Mesa Verde Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Costa Mesa, California.
- Location
- 661 Center Street, Costa Mesa, California 92627
- CMS Provider Number
- 056362
- Inspections on file
- 33
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Mesa Verde Post Acute Care Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
Medications were not securely stored as required, with one resident's diabetes medication found hidden in another resident's closet for several days after being taken by a CNA, and another resident's prescribed zinc oxide cream left in a bedside drawer. These actions violated facility policy and resulted in unauthorized access to medications.
A resident with type two diabetes mellitus was improperly discharged from the facility without necessary documentation and communication. The discharge planning indicated the resident would have a caregiver, but the facility failed to provide a discharge/transfer report, including evidence of teaching or training for the resident and caregiver. Interviews revealed that the discharge protocol was not followed, as no education or training was provided, and the caregiver was not present or contacted during the discharge.
A resident was discharged with home health services, but the facility failed to document a referral to a home health agency, risking the resident's post-discharge care. The order included follow-up by home health PT/OT/RN and a PCP visit, but no referral documentation was found. The SSD discussed the discharge with the resident but could not provide evidence of the referral, which was acknowledged by the Administrator and DON.
A facility administered COVID-19 and influenza vaccines to a resident without obtaining consent from the designated surrogate decision maker, despite the resident lacking capacity to make healthcare decisions. The resident's family member was the authorized decision maker, but the facility failed to inform them or obtain their consent prior to vaccination.
The facility failed to maintain accurate medical records for two residents. One resident's decision-making capacity entry was improperly corrected without a date or initials. Another resident's fall was not accurately documented in their LTC Evaluation note, despite being recorded in a Post Fall Evaluation. These discrepancies were confirmed by the DON.
The facility failed to assess two residents for the ability to self-administer medications. One resident self-administered insulin without a physician's order or care plan documentation, despite an assessment indicating they were not capable. Another resident was ordered to self-administer an antibiotic without proper assessment, despite fluctuating decision-making capacity. Staff were unaware of the lack of documentation supporting these actions.
The facility failed to ensure call lights were within reach and responded to in a timely manner for several residents. Residents were found with call lights on the floor, out of reach, and reported long wait times for assistance, particularly during night shifts. These issues were verified by staff and posed risks to residents' well-being.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident with a CVAD for IV antibiotic treatment lacked a care plan for its use, confirmed by the RN and DON. Another resident, requiring a cervical collar and TLSO brace, did not have a care plan addressing their application and noncompliance, with staff unaware of the resident's refusal to comply.
A resident who required a cervical collar after being hit by a car was not wearing it as ordered by the physician. The facility's staff, including the DOR, RNA, and LVNs, were unaware or did not act on the physician's order, and the resident's non-compliance was not documented or addressed. The DON and MDS Coordinator confirmed the oversight and lack of follow-up with an orthopedic specialist.
A resident was found to have cigarettes stored in their room, contrary to the facility's policy requiring secure storage of smoking materials. Despite the care plan indicating that smoking materials should be stored in a designated box, staff allowed the resident to keep them in their room. This posed a risk of fire and serious injuries to other residents.
A resident with a suprapubic catheter and recurrent UTIs was found with a urinary drainage bag on the floor, posing a risk for CAUTI. The resident admitted to placing the bag on the floor and was not educated by the facility about the risks. Staff confirmed the improper positioning and acknowledged the need for proper catheter care.
The facility failed to provide proper respiratory care for four residents by not labeling nasal cannulas and improperly storing nebulizer and CPAP masks. Staff confirmed these deficiencies, which were not in line with the facility's policies requiring proper storage and labeling of respiratory equipment.
A resident requiring dialysis care did not receive proper assessment and monitoring of their dialysis access site upon returning from the dialysis clinic. The facility's staff failed to conduct and document necessary assessments, as required by the facility's policy, leading to a deficiency in care.
The facility failed to document the administration of controlled pain medications for two residents, as required by their policy. An LPN confirmed that the medications were removed but not recorded in the MAR, indicating a lapse in pharmaceutical services.
A facility failed to act on a Pharmacy Consultant's recommendation for a resident's medication regimen. The resident was prescribed buspirone for anxiety, but the Consultant noted that the diagnosis was too subjective and recommended a specific behavior be documented. There was no evidence that the physician was notified or that the recommendation was acted upon. An RN claimed to have followed up with the physician but could not provide documentation.
The facility failed to remove expired medications from two medication carts. In Medication Cart B, expired vials of injectable sterile water were found, confirmed by an RN. In Medication Cart A, an open package of budesonide inhalation solution past its use-by date was discovered, verified by an LVN. This oversight violated the facility's policy on medication storage, risking the administration of expired medications to residents.
The facility did not adhere to menu and portion control guidelines, impacting residents' nutritional needs. The cook deviated from the recipe for pureed Spinach Au Gratin by omitting margarine and cheese, and used a #12 scoop instead of the required #8 scoop for serving, leading to incorrect portion sizes. These issues were confirmed by the DSS during observations and interviews.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as improper labeling and dating of food, unsanitary kitchen equipment, and inadequate air drying of utensils. Observations included unlabeled frozen foods, a dirty ice machine, and marred cutting boards, all of which could lead to foodborne illnesses among residents.
A facility failed to follow its policy on food storage brought by visitors for a resident. Unlabeled food containers were found in the resident's room, and the facility did not provide the resident and family with the policy guidelines as part of the admission packet. Staff interviews confirmed awareness of the issue but showed a lack of consistent communication and enforcement of the policy.
The facility failed to properly dispose of trash, as one of three dumpsters was found overflowing with boxes, preventing the lid from fully closing. This was confirmed by the Director of Maintenance, violating FDA Food Code 2013, 5-501.113, which requires waste receptacles to be covered with tight-fitting lids.
The facility failed to maintain confidentiality and accuracy in resident records. Confidential resident rosters were mistakenly included in a publicly accessible binder, and a resident's weight was inaccurately recorded due to a unit conversion error. The Administrator and DON confirmed these errors during interviews.
The facility failed to implement proper infection control practices, as observed when a CNA placed briefs and blue chucks on an isolation cart for distribution, risking contamination and infection spread. The CNA acknowledged the inappropriate handling of these items.
The facility failed to maintain essential equipment safely, with improper cleaning and sanitizing of the ice machine and mismatched serial numbers for the glucometer. The ice machine was not cleaned per manufacturer guidelines, and the glucometer's serial number did not match the quality control log, posing risks to resident safety.
The facility failed to conduct accurate and complete entrapment assessments for residents using bed rails, risking potential entrapment and injury. Observations showed residents with elevated side rails, but the maintenance director could not provide documentation of bed inspections or entrapment risk assessments. Measurements revealed gaps that could entrap a resident's arm or hand, confirming deficiencies in the facility's bed inspection process.
A facility failed to provide necessary GT care for a resident when the tube feeding bottle label lacked the start time and nurse's initials. Observations revealed non-compliance with the facility's policy, which required labeling with specific details. Interviews with staff confirmed the oversight, and the resident, who lacked decision-making capacity, had a physician's order for Jevity 1.2 feeding formula. This failure posed potential risks for complications and infections.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Medications Improperly Stored and Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and not kept at the bedside, as required by facility policy and professional standards. In one instance, a bubble pack of metformin prescribed for a resident with diabetes was found hidden in another resident's closet for ten days. The investigation revealed that a CNA, who also had diabetes, took the medication from the medication room when the door was left slightly open and hid it in the resident's room with the intention of taking it home, but forgot about it until it was discovered by the resident's family. The resident whose closet was used to hide the medication had no capacity to understand or make decisions, as documented in their medical record. Additionally, another resident's side table drawer was found to contain a medication cup filled with thick white cream and a tongue depressor, which the DON identified as zinc oxide cream prescribed for a pressure injury. This medication was not stored securely as required. Both incidents were acknowledged by facility leadership and were in direct violation of the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and not stored at the bedside.
Improper Discharge Process for a Resident with Diabetes
Penalty
Summary
The facility failed to ensure a proper discharge process for Resident 1, who was diagnosed with type two diabetes mellitus with hyperglycemia. The resident was discharged without the necessary documentation and communication of critical information. The discharge planning review form indicated that the resident was going home with a friend and would have a caregiver after discharge. However, the facility could not provide the discharge/transfer report, which should have included evidence of teaching or training provided to the resident and the caregiver, as well as a list of medications. Interviews with LVN 1 and the DON revealed that the discharge protocol was not followed. LVN 1 confirmed that no teaching or training was provided to the resident or the caregiver, and the caregiver was not present or contacted during the discharge. The DON acknowledged that Resident 1 required assistance with medication administration and could not self-administer insulin injections. The DON confirmed that the discharge was unsafe due to the lack of education and training provided to the resident and caregiver, and the absence of the responsible person during the discharge.
Failure to Document Home Health Referral for Discharged Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 1, who was discharged with home health services. The medical record review revealed that there was no documentation indicating that a referral to a home health agency was arranged prior to the discharge. This oversight placed Resident 1 at risk of not receiving the necessary care after leaving the facility. The Order Summary Report for Resident 1 included an order for discharge to home with current medications and follow-up by home health PT/OT/RN, with a subsequent follow-up with the PCP in one to two weeks. A progress note indicated that the SSD had discussed the discharge with Resident 1 and intended to arrange home health services as ordered. However, further review of the medical record did not show evidence of a referral being sent to the home health provider. During an interview, the SSD was unable to provide documentation for the home health services referral, and the Administrator and DON acknowledged these findings.
Failure to Obtain Proper Consent for Vaccination
Penalty
Summary
The facility failed to obtain the appropriate consent prior to administering COVID-19 and influenza vaccines to a resident who lacked capacity to make healthcare decisions. The resident, who was readmitted to the facility, had a family member designated as the surrogate decision maker according to a Durable Power of Attorney for Healthcare. Despite this, the resident personally signed the informed consent for immunizations, which was not valid due to their lack of capacity. The vaccines were administered without the consent of the designated family member. During an interview, the Director of Nursing confirmed that the facility did not inform or obtain consent from the resident's responsible party before administering the vaccines.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential care issues. For the first resident, the History and Physical examination document had a section where a decision-making capacity entry was struck through without a date or initials, making it unclear when and by whom the correction was made. This lack of proper documentation could lead to misunderstandings about the resident's ability to make medical decisions. For the second resident, there was a discrepancy in the medical records regarding a fall. The resident experienced an unwitnessed fall, which was documented in a Post Fall Evaluation note. However, a subsequent Long Term Care Evaluation note incorrectly stated that the resident had not experienced any falls since the last evaluation. This error was confirmed by the DON, who acknowledged that the record should have reflected the fall, indicating a failure in maintaining accurate records.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the ability to self-administer medications, as evidenced by the cases of two residents. Resident 23 was observed self-administering insulin without a physician's order permitting self-administration, and the resident's care plan did not document the ability to self-administer medications. Despite the resident's history and physical examination indicating the capacity to understand and make decisions, the most recent assessment showed the resident was not capable of self-administering subcutaneous injections, and all medications were to be administered by a nurse. LVN 1, who was responsible for the resident's care, was unaware of the lack of documentation supporting the resident's ability to self-administer insulin. Similarly, Resident 18 was not assessed for the ability to self-administer medications, despite a physician's order for unsupervised self-administration of an antibiotic. The resident's history indicated fluctuating capacity to understand and make decisions, and the assessment showed that all medications were to be administered by a skilled nurse. RN 1 confirmed that the resident was not capable of self-administration and acknowledged the transcription of the physician's order into the MAR, which had the potential for the resident to self-administer the antibiotic without proper assessment or documentation.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to promote dignity and respect for several residents by not ensuring that call lights were within reach and not responding to call lights in a timely manner. Specifically, Residents 18, 22, and 62 were observed with their call lights on the floor, out of reach, which prevented them from calling for assistance when needed. This was verified by staff members who acknowledged the issue. Resident 18, who had limited mobility and quadriplegia, was unable to reach the call light, and this was confirmed by an LVN. Similarly, Resident 22, who had multiple health issues including dementia and impaired communication, was also found with the call light on the floor, as verified by another LVN. Additionally, the facility did not ensure timely responses to call lights for Residents 4, 23, and 60. Resident 4 reported that staff would hide the call light during the night shift and that there were instances where the call light was turned off without attending to her needs. This resident, who was dependent on staff for toileting hygiene, expressed concerns about waiting over an hour for assistance. Resident 23, who required moderate assistance, also reported long wait times during the night shift and mentioned that staff cited insufficient staffing as a reason for delays. Resident 60's family member corroborated these issues, stating that the resident had to wait for hours for assistance, which caused agitation due to incontinence. The facility's policy and procedure on the communication-call system, dated 1/1/12, stated that call cords should be within the resident's reach and that nursing staff should answer call bells promptly and courteously. However, the observations and interviews conducted during the survey revealed that these policies were not being followed, leading to deficiencies in the care provided to the residents. These failures posed a risk to the residents' physical and emotional well-being, as they were unable to receive timely assistance for their needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 423, who was admitted with a central venous access device (CVAD) for intravenous antibiotic treatment, did not have a care plan problem developed to address the use of the CVAD. This oversight was confirmed through interviews and medical record reviews with the RN and the Director of Nursing (DON), who verified the absence of a care plan for the CVAD. Similarly, Resident 17, who required a cervical collar and a thoracic-lumbar-sacral orthosis (TLSO) brace following an accident, did not have a care plan addressing the application and noncompliance with these devices. Despite physician orders for the use of these devices, the resident was observed not wearing them, and staff interviews revealed a lack of awareness and documentation regarding the resident's refusal to comply. The DON and MDS Coordinator acknowledged the absence of a care plan for Resident 17's needs and noncompliance.
Failure to Apply Cervical Collar as Ordered
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident who required a cervical collar (c-collar) as ordered by a physician. The resident, who had been hit by a car while in a wheelchair, was observed without the c-collar on multiple occasions. The physician's order specified that the c-collar should be worn at all times, but the resident was non-compliant with this order. The facility's plan of care did not address the application of the c-collar or the resident's noncompliance. Interviews with various staff members, including the Director of Rehabilitation (DOR), Registered Nurse Assistant (RNA), and Licensed Vocational Nurses (LVNs), revealed a lack of awareness and action regarding the resident's need for the c-collar. The DOR acknowledged the resident's non-compliance and the need for a follow-up with an orthopedic specialist, but there was no documented evidence of notifying the physician or specialist about the resident's refusal. The Director of Nursing (DON) and MDS Coordinator confirmed the findings and acknowledged that the resident had not been seen by an orthopedic specialist during their admission.
Failure to Securely Store Smoking Materials
Penalty
Summary
The facility failed to provide a safe environment free from potentially serious accident hazards for a resident who was reviewed for smoking. The facility's policy and procedure for smoking residents required the interdisciplinary team to develop an individualized plan of care for the safe storage and use of smoking materials. However, during an observation and interview, it was found that the resident had a box of cigarettes stored inside a bag on the ground in his room. The resident stated that he kept the cigarettes in his room because the facility would forget about them, despite the facility's policy that smoking materials should be securely stored. Further investigation revealed that the resident's plan of care included an intervention for cigarettes and a lighter to be stored in a designated box. However, both an LVN and an RN confirmed that the resident was allowed to keep his smoking materials in his room, contrary to the facility's policy. The RN acknowledged that the cigarettes should not have been kept in the resident's room and proceeded to store them in a locked container at the nurse's station. This oversight posed a risk of fire and serious injuries to the residents in the facility.
Improper Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent a urinary tract infection (UTI) for a resident with a suprapubic catheter and a history of recurrent UTIs. The deficiency was identified when the resident's urinary drainage bag was observed laying on the floor during an initial tour of the facility. This improper positioning of the drainage bag posed a risk for the resident to develop a catheter-associated urinary tract infection (CAUTI), as it allowed urine to potentially flow back into the bladder. The resident, who had the capacity to understand and make decisions, admitted to placing the urinary drainage bag on the floor himself and sometimes putting it in a trash bag. He stated that the facility did not educate him about the risks associated with placing the drainage bag on the floor. Observations and interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that the urinary drainage bag should not be placed on the floor for infection control reasons. The MDS Coordinator acknowledged the findings and confirmed the resident's history of recurrent UTIs and the need for proper catheter care.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as observed during a survey. For two residents, the nasal cannula was not dated or labeled, and the nebulizer mask was improperly stored. One resident's CPAP mask was not stored correctly, and another resident's nasal cannula was left on top of a wheelchair instead of being stored properly. These actions were not in compliance with the facility's policies and procedures, which require respiratory equipment to be stored in labeled bags and changed regularly. The medical records of the residents involved showed that they had various respiratory conditions requiring specific treatments, such as oxygen therapy and nebulization. Interviews with facility staff, including LVNs and the DON, confirmed the improper storage and labeling of respiratory equipment. The staff acknowledged the deficiencies and verified that the equipment should have been stored according to the facility's policies to ensure safe and sanitary conditions for the residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 29, who required dialysis services. The deficiency was observed in the lack of proper assessment and monitoring of the resident's dialysis access site. Specifically, the licensed staff did not assess Resident 29's dialysis access site after returning from the dialysis clinic, nor did they document any assessment of the site upon the resident's return. This oversight was contrary to the facility's policy and procedure, which required licensed staff to inspect the dialysis access site for functionality and signs of complications, and to document pre- and post-dialysis assessments. Resident 29, who received dialysis on Tuesdays, Thursdays, and Saturdays, was observed with a dry dressing on the left upper arm dialysis access site, which should have been removed four hours post-dialysis for an accurate assessment. Interviews with LVN 3 and RN 1 confirmed that the necessary assessments were not conducted or documented. Additionally, a review of the resident's medical records revealed a lack of documentation regarding a post-dialysis assessment on a specific date, further indicating a failure to adhere to the required care protocols.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, specifically in the administration and documentation of controlled pain medications. For Resident 17, the Individual Narcotic Record indicated that an oxycodone 10 mg tablet was removed from the supply on May 23, 2024, at 1400 hours. However, this administration was not documented in the resident's Medication Administration Record (MAR) for May 2024. This discrepancy was confirmed during an interview and medical record review with LVN 1, who acknowledged the missing documentation. Similarly, for Resident 23, the Individual Narcotic Record showed that a Norco 5-325 mg tablet was removed on June 3, 2024, at 2140 hours, but this was not recorded in the MAR for June 2024. LVN 1 verified the removal of the medication and confirmed the absence of documentation on the MAR. The facility's policy and procedure for controlled medications require immediate documentation of administration details in both the accountability record and the MAR, which was not adhered to in these cases.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for a resident reviewed for unnecessary medications. The resident was admitted to the facility and had a physician's order to administer buspirone HCL, an antianxiety medication, for anxiety manifested by restlessness. The Consultant Pharmacist's Medication Regimen Review noted that agitation or restlessness was too subjective to be used as a diagnosis or behavior and recommended updating the order with a specific and quantifiable behavior. However, there was no documented evidence that the resident's physician was notified or that the Pharmacy Consultant's recommendation was acted upon. During an interview, an RN stated that she had followed up with the physician and changed the manifested behavior to resisting care, but was unable to provide documentation to support this claim.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure the removal of expired and potentially deteriorated medications from two of its three medication carts, specifically Medication Carts A and B. During an inspection of Medication Cart B, two 10 ml vials of injectable sterile water with past expiration dates were found. RN 1 confirmed the vials were expired and acknowledged they should have been removed. Similarly, an inspection of Medication Cart A revealed a box of budesonide inhalation solution with an open foil package containing two ampules, which should have been used within two weeks of opening. LVN 1 verified that the remaining medication should have been removed from the cart, as per the instructions on the medication box. These findings indicate a failure to adhere to the facility's policy and procedure for medication storage, which mandates the immediate removal and disposal of outdated or deteriorated medications. This oversight had the potential to result in the administration of expired or deteriorated medications to residents.
Failure to Follow Menu and Portion Control Guidelines
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion control guidelines, which could potentially impact the nutritional needs of the residents. During the preparation of pureed Spinach Au Gratin, the cook did not follow the recipe as outlined in the facility's documents. Instead of using margarine and cheese as specified, the cook boiled the spinach with soup base and added a thickener, omitting the required ingredients. This deviation from the recipe was confirmed during an observation and interview with the cook and the Dietary Services Supervisor (DSS). Additionally, the facility did not follow the portion control guidelines for serving Spinach Au Gratin. The facility's portion control chart specified using a #8 scoop for a 1/2 cup serving size, but the cook used a #12 scoop instead. This discrepancy was observed during a trayline inspection, where trays prepared for residents on regular and mechanical soft diets contained incorrect portion sizes. The DSS acknowledged the error and confirmed that the serving size did not match the facility's guidelines.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by several observations during a survey. Foods in the kitchen were not properly labeled and dated, which is a violation of the FDA Food Code 2022, Section 3-501.17. During an inspection, a bag of frozen egg omelets, cookies, donuts, and blueberries were found without opened dates inside Freezer #2. Additionally, the refrigerator designated for residents' food brought in from outside contained a box of chimichangas labeled with a resident's name and due date, but also had four unlabeled bags of ice. Unlabeled food containers and fruits were also found in a resident's room, indicating a lack of adherence to the facility's policy on food brought in by visitors. The facility's kitchen equipment and environment were not maintained in a sanitary condition. The ice machine was found with a yellowish slimy residue, and the kitchen exhaust hood had brownish black residue, which had not been cleaned since December 2023. The oven and heated plate dispenser were observed with food debris, and the blender machine had food debris as well. These conditions violate the FDA Food Code 2022, which requires non-food contact surfaces to be kept clean to prevent microorganism growth and pest harborage. Furthermore, the facility did not ensure proper air drying of kitchen items, as required by the FDA Food Code 2022. A blender container was found with water residue, and a dietary staff member was observed using a paper towel to dry a blender container and measuring cup after washing. Additionally, two green cutting boards were heavily marred with knife marks, making them difficult to clean and sanitize. These deficiencies in maintaining sanitary conditions in the kitchen had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Failure to Follow Food Storage Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedures (P&P) regarding the handling and storage of food brought in by visitors for a resident. Specifically, the facility did not ensure that food containers brought by the resident's family were labeled with the resident's name and date received, nor were they stored in a designated refrigerator. Instead, several fruits and unlabeled food containers were observed on the resident's bedside table, overbed table, floor, and bed. The facility's P&P required that residents and their families be provided with guidelines about the use and storage of food brought in by visitors as part of their admission packet, which was not done in this case. The medical records for the resident indicated a care plan problem related to the storage of extra food brought from home, with interventions including education on infection control and offering storage solutions. However, there was no documentation of continued communication with the resident and family about these issues, nor was there follow-up on the family's compliance with the storage guidelines. Interviews with facility staff, including a CNA, LVN, MDS Coordinator, and Admissions Director, confirmed awareness of the issue but revealed a lack of consistent communication and enforcement of the facility's P&P.
Improper Trash Disposal
Penalty
Summary
The facility failed to properly dispose of trash, as observed during a survey. One of three dumpsters located outside the facility was found overflowing with boxes, which prevented the lid from fully closing. This observation was made on 6/4/24 at 0755 hours. The issue was confirmed during a concurrent observation and interview with the Director of Maintenance at 0803 hours, who verified that the dumpster was indeed overflowing and the lid was not fully closed. This situation was in violation of the FDA Food Code 2013, 5-501.113, which requires receptacles and waste handling units for refuse to be kept covered with tight-fitting lids, thus potentially attracting pests and/or rodents.
Confidentiality Breach and Inaccurate Record-Keeping
Penalty
Summary
The facility failed to maintain accurate and confidential resident records, as evidenced by two specific incidents. Firstly, a binder labeled 'CDPH Annual Survey Binder' was observed on a table in the lobby for public review, containing confidential resident rosters with names and identifiers from various dates in 2021. During an interview and document review, the Administrator confirmed that these confidential rosters were mistakenly included in the binder, making protected information accessible to the public. Secondly, the facility did not accurately document Resident 29's monthly weight. A review of the resident's medical records showed inconsistent weight entries over the past six months, with a significant discrepancy in the June weight, which was recorded in kilograms instead of pounds. The Director of Nursing (DON) acknowledged the error during an interview and confirmed that the incorrect entry was due to a failure to convert the weight from kilograms to pounds, resulting in inaccurate medical records for the resident.
Inappropriate Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection control practices, compromising the safety and sanitation of the environment and increasing the risk of infection spread. On June 5, 2024, at 0410 hours, multiple briefs and blue chucks were observed stacked on top of an isolation cart in front of room A. Later, at 0515 hours, a CNA was seen distributing these items to rooms A, B, and another resident's room. During an interview at 0520 hours, the CNA admitted to placing the briefs and chucks on the isolation cart for distribution purposes, acknowledging that this practice could lead to contamination and infection spread. The CNA verified the findings, confirming the inappropriate handling of these items.
Deficiencies in Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine and glucometer. The ice machine was not cleaned and sanitized according to the manufacturer's specifications and the facility's policies and procedures. An incorrect ratio of nickel-safe cleaner was used, hot water was used instead of a sanitizing solution, and an unidentified spray bottle was used to sanitize the panels. These actions could potentially lead to the equipment not functioning as intended, posing a risk of food-borne illnesses for residents. During an inspection, yellowish slime was observed on a paper towel after wiping the inside of the ice machine, indicating improper cleaning. The Director of Maintenance admitted to using a capful of nickel-safe cleaner diluted with a little water, which did not align with the manufacturer's instructions. Additionally, the Director used hot water for sanitizing instead of the correct sanitizing solution, and the spray bottle used for sanitizing the panels was unlabeled and of unknown brand. The facility also failed to ensure the glucometer's serial number matched the one listed on the Quality Control Record. This discrepancy was discovered during an inspection of Medication Cart A, where the glucometer's serial number did not match the one documented in the quality control log. The LVN and DON confirmed that the serial numbers should match, indicating a lapse in proper documentation and equipment management.
Deficiency in Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not record measurements during bed inspections to identify areas of possible entrapment for three residents using side rails. The facility's policy requires that bed frames, rails, and mattresses leave no gaps wide enough to entrap a resident's head or body, and that maintenance staff routinely inspect beds to identify risks, including entrapment. For Resident 50, observations showed the resident lying in bed with both upper side rails elevated. The medical record indicated that the resident lacked the capacity to make decisions, and the bed rail assessment noted the use of bilateral side rails for mobility and safety. However, the maintenance director could not provide documentation of bed inspection or entrapment risk assessment for the resident's bed. Similarly, Resident 423 was observed with elevated side rails, and although a physician's order was in place for side rails, the maintenance director again failed to provide documentation of an entrapment assessment. Resident 18 was observed with elevated bed rails, and the medical record indicated fluctuating capacity to understand and make decisions. The plan of care included the use of side rails for ADL changes, mobility, and positioning. However, the maintenance director acknowledged not performing any entrapment assessment. Measurements taken by the environmental services staff revealed a gap that could potentially entrap a resident's arm or hand, confirming the deficiency in the facility's bed inspection and entrapment assessment process.
Failure to Properly Label Tube Feeding for a Resident
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident, identified as Resident 45, who was reviewed for GT care. The deficiency was observed when the label on Resident 45's tube feeding bottle did not include the start time of the feeding and the initials of the nurse who hung the tube feeding. This omission was noted during observations conducted on two separate days. The facility's policy and procedure for enteral feedings, dated 9/7/23, required that the bag and tubing be labeled with the date and time hung, with a hang time of no more than 24 hours. Interviews with facility staff, including the Infection Preventionist (IP), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that the labeling process was not followed as per the facility's policy. The staff acknowledged that the label should have included the resident's name, date, start time, room number, and the nurse's initials. Resident 45, who lacked the capacity to understand and make decisions, had a physician's order for Jevity 1.2 feeding formula to be administered via pump. The failure to properly label the tube feeding had the potential to lead to complications related to tube feedings and/or risk for infections, as noted in the report.
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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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