Milpitas Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milpitas, California.
- Location
- 120 Corning Avenue, Milpitas, California 95035
- CMS Provider Number
- 555757
- Inspections on file
- 27
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Milpitas Care Center during CMS and state inspections, most recent first.
The facility failed to develop person-centered care plans for therapy services for five residents who had active orders for PT, OT, and/or ST. Residents with muscle weakness, abnormalities of gait and mobility, and dysphagia received ordered therapy treatments without corresponding care plans that identified target symptoms, measurable goals, and specific interventions. During record review and interviews, the MDS coordinator, DON, and DOR all confirmed that therapy staff were responsible for initiating these therapy care plans and that none had been created, despite facility policy requiring interdisciplinary care planning that includes therapists.
The facility failed to maintain and integrate PT, OT, and ST documentation into the medical records for five residents who had active therapy orders for conditions such as muscle weakness, gait abnormalities, and dysphagia. Record review showed that, despite written orders for multiple weeks of PT, OT, and/or ST, there were no corresponding therapy treatment notes or care plans in the electronic medical record. The MDS coordinator, medical records director, LVN, and DON all confirmed that therapy documentation was not available in the system, and the director of rehabilitation stated that therapy notes were not routinely loaded into the electronic record, even though they are part of the resident’s medical record. Facility policies required progress notes for residents receiving specialized rehabilitation and documentation of treatments or services performed, but these requirements were not met.
A resident with multiple chronic conditions experienced ongoing, unplanned weight loss over several months. Despite documented declines in weight and inconsistent meal intake, the facility did not implement timely interventions, failed to accurately document weight changes, and did not adequately assess or accommodate the resident's food preferences. The registered dietitian did not participate in interdisciplinary meetings or communicate with the resident's representative, and weight variance meetings were not held until after significant weight loss had occurred.
Staff failed to follow proper hand hygiene and food handling protocols during meal service, including not sanitizing hands between assisting two residents and handling the drinking surface of a cup. Additionally, food storage shelves were in poor condition with peeling paint and residue, increasing the risk of food contamination.
Three residents were administered psychotropic medications, including Depakote, quetiapine, lorazepam, haloperidol, and bupropion, without required monitoring for side effects, quarterly assessments, or documentation of behavioral monitoring. The interim DON confirmed the lack of monitoring and assessments, which was not in accordance with the facility's policy on psychotropic medication management.
The facility did not ensure that regular and pureed potatoes were flavorful or served at the required temperature, as observed during a test-tray review by the CDM. The potatoes were found to be bland and below the policy-required temperature, with the CDM confirming ongoing issues in these areas. This failure had the potential to reduce food intake and nutrient consumption among residents.
A resident was not provided with written information or assistance regarding the right to formulate an advance directive, and there was no documentation that this topic was addressed or that help was offered, as required by facility policy.
A resident was not given a written Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare Part A coverage. Instead, the NOMNC was provided to the resident's representative on the day of discharge, after coverage had already ended, contrary to facility policy and federal requirements.
Two residents with documented schizophrenia were admitted without their mental health diagnoses being accurately recorded on PASARR Level I screenings. Nursing staff confirmed the screenings should have indicated serious mental disorders, as required by facility policy, but did not, resulting in missed referrals for PASARR Level II evaluations.
Staff failed to document an apical pulse before administering Digoxin to a resident with atrial fibrillation, and another resident received Carvedilol despite a low diastolic blood pressure, contrary to physician orders and facility policy. The DON confirmed that required checks were not performed or documented prior to medication administration.
A resident with a history of weight loss did not receive one-to-one feeding assistance with all meals or weekly weights as ordered by the physician. Instead, the resident was observed eating independently and was weighed only monthly, contrary to the care plan and physician's orders. The IDON confirmed these services were not provided as required.
The facility did not complete required annual performance reviews for a CNA and an LVN, resulting in missed opportunities to identify training needs and improve staff skills. Personnel files confirmed the absence of these evaluations, and the director of staff development acknowledged the oversight.
A deficiency was identified when staff failed to accurately document the number of lorazepam tablets for destruction. During a medication audit, the DON and an LVN counted 24.5 tablets, but the record sheet showed only 14.5 tablets for destruction, contrary to facility policy requiring accurate documentation of quantities destroyed.
Two residents receiving apixaban were not monitored for side effects and did not have care plans addressing the use of this anticoagulant, despite physician orders and facility policy requiring such oversight. The interim DON confirmed the absence of monitoring and care planning for both individuals.
A medication error rate of 8% was found when a nurse administered Metformin and Insulin Lispro to a resident without food, contrary to physician orders requiring these diabetes medications to be given with meals. The medications were given before dinner, with no food present, and facility policy required adherence to prescriber orders and optimal timing for therapeutic effect.
An opened box of lorazepam oral concentrate was discovered in the medication room refrigerator without an open-date label, as confirmed by the IDON. Facility policy requires refrigerated medications to be labeled, but this was not done in this case.
A resident's family refused the COVID-19 vaccine on his behalf, but the facility did not obtain or document the required consent from the responsible party, as mandated by facility policy. The infection preventionist confirmed the absence of this documentation during record review.
Rooms housing multiple residents were found to provide less than the required 80 square feet per resident, with each resident receiving approximately 71.96 square feet. Staff and residents reported no concerns about space or privacy, and care provision was not observed to be inhibited.
During a respiratory illness outbreak, the facility failed to implement isolation precautions for five residents who exhibited symptoms such as cough and runny nose. Despite physician orders for cough treatment, there was no documentation of isolation measures being taken, as confirmed by the Infection Prevention Nurse. This oversight was contrary to the facility's policy on Infection Prevention and Control, which mandates transmission-based precautions for residents with signs of transmissible infections.
A resident with dementia and a history of elopement left the facility without staff knowledge due to inadequate supervision and failure to check the functionality of her wander guard. Staff interviews revealed that the resident's whereabouts were not monitored as required, and the facility's elopement policy was not followed.
Failure to Develop Person-Centered Therapy Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop person-centered care plans that included target symptoms, measurable objectives, and specific interventions for residents receiving PT, OT, and ST services. For five sampled residents, the surveyor’s record review showed active therapy orders without corresponding individualized care plans for those services. One resident admitted with muscle weakness had orders for PT five times per week for 12 weeks and OT twice per week for 12 weeks, but there was no documented care plan addressing these therapies. Another resident with muscle weakness and abnormalities of gait and mobility had orders for PT, OT, and ST over several weeks, yet there was no individualized care plan for any of these treatments. A third resident with abnormalities of gait and mobility had PT and OT ordered, a fourth resident with abnormalities of gait, mobility, and dysphagia had PT and ST ordered, and a fifth resident with abnormalities of gait and mobility had PT ordered; none of these residents had documented care plans for the ordered therapy services. During concurrent record review and interviews, the MDS coordinator confirmed that there were no therapy care plans for any of the five residents and stated that therapy staff were responsible for initiating and implementing these care plans when residents received therapy. The DON also confirmed that therapy treatments were provided as ordered but that therapy staff had not initiated the required care plans. The director of rehabilitation similarly stated that therapy staff should have initiated separate care plans for therapy. The facility’s policy on care planning indicated that care plans are to be based on the comprehensive assessment and developed by an interdisciplinary team, including therapists as applicable.
Failure to Maintain and Integrate Therapy Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for progress notes, charting, and documentation of therapy services for five sampled residents. For each of these residents, physician orders were in place for PT, OT, and/or ST at specified frequencies and durations, but there was no corresponding documentation of the therapy treatments or services in the facility’s electronic medical record. The residents had diagnoses such as muscle weakness, abnormalities of gait and mobility, and dysphagia, and were admitted and, in some cases, discharged during the time periods when therapy orders were active. Record review showed that one resident admitted with muscle weakness had orders for PT five times per week for 12 weeks and OT twice per week for 12 weeks, but there was no documented evidence of PT or OT services provided. Another resident with muscle weakness and gait abnormalities had orders for PT, OT, and ST, yet the electronic medical record contained no documentation of any of these therapies. A third resident with gait and mobility abnormalities had orders for PT and OT, but again, no therapy treatment notes were found in the electronic record. Two current residents with gait and mobility abnormalities, and in one case dysphagia, had active orders for PT and/or ST, but there was no documentation of therapy services in their electronic medical records. Interviews with facility staff confirmed the absence of therapy documentation in the electronic medical record. The MDS coordinator verified that there were no PT, OT, or ST treatment notes available in the system and stated that therapy staff should document after each session. The medical records director confirmed there were no therapy treatment notes or care plans accessible and reported having no access to any therapy documentation, despite stating that such documentation should be part of the resident’s medical record. An LVN reported being unable to access therapy documentation and noted that access would help understand residents’ functional progress. The DON confirmed that no therapy treatment documentation was available in the electronic record and that staff should have access to review it. The director of rehabilitation acknowledged that therapy documentation was not included in the facility’s electronic system, explaining that it took a long time to load and was only provided upon request, while also stating that these documents are part of the resident’s medical record. Facility policies on Progress Notes and Charting and Documentation required that progress notes be maintained for residents receiving specialized rehabilitation services and that treatments or services performed be documented in the medical record, which was not done in these cases.
Failure to Address Insidious Weight Loss in a Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who experienced an unplanned, insidious weight loss over several months. The resident, who had multiple diagnoses including congestive heart failure, type 2 diabetes, hypothyroidism, Alzheimer's disease, and dementia, lost 10 pounds (6.8%) in three months and 16 pounds (9.8%) in six months. Despite this ongoing weight loss, the facility did not implement timely or adequate interventions to address the issue. The resident's dietary intake was inconsistently documented, and the registered dietitian (RD) repeatedly noted that the resident was meeting estimated nutritional needs based on meal intake percentages, without specifying time frames or providing evidence that caloric intake actually met the resident's requirements. The RD discontinued a nutritional supplement due to frequent refusals but did not recommend alternative interventions until significant weight loss had already occurred. The RD also did not participate in interdisciplinary team (IDT) meetings or communicate with the resident's representative regarding weight goals or preferences. The facility's documentation showed that weight variance IDT meetings were not held to address the resident's ongoing weight loss until after a significant decline was documented. Additionally, the resident's food preferences were not adequately assessed or accommodated, as the dietary manager did not consult with the resident's family and the facility did not offer culturally preferred foods, despite the resident's cognitive impairment and expressed dissatisfaction with the meals. Further, the facility failed to accurately document significant weight loss in the Minimum Data Set (MDS) assessments, and staff interviews confirmed that required reviews and discussions regarding the resident's nutritional status and weight changes were not consistently performed. The lack of timely intervention, inadequate assessment of intake and preferences, and insufficient interdisciplinary communication contributed to the resident's continued insidious weight loss.
Deficient Food Safety and Infection Control Practices During Meal Service
Penalty
Summary
Staff failed to adhere to professional standards for food safety and infection control during food service and storage. Certified nursing assistants (CNAs) were observed assisting multiple residents with feeding and handling their cups without performing hand hygiene between residents. One CNA handled the drinking surface of a resident's cup, and another CNA did not sanitize her hands after leaving a resident's room before touching and shifting lunch trays on the meal cart. These actions were contrary to the facility's hand hygiene policy, which requires hand sanitization before and after resident contact and before handling food items or trays. Additionally, the facility's dry food storage area was found to be in poor condition, with shelving that had peeling paint, a rough texture, and black residue. The Certified Dietary Manager acknowledged the unsatisfactory state of the shelves. According to the FDA Food Code, food storage areas must be maintained in good repair and food must be stored in clean locations to prevent contamination. The observed conditions and staff practices had the potential to result in bacterial or physical contamination of food served to residents.
Failure to Monitor and Assess Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that appropriate monitoring and assessments were conducted. One resident received Depakote as a mood stabilizer without any monitoring for side effects or quarterly assessment, as confirmed by review of the clinical record and by the interim director of nursing (IDON). Another resident was also given Depakote for mood stabilization without a quarterly assessment, which was similarly confirmed by the IDON upon review of the clinical record. A third resident was prescribed multiple psychotropic medications, including bupropion, haloperidol, lorazepam, and quetiapine, for various behavioral and mood-related indications. However, there was no monitoring documented for the behaviors associated with the use of these medications. The IDON confirmed that there was no monitoring in place for these medications and acknowledged that such monitoring should have occurred. The facility's own policy requires adequate monitoring for efficacy and adverse consequences of psychotropic medications, as well as comprehensive review and evaluation of the resident's signs and symptoms prior to use.
Failure to Serve Palatable and Properly Heated Potatoes
Penalty
Summary
The facility failed to ensure that both regular and pureed potatoes served to residents were flavorful and maintained at a palatable temperature. During a test-tray observation, the Certified Dietary Manager (CDM) measured the temperature of regular diced potatoes at 100°F, which was below the facility's policy requirement of at least 120°F for hot foods. The CDM acknowledged ongoing issues with maintaining proper potato temperatures, and when tasted, the potatoes were barely warm. Additionally, both the regular and pureed potatoes were found to be bland, with the pureed version described as milky-bland and lacking flavor. The facility's policies require that hot foods be served at or above 120°F and that prepared foods be sampled to ensure satisfactory flavor, with the use of herbs and spices encouraged to enhance taste. The CDM confirmed that the potatoes did not meet these standards for temperature or flavor. These deficiencies had the potential to result in residents consuming less food and receiving inadequate nutrient intake.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to one of five residents regarding the right to formulate an advance directive. Review of the resident's admission and clinical records showed that the resident did not have an advance directive on file, nor was there documentation that the topic had been addressed or that assistance was offered to the resident or their representative in formulating one. During an interview, a registered nurse confirmed the absence of both an advance directive and any acknowledgment that the resident had been informed or assisted in this matter. The facility's policy requires staff to offer assistance in establishing advance directives if the resident or representative has not already done so, and to document whether assistance was accepted or declined.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a resident with a written Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before the end of Medicare Part A coverage. Record review showed that the NOMNC was issued to the resident's representative on the same day as the resident's discharge, which was one day after the last covered day. During an interview, the Social Services Director confirmed that the notification was not issued in a timely manner and acknowledged that neither the resident nor the representative was informed about the last Medicare covered day prior to discharge. Facility policy requires that the NOMNC be given in advance, no later than two days before the termination of services.
Failure to Accurately Complete PASARR Screenings for Residents with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the federally mandated Preadmission Screening and Resident Review (PASARR) Level I screenings for two residents who had documented diagnoses of schizophrenia. For both residents, the PASARR Level I forms incorrectly indicated that they did not have a serious diagnosed mental disorder, despite their admission records and hospital discharge summaries clearly listing schizophrenia as a diagnosis. Registered nursing staff responsible for completing the PASARR screenings confirmed during interviews that the forms should have reflected the residents' mental health diagnoses. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and to refer individuals for a Level II evaluation if a serious mental disorder is identified. By failing to accurately document the residents' mental health conditions on the PASARR Level I screenings, the facility did not ensure that the appropriate PASARR Level II evaluations were conducted for these residents.
Failure to Adhere to Medication Administration Standards for Two Residents
Penalty
Summary
Facility staff failed to provide services that meet professional standards of quality for two residents. For one resident with a diagnosis of unspecified atrial fibrillation and an order for Digoxin, staff did not document the apical pulse prior to administering the medication, as required by both physician order and standard nursing practice. The Medication Administration Record (MAR) showed Digoxin was given daily at 9:00 a.m., but no apical pulse reading was recorded at that time. Although apical pulse readings were documented twice daily, they were not specifically taken or recorded immediately before the Digoxin dose, and the Interim Director of Nursing confirmed this omission during interview and record review. In a separate incident, another resident with an order for Carvedilol to be held if systolic blood pressure was less than 105 or pulse less than 55 was administered the medication despite a recorded diastolic blood pressure of 50 mmHg, which is considered low. The nurse did not recheck the blood pressure or consult the physician prior to administration. The Interim Director of Nursing verified the physician order and the low diastolic blood pressure reading prior to medication administration, acknowledging that the nurse should have taken additional steps before giving the medication. Facility policy requires vital signs to be checked and verified prior to medication administration when necessary.
Failure to Provide Ordered Feeding Assistance and Weekly Weights
Penalty
Summary
Resident 15, who had a history of insidious weight loss since October 2023, was admitted to the facility and had physician orders for one-to-one feeding assistance with all meals starting on 2/13/24 and weekly weights every Tuesday starting on 5/21/24. Despite these orders, documentation showed that the resident was only weighed about once a month rather than weekly, and multiple observations revealed that the resident was eating meals independently without the required one-to-one feeding assistance. The interim director of nursing confirmed that the resident should have received weekly weights and one-to-one feeding assistance as ordered, but these services were not provided as required.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for one certified nursing assistant (CNA) and one licensed vocational nurse (LVN), as required by facility policy. Review of personnel files showed that the CNA, hired on 9/26/22, did not have a performance review completed in 2023, and the LVN, hired on 8/18/22, had not received any performance review since being hired. During an interview, the director of staff development confirmed the absence of these required evaluations and acknowledged that annual performance reviews should have been conducted. The facility's policy, dated 9/2020, specifies that each employee's job performance must be reviewed and evaluated at least annually.
Inaccurate Documentation of Controlled Medication Destruction
Penalty
Summary
A deficiency occurred when the facility failed to maintain an accurate record of medication disposition for lorazepam tablets designated for destruction. During a random audit, the Interim Director of Nursing (IDON) and the Administrator (ADM) observed that a bottle of lorazepam 0.5 mg tablets contained 24.5 tablets, while the record sheet indicated only 14.5 tablets were to be destroyed. The IDON acknowledged that the correct number should have been recorded as 24 tablets and confirmed that the count was performed with a Licensed Vocational Nurse (LVN) prior to documentation. LVN B also verified the count of 24.5 tablets and stated she participated in the count with the IDON before documentation. Review of the facility's policy confirmed that the medication disposition record should include the quantity destroyed.
Failure to Monitor and Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that two residents receiving apixaban, an anticoagulant, were monitored for side effects and had appropriate care plans in place regarding the use of this medication. For both residents, physician orders were present for apixaban administration, but their clinical records did not show evidence of monitoring for adverse effects or documentation of care planning related to the medication. The interim director of nursing confirmed during interviews that neither resident was monitored for side effects nor had a care plan addressing the use of apixaban. The facility's own anticoagulation clinical protocol required assessment for signs or symptoms of adverse drug reactions, but this was not followed for the two residents in question. The lack of monitoring and care planning was identified through record review and staff interviews, indicating a failure to comply with both physician orders and facility policy regarding the safe administration and oversight of anticoagulant therapy.
Medication Error Rate Exceeds Threshold Due to Improper Timing of Diabetes Medications
Penalty
Summary
A medication error rate of 8% was identified during a medication pass observation, exceeding the acceptable threshold of less than 5%. Specifically, a licensed vocational nurse administered Metformin 1000 mg orally and Insulin Lispro 4 units subcutaneously to a resident without providing food, despite physician orders specifying that both medications should be given with meals. At the time of administration, there were no snacks or food present at the resident's bedside, and dinner was not scheduled to be served until later. Review of the resident's physician orders confirmed that Metformin and Insulin Lispro were to be administered with meals for diabetes management. The facility's policy and procedure also required medications to be given in accordance with prescriber orders and at times that enhance optimal therapeutic effect. The interim director of nursing verified the orders and acknowledged that the medications should have been given with food.
Failure to Label Opened Medication in Refrigerator
Penalty
Summary
During an observation in the medication room, an opened box of lorazepam oral concentrate was found inside the refrigerator without an open-date label. The Interim Director of Nursing (IDON) confirmed the medication was opened and not labeled with the date it was first used. Facility policy requires that medications stored in the refrigerator be labeled accordingly, but this procedure was not followed in this instance. No information about specific residents or their medical history was provided in relation to this deficiency.
Failure to Obtain Documented Consent for COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to obtain documented consent from the responsible party for a resident regarding the refusal of the COVID-19 vaccine. The resident was admitted with one of his sons designated as his responsible party. According to the resident's COVID-19 immunization record, the family refused the vaccine for the resident on a specific date. However, upon review, the infection preventionist was unable to locate any documentation of consent or refusal from the responsible party in the clinical record. The facility's policy requires that residents or their representatives sign a consent form prior to vaccination, provided in a language and format they understand. This requirement was not met in this instance.
Multi-Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Multi-resident rooms were found to provide less than the required 80 square feet per resident, with rooms 6, 7, and 10 each offering approximately 71.96 square feet per bed for four residents. Observations during the survey indicated that neither staff nor residents experienced any limitations in movement or care provision within these rooms. Both staff and residents reported no complaints or concerns regarding space or privacy during interviews and observations. Despite the lack of reported issues from staff and residents, the physical measurements of the rooms did not meet the regulatory requirement for minimum square footage per resident in multi-resident rooms.
Failure to Implement Isolation Precautions During Respiratory Outbreak
Penalty
Summary
The facility failed to implement its policy on Isolation-Initiating Transmission-Based Precautions during a respiratory illness outbreak, affecting five residents. The Infection Prevention Nurse (IP) acknowledged that in March 2024, several residents exhibited symptoms such as runny nose and cough, and a physician was notified to obtain orders for cough treatment and isolation precautions. However, the facility did not document any isolation precautions for the affected residents, despite the presence of symptoms indicative of a transmissible infection. Resident 1 was noted to have a persistent non-productive cough, and a physician's order for guaifenesin was issued, but there was no evidence of isolation precautions being implemented. Similarly, Residents 2, 3, 4, and 5 all exhibited productive coughs, and while they received physician orders for guaifenesin, there was no documentation of isolation precautions being taken. The IP confirmed the absence of physician orders for isolation precautions for these residents during the outbreak. The facility's policy on Infection Prevention and Control, as well as the specific policy on Isolation-Initiating Transmission-Based Precautions, requires the initiation of transmission-based precautions when a resident shows signs of a transmissible infection. Despite this, the facility did not follow through with the necessary precautions, as evidenced by the lack of documentation and physician orders for isolation during the outbreak, potentially allowing the spread of infectious disease among residents and staff.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident at risk for elopement from leaving the facility without staff knowledge or permission. The resident, who had a history of dementia, hypertension, hyperlipidemia, and falls, was readmitted to the facility and had previously eloped on two occasions. Despite these risks, the resident's wander guard, a device intended to monitor her movements, was not checked for functionality, and staff did not provide the necessary supervision or assistance. Interviews with facility staff revealed that the wander guard was not checked, and the resident's whereabouts were not monitored as required. A licensed vocational nurse confirmed that the failure to check the wander guard led to the staff being unaware of the resident's departure. A certified nursing assistant also admitted to not checking the wander guard or the resident's location due to being occupied with another resident. The facility's policy on elopement required staff to investigate and report missing residents and ensure wander guard devices and alarms were functioning, which was not adhered to in this case.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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