Mid-town Oaks Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 2600 L Street, Sacramento, California 95816
- CMS Provider Number
- 055493
- Inspections on file
- 47
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Mid-town Oaks Post-acute during CMS and state inspections, most recent first.
Staff failed to follow contact isolation requirements and use appropriate PPE for two roommates, one with an active C. diff infection and the other identified as at risk. Despite signage indicating contact precautions and a facility policy requiring gown and gloves based on transmission-based precautions, CNAs entered the shared room without PPE to deliver a meal tray, manipulate the light cord, and reposition a bed, and an LN administered injectable medications while her clothing contacted the bed and linens, all without donning a gown. Staff interviews confirmed lack of PPE use, misunderstanding of when gowns were required, and awareness that both residents were considered under contact isolation, while the DON confirmed the expectation that all staff entering the room and providing care should use gowns and gloves.
A resident with osteoarthritis, anxiety disorder, and moderate cognitive impairment submitted multiple written requests for copies of her medical and therapy records, which were not provided within the required two-business-day timeframe. In the first instance, the request was relayed from rehab to medical records, forwarded to legal, and ultimately fulfilled several days later by email from the DON. In the second instance, the resident emailed medical records directly, was given a facility authorization form, and after she returned the form, the MRA sought legal approval before releasing the records by email several days after the initial request. Both responses exceeded the facility’s two-business-day standard for providing requested records, resulting in delayed access to the resident’s medical information.
A resident with osteoarthritis, anxiety, and moderate cognitive impairment reported left-hand nerve issues and decreased thumb strength, which were documented by a physician, and also had a cracked molar with sharp edges that caused a sizable tongue ulcer. Despite these documented concerns and the resident’s report that no one was monitoring the ulcer’s progression, review of the record showed no monitoring orders or comprehensive care plans addressing either the left-hand weakness or the tongue ulcer. The DON acknowledged the facility was aware of these issues and expected them to be monitored and care planned, but this was not done in accordance with the facility’s comprehensive, person-centered care plan policy.
Two residents with cognitive impairment eloped without staff awareness, demonstrating a failure to provide adequate supervision and prevent accidents. One resident with metabolic encephalopathy, psychotic disorder, and moderate cognitive impairment twice left the facility and went to a nearby hospital ER without staff knowledge, with the facility only learning of his location when contacted by hospital staff. Another resident with dementia, severe cognitive impairment, and difficulty walking eloped and was later found by an LPN outside the front door on the ground near a wheelchair, crying and with visible injuries including facial bruising, a bleeding elbow skin tear, and a knee abrasion. An internal investigation identified an unattended reception area near the front door as a likely contributing factor, despite facility policies requiring identification and implementation of safety interventions for residents at risk of wandering, elopement, and falls.
The facility failed to document and replace emergency medication kits (E-Kits) for 95 residents. An IV E-Kit was opened, and dextrose was removed but not replaced, and a refrigerated E-Kit had insulin removed without notifying the pharmacy. The DON expected E-Kits to be replaced within 72 hours, as per policy, which was not followed.
The facility failed to properly label, store, and dispose of medications, leading to deficiencies such as an unlocked medication refrigerator, expired pharmaceutical products, and lack of resident-specific labels. These issues were identified during observations and interviews with nursing staff and the DON, highlighting potential risks of medication misuse and errors.
The facility did not follow the prescribed menu for residents on a pureed diet, serving carrots with a runny consistency due to excess liquid. The Dietary Services Supervisor confirmed the issue, and the Registered Dietician noted that the recipe was altered without using a thickener as suggested in the facility's documentation.
The facility failed to provide pureed food with appropriate textures for 10 residents on a pureed diet, potentially compromising their medical and nutritional status. Observations revealed that pureed carrots were runny and pureed wheat rolls were stiff and lumpy, contrary to the facility's guidelines for pureed foods. The Dietary Services Supervisor and Registered Dietitian confirmed the inappropriate textures, noting potential difficulties in consumption and aspiration risks.
The facility failed to follow professional standards for food service safety, affecting 95 residents. Expired hamburger buns were found in storage, and metal serving containers were improperly stored while still wet. Additionally, sanitizer buckets contained a solution below the required strength for effective decontamination. These deficiencies could lead to contamination and foodborne illness.
The facility failed to maintain infection control by not using PPE in EBP rooms and storing clean linen uncovered. Staff, including a PT and CNAs, did not wear gowns and gloves during high-contact interactions, contrary to facility policy. Additionally, a clean-linen cart was stored uncovered, risking contamination.
A resident with chronic kidney disease and a permanent catheter did not have a comprehensive care plan addressing catheter care. The resident reported no dressing changes or monitoring since admission, and the facility's policies on catheter care were not followed. The absence of a care plan was confirmed by the DON.
A resident receiving apixaban for anticoagulation was not monitored for side effects, as there were no orders or care plan in place. This oversight was confirmed by a licensed nurse and acknowledged by the DON, who stated that monitoring is essential to prevent unmonitored bleeding. Facility policies require medication orders to be supported by care processes, which were not adhered to in this instance.
A resident with malignant breast neoplasm and generalized muscle weakness was unable to receive assistance due to a non-functional call light system. Despite pressing the call button, the light did not activate, leaving the resident at risk of falling. A CNA confirmed the malfunction, and the DON acknowledged the call light should be operational at all times.
A resident's right to self-determination was violated when their medical appointment was canceled by the facility without consulting the resident or their family. The resident, who was capable of making medical decisions, had an appointment necessary for a pre-operation work-up. The Social Services Assistant canceled the appointment due to transportation issues and based on information from a receptionist, without confirming the necessity of the appointment with qualified personnel. The Social Services Director later confirmed the appointment was necessary.
A resident with type 2 diabetes experienced low blood sugar, but the LTC facility failed to follow its hypoglycemia management policy. The resident's blood sugar was not rechecked, and the provider was not notified, leading to signs of unconsciousness. The facility's policy required immediate action, which was not documented.
A resident with severe cognitive impairment was not protected from sexual abuse when another resident, also cognitively impaired, was observed with his hand underneath her shirt. Staff confirmed that the resident could not consent to such contact, and the facility's policy defines this as sexual abuse.
A resident with dementia and osteoporosis was found with a fractured wrist of unknown origin, which the LTC facility failed to report as required. Despite the severity of the injury, staff interviews revealed no clear cause, and the resident could not recall the incident. The facility's policy mandates immediate reporting of such injuries, but this was not followed, delaying the investigation process.
Failure to Use Required PPE for Residents on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, specifically contact precautions and PPE use, for two residents placed under contact isolation for Clostridium difficile (C. diff). One resident, admitted in May 2025 with diagnoses including diabetes mellitus and sepsis, had an active order for contact isolation for C. diff requiring staff to don gown and gloves prior to room entry and care. The roommate, admitted in January 2026 with diabetes mellitus and colostomy status, had a care plan indicating potential for C. diff infection and the need to use infection control principles and contact precautions as indicated. A sign posted at the room door instructed staff to apply gown and gloves before entering. Surveyors observed multiple staff entering and providing care in this isolation room without required PPE. A CNA entered the room without gown or gloves to deliver and set up a breakfast tray for the resident on contact isolation and, at the resident’s request, pulled the light cord with bare hands, later confirming he had touched room surfaces and was unsure which resident the isolation applied to. Two other CNAs entered the same room without gowns to reposition the exposed roommate’s bed and stated they believed gowns were only needed for close contact care involving the urinary catheter. A licensed nurse entered the room without a gown to administer two injectable medications to the resident on contact isolation, during which her clothing contacted the bed and linens; she later confirmed she knew the resident was on contact isolation for C. diff and that she should have used gown and gloves. The DON confirmed both roommates were considered under contact isolation precautions and that all staff entering and providing care to either resident were expected to use gowns and gloves, consistent with the facility’s PPE policy that PPE type is based on transmission-based precautions.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records within two working days following written requests, as required by regulation and facility policy. The resident, who had osteoarthritis of the knees, an anxiety disorder, and moderate cognitive impairment per the MDS dated 1/9/26, reported emailing multiple requests for medical records that were not fulfilled timely and stated she had to "hold staff's feet to the fire" to get anything done. On 1/22/26 after business hours, the resident emailed the Director of Rehabilitation (DOR) to follow up on previously requested medical records, specifically therapy records. The DOR notified the Medical Records Assistant (MRA) on 1/23/26, and the MRA documented receiving the request around noon that day and forwarding it to the legal department. The legal department responded at 4:37 p.m. on Friday when the MRA was out of the office, and the records were ultimately emailed to the resident by the DON on 1/27/26 at 4:46 p.m., exceeding the two-business-day timeframe. A second written request was emailed directly to the MRA on 2/5/26 at 11:51 a.m., using the resident’s own request format. The MRA documented that on 2/6/26 she went to the resident’s room and provided the facility’s authorization form for release of health information, which the resident accepted but stated she would complete when she had time, while asserting that the facility was violating federal law by not providing the records right away. The resident later emailed the completed authorization form on 2/9/26, backdated to 2/5/26, but the MRA noted it was not properly filled out when received. The MRA emailed the legal team for approval, received a response at 4:28 p.m. that the records could be released, and the records were emailed to the resident on 2/10/26. This second fulfillment also occurred more than two business days after the initial written request. The facility’s policy, revised 5/2017, states that residents may submit oral or written requests and may obtain copies of their records within two business days of such a request and completion of the authorization form, but in both instances the records were provided beyond the two-business-day requirement, resulting in delayed provision of medical records and decreasing the likelihood of the resident making informed medical decisions regarding her care.
Failure to Care Plan for Hand Weakness and Oral Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident’s identified clinical issues. The resident, admitted in early 2026 with osteoarthritis of the knees and an anxiety disorder and assessed as having moderate cognitive impairment on the MDS dated 1/9/26, reported decreased strength and nerve issues in the left hand, with the thumb observed to be overextended backwards. A physician’s note dated 1/7/26 documented the resident’s complaints of left hand thumb weakness. Despite this, review of the resident’s current orders and care plans showed no monitoring orders or care plan addressing the left hand problem. The same resident also had an oral issue involving a cracked molar tooth with sharp edges that caused sores on the tongue. A progress note dated 1/27/26 documented the resident’s ongoing concern with the cracked molar that was bothering her and causing sores on her tongue. During observation and interview, the resident demonstrated an ulcer on the right side of the tongue, approximately 1 cm wide and 2 cm long, and stated that it developed after the tooth broke and that nobody was looking at or monitoring the progression of the ulcer. Review of the care plan and orders revealed no monitoring orders or care plan for the tongue ulcer. The DON confirmed the facility was aware of the resident’s left hand and tongue issues and stated he expected these issues to be monitored and care planned, which was not done, contrary to the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes for each resident’s needs.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with cognitive impairment. One resident, admitted with metabolic encephalopathy, cognitive communication deficit, and a psychotic disorder with hallucinations, had a BIMS score of 11/15 indicating moderate cognitive impairment. This resident exited the facility without staff authorization on two separate occasions. On both dates, the resident went to a nearby hospital emergency room (ER) during times such as lunch, and facility staff were unaware of the resident’s absence until contacted by hospital staff. The DON confirmed that both elopements occurred without the facility’s knowledge and that an electronic wander guard device was not implemented until after the second elopement. The second resident involved in the deficiency was admitted with unspecified dementia, cognitive communication deficit, and difficulty in walking, and had a BIMS score of 3/15 indicating severe cognitive impairment. This resident experienced an unwitnessed fall after eloping from the facility and was found by staff outside the front door at the top of a sloped walkway, sitting on the ground next to her wheelchair and crying. The resident had visible injuries, including a bluish bump to the left cheek and temporal area, a skin tear to the left elbow with moderate bleeding, and an abrasion to the left knee. A licensed nurse reported seeing the resident on the ground outside, observing the bleeding elbow and the developing facial bump. Record review of an investigation summary for the second resident’s unwitnessed fall and elopement identified that the most likely contributing factor to the elopement was the reception area near the front door being unattended for a brief period. The facility’s own policies on wandering, elopements, and fall risk management state that residents at risk for unsafe wandering or elopement should have care plan strategies and interventions to maintain safety, and that staff will identify interventions related to specific risks and causes to try to prevent falls. Despite these policies and the residents’ documented cognitive impairments and mobility issues, the residents were able to leave or be outside the facility without staff awareness or supervision, resulting in elopements and, for one resident, an unwitnessed fall with injuries.
Failure to Document and Replace Emergency Medication Kits
Penalty
Summary
The facility failed to accurately document and replace emergency medication kits (E-Kits) for a census of 95 residents. During an observation and interview, it was found that an intravenous E-Kit had been opened on October 16, 2024, and a liter of dextrose was removed but not replaced. The Licensed Nurse (LN 3) acknowledged that the medication sticker should have been faxed to the pharmacy for replacement and documented in a binder at the nursing station, which was not done. Additionally, a refrigerated E-Kit was found to have been opened on August 16, 2024, with a vial of insulin removed, but the pharmacy was not notified, and the E-Kit was not replaced. The Director of Nursing (DON) stated that the expectation was for nurses and pharmacy to follow the process to replace E-Kits within 72 hours to ensure availability of emergency medications. The facility's policy required immediate recording of medication use and notification to the pharmacy for replacement, which was not adhered to in these instances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications and medical supplies, leading to several deficiencies. During an observation, a medication refrigerator in the second-floor medication room was found unlocked, which was against the facility's policy. Licensed Nurse 3 acknowledged that the refrigerator should have been locked to prevent unauthorized access to medications. The Director of Nursing confirmed that the expectation was for the refrigerator to be locked at all times. Expired pharmaceutical products were discovered in various locations, including a medication refrigerator, medication carts, and treatment carts. Specific examples included a bottle of lansoprazole with an expiration date of 10/20/24, a bottle of latanoprost expired on 11/3/24, and a bottle of sodium hypochlorite solution expired in August 2024. Licensed nurses acknowledged the presence of expired medications and the potential issues they could cause, such as inaccurate medication strength and ineffectiveness. The Director of Nursing stated that expired medications should have been removed promptly according to the facility's policy. Additionally, prescription pharmaceutical products were found without resident-specific labels, and open date labels were not used to determine expiration dates. This included silver sulfadiazine and lidocaine ointment without resident-specific labels, and semaglutide and blood glucose test strips without open dates. The lack of proper labeling raised concerns about potential cross-contamination and medication errors. The Director of Nursing confirmed that medications should have resident-specific labels and open dates to ensure proper administration and expiration tracking.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, which is a therapeutic diet modification necessary for certain medical conditions. During lunch, 10 residents were served pureed carrots that did not meet the required consistency as per the recipe. The Dietary [NAME] 1 (DC 1) prepared the pureed diet by adding 1 1/2 cups of chicken broth to the carrots, resulting in a runny mixture. This was observed during the tray line service, where the carrot mixture oozed into other plated food items, indicating that the consistency was not as intended. The Dietary Services Supervisor (DSS) confirmed the runny consistency during a test tray tasting and acknowledged that the extra liquid could have contributed to the issue. The Registered Dietician (RD) noted that the recipe was altered and suggested that a food thickener could have been used to achieve the correct texture. The facility's recipe documentation indicated the appropriate amount of liquid to be used and suggested options for thickening, which were not followed in this instance.
Inadequate Pureed Food Textures for Residents
Penalty
Summary
The facility failed to provide pureed food with appropriate textures for 10 residents on a pureed diet, potentially compromising their medical and nutritional status. During an observation, the Dietary staff member (DC 1) prepared pureed carrots by adding chicken broth, resulting in a runny mixture. DC 1 expected the mixture to thicken on the steam tray but did not add any further ingredients before serving. Similarly, DC 1 prepared pureed wheat rolls by adding milk and butter, resulting in a thick consistency initially, which was then thinned with additional milk and butter. The pureed bread was expected to thicken on the steam tray, but it was served with a stiff and lumpy texture. During the tray line observation, the pureed items served included a watery carrot mixture and stiff bread roll puree, which seeped into other plated food items. The Dietary Services Supervisor (DSS) confirmed the inappropriate textures, noting that the thin carrot puree and lumpy bread puree could make consumption difficult for residents on a pureed diet. The Registered Dietitian (RD) indicated that an approved thickener could have been used for the carrots, and the stiff, lumpy bread posed an aspiration risk. The facility's document on the International Dysphasia Diet Standardization Initiative (IDDSI) Transition outlined that pureed foods should be smooth, free of lumps, and not too firm or sticky, which was not adhered to in this instance.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 95 residents. During an inspection, expired food items, specifically hamburger buns, were found in dry storage. The Dietary Services Supervisor (DSS) acknowledged that the bread was expired and should not have been kept on the bread rack beyond five to seven days from the opening date. Additionally, metal serving containers were improperly stored while still wet, which contradicts the facility's policy and the FDA Food Code that requires air drying before stacking to prevent microorganism growth. A sticky residue was also found on a metal serving container, indicating inadequate sanitization. Furthermore, the facility did not maintain proper sanitizing procedures. Two out of three sanitizer buckets contained quaternary ammonia sanitizer at only 100 parts per million (ppm), below the required 200 ppm for effective decontamination. The Dietary Aide and DSS confirmed that the sanitizer solution was too weak and should be replaced every two hours or when dirty. The Registered Dietician also stated that 100 ppm was insufficient for adequate decontamination. These deficiencies in food storage and sanitization practices had the potential to lead to contamination and foodborne illness among residents.
Infection Control Lapses in PPE Use and Linen Storage
Penalty
Summary
The facility failed to maintain proper infection control practices for a census of 95 residents. Staff members did not adhere to Enhanced Barrier Precautions (EBP) by neglecting to wear gowns and gloves during high-contact interactions in EBP rooms. Multiple staff members, including a physical therapist, certified nursing assistants, and a hospice nurse, were observed not using the required personal protective equipment (PPE) while performing tasks such as transferring residents, changing linens, and assessing residents. These actions were contrary to the facility's policy, which mandates the use of gowns and gloves in EBP rooms to prevent the transmission of communicable diseases. Additionally, a clean-linen cart was found stored uncovered in the basement, which was against the facility's policy that requires clean linen to be protected from environmental contamination. The Infection Preventionist and Director of Nursing confirmed that the uncovered linen was considered contaminated and posed a risk of infection. These lapses in infection control practices had the potential to facilitate the spread of communicable diseases among residents.
Failure to Develop Comprehensive Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a permanent catheter, which was not addressed in the care plan. This deficiency was identified during a survey when it was observed that the resident, who was admitted with chronic kidney disease, did not receive any dressing change or monitoring for her right upper chest catheter since her admission a week prior. The resident confirmed this lack of care during an interview, and a review of her order summary report showed no orders for catheter care and dressing monitoring. Further investigation revealed that during the resident's admission assessment, the charge nurse noted the skin was intact without any vascular access, indicating a failure to properly assess and document the presence of the catheter. The Licensed Nurse confirmed the absence of orders for catheter care, and the Director of Nursing acknowledged the lack of a care plan for catheter care. The facility's policies on dressing changes and preventing catheter-related infections were not followed, as there was no daily assessment or routine dressing change for the catheter site.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to provide services according to professional standards for a resident who was receiving anticoagulant medication, specifically apixaban, without appropriate monitoring in place. The resident was admitted with diagnoses including hemiplegia and cerebral infarction, conditions that necessitate careful management of blood clotting. A review of the resident's Medication Administration Record revealed that there were no orders to monitor for side effects such as excessive bleeding or bruising, which are critical when administering anticoagulants. During an interview and record review, a licensed nurse confirmed the absence of orders or a care plan for anticoagulant monitoring, acknowledging the risk this posed to the resident. The Director of Nursing also stated that residents on anticoagulants should have monitoring orders and a care plan to prevent unmonitored bleeding. The facility's policies on medication therapy and comprehensive person-centered care plans emphasize the need for supporting medication orders with appropriate care processes and establishing measurable objectives and expected outcomes, which were not followed in this case.
Non-Functional Call Light System for Resident
Penalty
Summary
The facility failed to ensure that the call light system was functioning for a resident, identified as Resident 37, which decreased the facility's ability to provide timely assistance. Resident 37, who was admitted in April 2024 with diagnoses including malignant breast neoplasm and generalized muscle weakness, required partial to moderate assistance to roll from side to side in bed. On November 4, 2024, during an observation and interview, Resident 37 was found pressing the call light button without receiving any response, expressing fear of sliding off the bed and falling. Certified Nursing Assistant 4 confirmed that the call light was not working after checking the system, which was securely plugged in but failed to activate the light outside the room. The Director of Nursing later acknowledged that the call light should be operational at all times and that staff should have checked on Resident 37 every two hours or more frequently to ensure the call light's functionality. The facility's policy, dated September 2022, mandates that the resident call system remains functional at all times.
Resident's Right to Self-Determination Violated by Appointment Cancellation
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by canceling a medical appointment without consulting the resident or their family. This incident involved a resident admitted with multiple diagnoses, including a pressure ulcer and type 2 diabetes mellitus. The resident's daughter reported that the facility canceled a necessary pre-operation work-up appointment without prior consultation. The resident's active orders indicated that the resident was capable of making medical decisions and participating in their treatment plan. The Social Services Assistant (SSA) canceled the appointment due to a lack of transportation and based on information from a receptionist at the doctor's office, who stated the appointment was unnecessary. However, the SSA was unsure if the receptionist was qualified to make such a decision. The Social Services Director confirmed the appointment was necessary and had to be rescheduled. The facility's policy on resident rights emphasizes the importance of self-determination and participation in decision-making, which was violated in this case.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with type 2 diabetes mellitus, who experienced an episode of low blood sugar. The resident was admitted to the facility with multiple diagnoses, including diabetes, and was taking high-risk medications that could cause hypoglycemia. On a specific date, the resident's blood sugar was recorded at 62 mg/dl, which is below the threshold for Level 1 hypoglycemia. The facility's policy required immediate notification of the provider, administration of glucose, and a recheck of blood sugar in 15 minutes. However, there was no documentation indicating that these steps were followed. The resident's progress notes and medication administration record showed no follow-up finger stick to check blood sugar, and the resident later showed signs of unconsciousness. During an interview, a licensed nurse confirmed the absence of documentation for the required follow-up actions. The facility's policy on managing hypoglycemia, dated November 2020, outlined the necessary steps for addressing low blood sugar, which were not adhered to in this case.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a staff member witnessed inappropriate contact between two residents. Resident 1, who had severe cognitive impairment and a history of altered mental status and post-traumatic stress disorder, was observed by a Certified Nursing Assistant (CNA) with his hand underneath Resident 2's shirt. Resident 2, also with severe cognitive impairment due to dementia, was unable to consent to such contact. The incident was reported by CNA 2, who heard a scream from Resident 2's room and upon entering, observed the inappropriate contact and noted that Resident 2 appeared scared. Interviews with facility staff, including the Social Service Director and a Licensed Nurse, confirmed that Resident 2 lacked the mental capacity to consent to being touched. The facility's policy on identifying sexual abuse and capacity to consent, revised in September 2022, clearly states that consent is not valid if obtained from a resident who lacks the capacity to consent, and defines sexual abuse as non-consensual sexual contact of any type. The policy further specifies that intimate touching, especially of the breasts, is considered sexual abuse if the resident does not have the cognitive ability to consent or does not want the contact to occur.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an injury of unknown origin for a resident, which is a requirement under the regulations. The resident, who was admitted with dementia, a history of falling, and osteoporosis, was found to have a swollen and painful right wrist with limited range of motion. An X-ray revealed a fracture involving the distal ulnar shaft with displacement. Despite the severity of the injury, the facility did not report the incident as an injury of unknown origin, delaying the abuse investigation process. The resident's condition was first noted when a licensed nurse observed swelling on the wrist while adjusting the resident's blanket. The resident, due to severe cognitive impairment, was unable to recall or explain the cause of the injury. Interviews with staff, including certified nurse assistants and licensed nurses, revealed that none of them could provide an explanation for the injury, and there was no observed behavior that could have led to the fracture. The Social Services Director confirmed that the cause of the fracture was unknown and acknowledged that the incident should have been reported within two hours if abuse was suspected. The Director of Nursing and the Administrator both conducted investigations but did not conclude that the injury was due to abuse, attributing it instead to a previous fall. However, the facility's policy requires that any injury of unknown origin be reported immediately, which was not done in this case. The delay in reporting and investigating the injury potentially compromised the safety of the resident and hindered a thorough investigation into the cause of the injury.
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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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