, MDS coordinator, Director of Staffing Development, and DON confirmed that Res 2’s electronic medical record contained no nursing assessment, no nurses’ notes, no care plan updates, and no IDT documentation related to the 3/13/26 incident, despite the expectation that both residents would be assessed and that care plans and IDT notes would reflect the event and any new interventions. For Res 1, the MDS coordinator and Social Services Director identified that the care plan had been updated only to address behaviors of making false statements toward residents and staff, but not to address the documented aggressive behavior toward another resident and staff, nor the incident of Res 2 kicking Res 1’s wheelchair. There was no IDT documentation discussing the aggressive behavior, the pushing of another resident’s wheelchair, or any planned interventions to ensure safety and manage behaviors after the incident. Social services staff and the Administrator stated they followed up and interviewed staff present during the event, but these actions were not documented. The facility’s policies on comprehensive, person‑centered care planning and on abuse investigation and reporting require ongoing assessments, timely care plan revisions when residents’ conditions or behaviors change, and thorough documentation of investigations and findings. The lack of documented reassessment, care plan revision, and IDT planning for both residents after the 3/13/26 resident‑to‑resident aggression constituted the cited deficiency and was identified as placing both residents at risk for psychosocial distress and for not being comprehensively reassessed for appropriate individualized services to assure their highest practicable physical, mental, and psychosocial well‑being.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Onsite Dietician Oversight and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that a registered dietician (RD) consultant was able to conduct required onsite sanitation inspections and observe food safety and handling practices for the majority of residents consuming food prepared in the kitchen. The RD, who worked remotely, stated she was unable to perform these onsite tasks, and since the previous onsite RD left in March 2025, no monthly sanitation audits had been conducted. This resulted in a lack of oversight for kitchen sanitation and food safety practices. Observations revealed multiple sanitation issues in the kitchen, including yellow and gray dried residue with small white particles on the steam table knob, dried food residue on stove knobs and the stainless-steel base, and dried brown residue and food particles inside the oven. The oven door and metal shelves also showed discoloration and residue. Additionally, outside the kitchen, dumpsters were found uncovered and surrounded by litter and cardboard boxes, contrary to facility policy requiring dumpsters to be kept closed and the area free of clutter. Interviews with the Certified Dietary Manager (CDM) and the Administrator confirmed that the facility had not maintained expected sanitation standards and had not followed established policies regarding garbage disposal and kitchen cleanliness. The CDM acknowledged the lack of recent sanitation audits and the presence of residue and buildup on kitchen equipment. The Administrator confirmed that the facility had only remote RD coverage, which did not allow for required onsite inspections, and that the facility was not meeting its own expectations or policies for sanitation and refuse disposal.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain safe food storage and handling practices in accordance with professional standards, affecting 73 of 74 residents who consumed food from the kitchen. Surveyors observed expired food items in both the refrigerator and dry storage areas, including open containers of red bell peppers and whole watermelons with use-by dates calculated as one year from the opening date. Staff interviews revealed inconsistent understanding of labeling practices, with some staff stating that foods should be used within seven days of opening, while others indicated a one-year use-by date. The Certified Dietary Manager (CDM) and Registered Dietician (RD) both acknowledged that food should be disposed of when beyond the use-by date, and that serving expired food could result in foodborne illness. Documentation review showed that facility policies required proper labeling and disposal of food by the use-by date, but these policies were not consistently followed. In addition to expired food, the facility did not maintain cleanliness of kitchen equipment and surfaces. Observations revealed food residue and build-up on the stove, oven, and steam table, as well as on the floor and other kitchen surfaces. The CDM stated that cleaning was supposed to occur daily and on a weekly schedule, but records showed that scheduled cleaning tasks were not always completed. The RD, who worked remotely, confirmed that she was unable to conduct sanitation inspections or observe food safety practices in person, and that the kitchen equipment appeared unclean based on photographic evidence. Previous sanitation audits also documented recurring issues with debris and build-up on kitchen equipment and surfaces. Job descriptions and facility policies reviewed by surveyors indicated that dietary staff and management were responsible for adhering to sanitation, safety, and procedural guidelines, including regular cleaning and monitoring of food storage for regulatory compliance. However, the lack of consistent oversight, incomplete cleaning schedules, and failure to follow established food labeling and disposal procedures contributed to the deficiencies observed during the survey.
Improper Garbage Disposal and Overflowing Dumpsters Create Sanitation Deficiency
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations of an uncovered blue dumpster overflowing with cardboard boxes stacked above the rim, additional piles of cardboard on the ground next to a second dumpster, and two piles of cardboard boxes on the concrete walkway outside the kitchen back door. These conditions were directly observed during a site visit, and photographic evidence confirmed the presence of uncovered and overflowing dumpsters as well as littered areas adjacent to the kitchen. Interviews with facility staff, including the Certified Dietary Manager (CDM), Infection Preventionist (IP) Nurse, Registered Dietician (RD), Director of Nurses (DON), and Administrator (ADM), revealed that the facility routinely experienced issues with garbage accumulation, particularly on Mondays following multiple departmental deliveries. Staff acknowledged that the dumpsters were often too full to accommodate all waste, leading to overflow and improper storage of refuse. The CDM and IP Nurse both noted that the homeless population sometimes rummaged through the dumpsters, leaving them uncovered and contributing to the problem. The RD, who provided services remotely, confirmed that she was unable to conduct required sanitation inspections, and the ADM acknowledged that the facility did not meet its own policy expectations for garbage disposal and area cleanliness. A review of facility policies, job descriptions, and a recent sanitation audit further substantiated the deficiency. The facility's policy required all garbage containers to have tight-fitting lids and to be kept covered, and outside dumpsters to be closed and free of surrounding litter. The sanitation audit and job descriptions for key staff emphasized the importance of maintaining sanitary conditions and conducting regular inspections. Despite these requirements, the facility did not ensure that garbage was properly contained and disposed of, resulting in unsanitary conditions with the potential to attract pests and create cross-contamination risks for the food prepared for nearly all residents.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident with a urinary catheter was not provided with a dignity bag to cover the catheter drainage bag, resulting in the resident's urine being visible to anyone entering the room. During an observation, the catheter bag was found hanging at the end of the resident's bed without a dignity bag, and this was confirmed by both a CNA and the Infection Preventionist. Both staff members acknowledged that the catheter bag should be covered at all times to protect the resident's dignity and privacy, and that its visibility could cause embarrassment to the resident. The resident involved had multiple medical conditions, including hydronephrosis, urinary tract infection, muscle weakness, contracture of the left hand, schizophrenia, and type 2 diabetes. The resident was assessed as cognitively intact with a BIMS score of 13. Facility policy requires that urinary catheter bags be covered to maintain resident dignity, and staff are expected to assist residents in keeping catheter bags covered. The failure to follow this policy resulted in a violation of the resident's right to dignity and privacy.
Resident's Right to Medication Timing Not Honored
Penalty
Summary
A deficiency occurred when a resident diagnosed with insomnia, who had no cognitive impairment, was not allowed to receive his melatonin medication at his preferred time of 11:00 p.m. or 12:00 a.m. Despite the resident's repeated requests to nursing staff to adjust the timing of his melatonin to help him sleep through the night, the medication continued to be administered at 9:00 p.m. This led to the resident experiencing ongoing sleep difficulties since admission, as he would awaken during the night due to the early administration of his sleep aid. Interviews with staff confirmed that the resident's request was communicated to a nurse, but no action was taken to change the medication schedule. The facility's policies indicate that residents have the right to participate in decisions about their treatment, and staff acknowledged the importance of honoring the resident's preferences. However, the failure to follow up on the resident's request and adjust the medication timing resulted in the resident's right to make choices about his healthcare services not being honored.
Failure to Maintain Comfortable Noise Levels at Night
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not controlling excessive noise levels, particularly from resident televisions and staff shift changes during nighttime hours. Two residents reported being unable to sleep due to loud televisions, with one resident specifically stating that the noise made him irritable and upset. Observations confirmed that television volumes were excessively high, with one measured at 100 decibels in the hallway, and staff interviews acknowledged awareness of the issue but did not take effective action to address it. Staff, including RNs and LVNs, confirmed that televisions were loud and could be heard from the front lobby, and that the noise should have been reduced after 10 p.m. to allow residents to sleep. One resident with hearing impairment required a higher television volume, but staff did not implement measures to balance this need with the comfort of other residents. The Director of Nursing, Social Services Director, and Administrator all acknowledged that staff were responsible for maintaining a comfortable noise level and that the facility did not follow its own policy regarding noise control. The residents affected had significant medical histories, including hypertension, depression, muscle weakness, hemiplegia, cirrhosis of the liver, and restless legs syndrome. Cognitive assessments indicated varying levels of impairment among the residents involved. Resident council meeting minutes and facility policy both emphasized the importance of maintaining a comfortable noise level, but these were not adhered to, resulting in residents experiencing sleep disturbances and irritability.
Failure to Timely Update Care Plan with Fluid Restriction Orders
Penalty
Summary
The facility failed to ensure the timely review and revision of a resident's person-centered, comprehensive care plan when a physician ordered a fluid restriction. Specifically, a resident with diagnoses including end stage renal disease, hypertensive heart disease, heart failure, and a right femur fracture was placed on a fluid restriction of 960 mL per 24-hour period, with specific allocations for nursing and dietary staff. Despite this order, the resident's care plan did not reflect the fluid restriction or the distribution of fluids among the nursing and dietary disciplines for several weeks after the order was written. Record reviews and staff interviews confirmed that the care plan, dated prior to the fluid restriction order, only addressed risks related to renal failure and fluid imbalances but did not include the new fluid restriction or its breakdown by discipline. The Certified Dietary Manager acknowledged that the care plan lacked this information and was unaware of the policy requiring the dietary supervisor to ensure the care plan included fluid distribution. Nursing staff, including a Licensed Vocational Nurse and the Director of Nursing, also confirmed that the care plan was not updated in a timely manner to reflect the new physician order, and that this omission could result in staff not providing individualized care as required. Facility policies and job descriptions reviewed during the investigation indicated that care plans should be updated within 72 hours of changes in a resident's condition or treatment, and that both nursing and dietary staff are responsible for ensuring care plans are accurate and current. However, the care plan for this resident was not revised to include the fluid restriction and its distribution until several weeks after the order was placed, contrary to facility policy and professional standards.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and administration policies in two distinct instances. In the first instance, an unsecured and unlabeled round white pill was found on a resident's dresser during an observation. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 11 and diagnoses including COPD, CHF, dementia, and CVA, was unaware of the pill's presence. Multiple staff interviews confirmed that medications should not be left unsecured or unattended in resident rooms, and that the nurse should observe the resident taking the medication or properly dispose of it if dropped. The facility's own policies and professional references reviewed also emphasized that medications must be secured and not left at the bedside or in resident areas. In the second instance, two bottles of Erythromycin Ophthalmic Ointment were found in a medication cart with incorrect expiration dates. The bottles were labeled to expire 30 days after opening, but the manufacturer's guidelines specified a 28-day expiration period. Staff interviews, including those with the RN, DON, and pharmacy consultant, confirmed that medications should be labeled with the correct expiration date and that expired medications could lose efficacy. The facility's policies and job descriptions for nursing staff and the DON outlined responsibilities for ensuring proper medication storage and administration, including checking for expired medications. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and professional guidelines. The findings demonstrated lapses in following established procedures for medication security and accurate labeling, as required by both facility policy and accepted professional standards.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
A deficiency occurred when a resident was served milk with his lunch meal tray despite having a documented dislike of milk. The resident had previously informed staff that he did not want milk served with his meals. During observation and interviews, it was confirmed by the Director of Staff Development, Certified Nursing Assistant, Certified Dietary Manager, and Director of Nursing that the resident's meal ticket clearly listed milk as a dislike, and that the resident should not have been served milk. The staff acknowledged that all CNAs and nurses were responsible for ensuring meal trays matched residents' preferences and that the tray should have been checked for accuracy before being served. As a result of receiving milk, the resident refused to eat lunch and missed out on the nutritional value of the meal. The facility's policy indicated that individual food preferences are to be assessed upon admission and communicated to the interdisciplinary team. The failure to accommodate the resident's documented meal preference led to the resident not eating his meal.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required living space of at least 80 square feet per resident in multiple occupancy rooms for two out of 29 rooms, specifically rooms 14 and 17. During an environmental tour with the Maintenance Supervisor, it was observed that these rooms, each housing four residents, measured 292 and 289 square feet respectively, which is below the regulatory requirement. Despite this, the report notes that variations were made according to the particular needs of the residents, and that privacy, storage, bedside stands, space for nursing care, ambulation, and accessibility to wheelchairs and toilet facilities were adequate at the time of the survey.
Inadequate Supervision in Memory Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents in the Memory Unit dining room, leading to an altercation between two residents. Certified Nursing Assistant (CNA) 3 left the dining room unattended to assist another resident, leaving Residents 1 and 2 without the required supervision. This resulted in Resident 1 striking Resident 2 in the face, although no injuries were noted. The absence of a licensed staff member in the dining room at the time of the incident was against the facility's standard practice, which mandates that a trained and licensed staff member be present to ensure resident safety. Resident 1, who was admitted with a history of Other Specified Disorders of the Brain, displayed behaviors of agitation and striking out at staff, as noted in their Care Plan Report. Their Minimum Data Set (MDS) indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4. Resident 2, admitted with a history of Dementia, required substantial assistance with activities of daily living and had a BIMS score of 0, indicating severe cognitive impairment. Resident 2's Care Plan Report highlighted increased agitation and aggression, with interventions including one-on-one supervision as needed. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the facility's policy required a licensed staff member to be present in the Memory Unit dining room to provide supervision. The DON and Administrator acknowledged that housekeeping staff were not trained to work in the Memory Unit and were not required to complete the annual Alzheimer and Dementia in-service. The incident occurred due to CNA 3's decision to leave the dining room without alerting another licensed staff member, resulting in a lack of supervision and the subsequent altercation between the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to adhere to its policy regarding the proper disposal of garbage and refuse, as observed by surveyors. During an observation in the alley behind the facility, two outside trash bins were found with their lids open. A large blue trash bin had its lid hanging on the back, exposing its contents, while a large grey trash bin had its lid propped open with an empty cardboard box. Two cats were seen at the bottom of the bins, indicating the potential for attracting animals and pests. Interviews with the Certified Dietary Manager, Registered Dietitian, and Maintenance staff confirmed that the trash bins should always be closed to prevent pest infestations and the spread of disease. The facility's policy, reviewed during the survey, stated that garbage and refuse containers should be covered, aligning with the staff's statements.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as observed during a survey. Specifically, the privacy and window curtains in the rooms of four residents were not properly hung on the hooks, which compromised the residents' privacy and the homelike atmosphere of their rooms. Staff members, including a CNA, LVN, Maintenance Supervisor, Housekeeping Supervisor, Director of Staff Development, Director of Nursing, and the Administrator, acknowledged the issue and its impact on the residents' environment. The curtains were described as having missing or damaged hooks, preventing them from functioning correctly and providing adequate privacy. Additionally, the facility did not address the issue of chipped and peeling paint on the walls of a room shared by three residents. The paint was missing in a significant section of the wall, which detracted from the homelike environment that the facility is required to provide. The Maintenance Supervisor and the Administrator both recognized that the condition of the walls did not meet the standards for a homelike setting and should have been addressed. The residents involved in these deficiencies had various medical conditions, including severe cognitive impairments, diabetes, dementia, and other chronic health issues. The failure to maintain a homelike environment, as evidenced by improperly hung curtains and damaged walls, was noted during observations and interviews with staff and residents. The facility's policies and job descriptions emphasize the importance of maintaining a clean, safe, and homelike environment, yet these standards were not met in the instances observed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, leading to unmet needs and potential risks. Residents 69 and 127 did not have individualized care plans for Activities of Daily Living (ADL), which could result in their ADL needs not being met. Resident 69, with severe cognitive impairment and multiple health issues, required assistance with transfers, but specific interventions were not documented in the care plan. Similarly, Resident 127, who was bed-bound and required total assistance, lacked a care plan addressing her transfer needs, potentially placing her at risk for falls or injury. Additionally, Residents 1, 16, and 26 did not have care plans to ensure they were regularly out of bed, increasing the risk of developing pressure ulcers. These residents, all with severe cognitive impairments and various health conditions, were observed lying in bed without documented attempts to get them up. Staff interviews revealed a lack of communication and planning to address this issue, with no care plans in place to guide staff in getting these residents out of bed for socialization and pressure sore prevention. The facility's policies and procedures required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to these policies, as evidenced by the lack of individualized care plans for the sampled residents. This deficiency was acknowledged by the Director of Nursing and other staff members, who recognized the importance of care plans in guiding resident care and preventing potential harm.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to meet professional standards of practice for two residents who required supplemental oxygen due to their chronic obstructive pulmonary disease (COPD). For the first resident, there were no physician orders in place for the administration of oxygen, despite the resident's dependence on supplemental oxygen. Observations and interviews with staff revealed that the resident was receiving oxygen continuously via a nasal cannula, but the necessary physician orders were missing. The facility's policy required a physician's order for oxygen administration, which was not adhered to in this case. For the second resident, the facility did not follow the physician's orders regarding the oxygen delivery rate. The resident was observed receiving three liters of oxygen per minute, while the physician's order specified two liters per minute. Interviews with staff confirmed that the oxygen delivery rate was not in accordance with the doctor's orders, and the care plan also indicated the correct rate of two liters per minute. The facility's policy emphasized the importance of verifying physician orders for oxygen administration, which was not followed in this instance. Both deficiencies highlight the facility's failure to ensure that physician orders for oxygen administration were in place and followed, as required by their policies. The lack of proper documentation and adherence to physician orders had the potential to impact the residents' health, as they were not receiving the prescribed amount of oxygen necessary for their condition.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety, affecting 71 of 73 residents. During an observation, a plastic lid was found discarded on a pantry shelf in the dry food storage area, which the Certified Dietary Manager (CDM) acknowledged should not be there. Additionally, a canister of oatmeal in the dry food storage area was found with incorrect labeling regarding its received, use by, and opened dates, which the CDM admitted could cause confusion and result in residents receiving expired food. Furthermore, the facility's kitchen was found to lack an air gap under the food preparation sink, a necessary feature to prevent sewage backup and food contamination. The CDM was unaware of the requirement for an air gap, and the Maintenance Supervisor confirmed the absence of an air gap, acknowledging its importance. Additionally, a box of frozen mixed vegetables in the freezer was mislabeled, with the CDM noting the labeling was confusing and did not match the manufacturer's use by date. The Registered Dietitian also highlighted the risks of mislabeling, which could lead to residents consuming expired food.
Inadequate Maintenance of Oxygen Concentrators
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper maintenance of oxygen concentrators for three residents. Resident 4's oxygen concentrator was observed operating without a filter, which is a critical component for ensuring clean air delivery. This deficiency was confirmed during an observation and interview with a registered nurse, who acknowledged that the absence of a filter was unacceptable and could exacerbate the resident's respiratory condition. The Director of Nursing also confirmed that using an oxygen concentrator without a filter could lead to respiratory infections such as pneumonia and bronchitis. Additionally, the oxygen concentrator filters for Residents 12 and 58 were found to be covered with lint and dust, indicating a lack of regular cleaning and maintenance. Both residents expressed concerns about the cleanliness of their oxygen concentrators, and the registered nurse confirmed that the condition of the filters was unacceptable. The facility's policy and procedure documents, as well as the oxygen concentrator manual, emphasize the importance of maintaining clean equipment to prevent infections. The facility's job descriptions for licensed vocational nurses and registered nurses include responsibilities for ensuring equipment is in good operating order and following infection control policies. However, the observations and interviews revealed a failure to adhere to these responsibilities, as well as the facility's infection control policies and procedures. The maintenance department is also responsible for following the manufacturer's recommended maintenance schedule, which was not followed in these cases.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering her nephrostomy catheter bag, leaving the urine visible. This deficiency was observed during a survey when the resident was seen in her room with the catheter bag uncovered and placed on her lap. The resident's medical history included a urinary tract infection, hydronephrosis, and a ureter stone. The lack of coverage for the catheter bag was noted during multiple observations and interviews with staff members, including a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON). The staff members acknowledged that the nephrostomy catheter bag should have been covered to maintain the resident's dignity and privacy. The CNA stated that catheter bags need to be covered to prevent embarrassment or discomfort for the resident. The LVN confirmed that both CNAs and LVNs are responsible for applying a privacy bag over catheter bags. The DSD and DON reiterated the expectation that catheter bags should always be covered to protect residents' dignity, as outlined in the facility's policy and procedure on dignity. The policy emphasized that residents should be treated with dignity and respect at all times, and demeaning practices that compromise dignity are prohibited.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in two of its rooms, specifically rooms 14 and 17. During an environmental tour with the Maintenance Supervisor and Maintenance Staff, it was observed that these rooms did not meet the regulatory requirement of at least 80 square feet per resident. Room 14 had 292 square feet for four residents, and room 17 had 289 square feet for four residents. Despite this deficiency, the facility ensured that the variations in room size were in accordance with the particular needs of the residents, providing a reasonable amount of privacy, adequate closets and storage space, bedside stands, and sufficient room for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible, and it was determined that the waiver would not adversely affect the health and safety of the residents.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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