Mission Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 4800 Delta Avenue, Rosemead, California 91770
- CMS Provider Number
- 555796
- Inspections on file
- 34
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mission Care Center during CMS and state inspections, most recent first.
A CNA and a treatment nurse did not wear required isolation gowns while providing high-contact care, including wound treatment and personal hygiene, to a resident on Enhanced Barrier Precautions due to a suprapubic stoma and pressure injuries. Both staff acknowledged forgetting to follow the facility's infection control policy, and the DON confirmed that gown use was required for such care activities.
A resident with paraplegia and existing pressure injuries was found to have a low air loss (LAL) mattress set for a 300-pound person, despite weighing 197 pounds. The treatment nurse admitted to forgetting to adjust the mattress setting according to the resident's weight, as required by facility policy and manufacturer guidelines. The DON confirmed the error and acknowledged the importance of proper mattress settings for pressure injury management.
The facility failed to properly label and store food items, including bell peppers, carrots, and expired cinnamon roll dough, according to professional standards and its own policy. This oversight could lead to foodborne illnesses among the 54 residents. The Dietary Supervisor acknowledged the lapse in following the policy, which requires a 'use by' date for all stored food items.
The facility did not follow its smoking safety policy by failing to post necessary signage and provide a fireproof blanket in the designated Smoking Patio. An Activities Assistant confirmed the absence of a sign indicating the smoking area and a sign prohibiting oxygen use, as well as the lack of a fireproof blanket, which could pose a risk to residents.
A facility failed to ensure a resident's Advance Directive was obtained and available in their medical records. Despite the resident having moderately impaired cognition and a POLST indicating an Advance Directive, it was not present in the records. The Social Services Director was unable to obtain it from the family, and the Director of Nursing highlighted its importance for honoring the resident's wishes. The facility's policy required the Advance Directive to be in the health record, but this was not done.
A facility failed to conduct a background check for a CNA before employment, contrary to its policy. The CNA began working before the background check was completed due to delays attributed to the COVID-19 pandemic. Facility staff misunderstood the continuation of a temporary policy allowing employment to start before background checks were finalized. This oversight increased the risk of exposing residents to potential abuse.
A resident with severe cognitive impairment and chronic conditions was not receiving continuous oxygen therapy as ordered, with the nasal cannula found hanging from the concentrator. The facility's policy on oxygen use was not followed, as confirmed by an Infection Preventionist Nurse.
A resident with glaucoma was incorrectly administered Timolol Maleate Ophthalmic Solution to both eyes instead of the left eye only, as per the physician's order. The LVN did not read the medication label or order correctly, leading to this error. The DON emphasized the importance of following doctor's orders to ensure resident safety.
The facility failed to properly label and store medications, leading to potential issues with medication effectiveness. In one instance, an opened package of Albuterol for a resident with acute respiratory failure was found without an open date label. In another case, an opened package of Albuterol for a resident with COPD was not discarded despite being past its expiration date. The QAN and DON acknowledged the importance of proper labeling to prevent the use of expired medications.
A resident's discharge documentation was inconsistent, with progress notes and the MDS indicating a transfer to a general acute hospital, while the Physician's Discharge Summary incorrectly stated a discharge home. The MRD, responsible for chart audits, confirmed the discrepancy but was unaware of the importance of matching documentation. The DON highlighted the need for accurate records to ensure all parties are informed of resident updates.
The facility failed to maintain the walk-in freezer according to its policy, as temperatures were not documented twice daily, and the freezer had condensation issues. The Dietary Supervisor confirmed that temperatures were only logged once in the morning, and the Kitchen Manager noted reliance on a single thermometer due to another being broken. The Air Conditioning Technician identified a cracked condensate line, contributing to the freezer's issues.
The facility failed to implement effective COVID-19 infection control measures, including visitor screening, biweekly PCR testing, and proper use of PPE and social distancing in common areas. The lack of procedures and equipment, compounded by the unavailability of the medical director and supply shortages, led to deficiencies in managing the spread of the virus.
A resident with severe mobility impairments and high fall risk did not have a wheelchair sensor pad alarm applied as ordered by the physician and outlined in the care plan. The resident was found on the floor, and interviews revealed the sensor pad was often unplugged or missing. The facility's policy emphasized accident prevention, but the failure to implement the care plan interventions exposed the resident to potential falls.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 and Treatment Nurse (TN) 1 failed to follow the facility's infection control protocols by not wearing an isolation gown while providing direct contact care to a resident who was on Enhanced Barrier Precautions (EBP). The resident had a suprapubic stoma for intermittent catheterization and pressure injuries on the left ischium and right heel, conditions that placed them at higher risk for multidrug resistant organisms (MDROs). During wound care, bed bathing, and brief changing, both CNA 1 and TN 1 provided high-contact care without donning the required isolation gown, despite signage at the resident's doorway and facility policy indicating the necessity of gown and glove use for such activities. Interviews with CNA 1 and TN 1 revealed that both staff members acknowledged forgetting to wear the gown during the high-contact care activities, and recognized that this was contrary to facility policy and infection control standards. The Director of Nurses (DON) confirmed that the resident was on EBP due to their medical conditions and that staff were required to wear gowns during high-contact care, such as bathing, changing briefs, and wound care. Review of the facility's infection prevention and control policy further supported that gown and glove use was mandatory for residents on EBP during these types of care activities.
Incorrect LAL Mattress Setting for Resident with Pressure Injuries
Penalty
Summary
A resident with a history of paraplegia, recent genitourinary surgery, urinary retention, and existing pressure injuries on the left ischium and right heel was admitted to the facility and assessed as being at moderate risk for pressure injuries. The resident required a low air loss (LAL) mattress as part of their care plan to manage and prevent further skin breakdown. According to the resident's current weight of 197 pounds, the LAL mattress was supposed to be set according to the manufacturer's guidelines, which specify adjusting the mattress pressure based on the patient's weight. During observation and interview, it was found that the LAL mattress was incorrectly set for a 300-pound person, rather than the resident's actual weight. The treatment nurse acknowledged responsibility for ensuring the correct mattress setting and admitted to forgetting to adjust it that morning. The DON confirmed that the mattress should have been set according to the resident's weight and that the incorrect setting could delay healing of existing pressure injuries and potentially result in new ones. Facility policy and manufacturer guidelines both require the LAL mattress to be set according to the resident's weight.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and its own policy and procedure regarding the storage and labeling of food. During an observation, it was found that several food items, including bell peppers, carrots, tomatoes, lettuce, celery, cucumbers, onions, oranges, cantaloupes, and pineapples, were not labeled with a 'use by' date. This lack of labeling could lead to the food going bad, potentially causing foodborne illnesses among the 54 residents in the facility. The Dietary Supervisor acknowledged that all food items in the refrigerator should have a 'use by' date to prevent spoilage and ensure resident safety. Additionally, an expired box of Traditional Cinnamon Roll Dough was found in the refrigerator, 51 days past its expiration date. The Dietary Supervisor confirmed that the expired dough should not have been stored in the refrigerator, as it could mistakenly be used by staff, posing a risk of foodborne illness to residents. The facility's policy, as reviewed, mandates that commercially processed, ready-to-eat foods intended for storage longer than 24 hours must be marked with a 'use by' date. The Dietary Supervisor admitted that the facility was not following this policy, which could affect all residents by increasing the risk of consuming expired or spoiled food.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking safety measures in the designated Smoking Patio. During an observation, it was noted that the Smoking Patio lacked a sign indicating it was a designated smoking area and a sign prohibiting the use of oxygen in the area. Additionally, the patio did not have a fireproof blanket available, which was required by the facility's policy. These omissions were confirmed during an interview with the Activities Assistant, who acknowledged the absence of the necessary signage and fireproof blanket. The Activities Assistant expressed concerns that without proper signage, residents might not be aware of the designated smoking area, and those on oxygen might inadvertently enter the area, posing a risk of burns. The absence of a fireproof blanket was also highlighted as a safety concern, as it would serve as a backup in case the fire extinguisher was not functional. The facility's policy, reviewed during the interview, clearly stated the requirement for both a fire extinguisher and a fireproof blanket in the smoking area, indicating non-compliance with established safety protocols.
Failure to Obtain and Document Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive was obtained and readily available in the resident's medical records. The resident, who was admitted with diagnoses including a urinary tract infection, difficulty walking, and hypertension, had moderately impaired cognition as indicated by the Minimum Data Set. Despite having decision-making capacities noted in the History and Physical, the resident's Physician Orders for Life Sustaining Treatment indicated the presence of an Advance Directive. However, during a review of the resident's medical chart and electronic records, the Quality Assurance Nurse confirmed that the Advance Directive was not present. Interviews with facility staff revealed that the Social Services Director had been unable to obtain the Advance Directive from the resident's family member, despite repeated requests. The Director of Nursing emphasized the importance of having the Advance Directive to honor the resident's and family's wishes, especially if the resident becomes unable to make decisions. The facility's policy required obtaining and placing a copy of the Advance Directive in the resident's health record, but this was not done, leading to the potential for misinformation and not honoring the resident's wishes in healthcare decisions.
Failure to Complete Background Check Before Employment
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) underwent a background screening and criminal history check prior to employment, as required by the facility's policy and procedure titled 'Pre-employment Investigation.' CNA 1 was offered employment on a contingent basis pending the results of reference checks, a criminal background check, and a drug screening. However, CNA 1 began working at the facility on November 7, 2024, before the background check was completed on November 20, 2024. This oversight was attributed to delays in obtaining background check results due to the national public health emergency declared during the COVID-19 pandemic. Interviews with facility staff revealed a misunderstanding regarding the continuation of a temporary policy that allowed staff to begin employment before completing their background checks during the pandemic. The Director of Staff Development (DSD) and Human Resources (HR) staff indicated that they believed CNA 1 was cleared to work based on outdated guidance. The Director of Nursing (DON) confirmed that the facility's policy requires background checks to be completed before starting the orientation process. The facility's failure to adhere to its policy increased the risk of applicants and employees with potential criminal convictions having direct access to residents, thereby placing them at risk of abuse and feelings of intimidation.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident 150 received oxygen therapy as ordered by the attending physician. Resident 150 was admitted with diagnoses including hemiplegia, hemiparesis, and chronic kidney disease. The Minimum Data Sets (MDS) indicated that the resident's cognition was severely impaired and that they were receiving continuous oxygen therapy. A physician's order dated 2/11/2025 specified that the resident should receive continuous oxygen at 2 liters via nasal cannula to maintain oxygen saturation above 90% for shortness of breath. During an observation on 2/14/2025, Resident 150 was seen sitting in bed without the nasal cannula in use, as it was hanging from the oxygen concentrator. The Infection Preventionist Nurse confirmed that the nasal cannula should not have been hanging and that the resident should have been receiving continuous oxygen therapy. The facility's policy on the use of oxygen, revised in May 2007, emphasizes promoting resident safety in administering oxygen, which was not adhered to in this instance.
Failure to Follow Medication Administration Orders
Penalty
Summary
The facility failed to prevent unnecessary medication administration for one resident by not adhering to the physician's order for Timolol Maleate Ophthalmic Solution. The order specified that the medication should be administered to the resident's left eye only, once a day, to treat glaucoma. However, during a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering the medication to both the left and right eyes of the resident. The resident involved had been admitted with diagnoses including metabolic encephalopathy and primary open-angle glaucoma. The LVN admitted to not reading the medication bottle label or the specific part of the order that indicated the medication was to be administered to the left eye only. The Director of Nursing confirmed that all nurses are expected to check and follow doctor's orders to ensure the correct medication is given, highlighting a lapse in following the facility's medication administration policy.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to prescription labels, leading to potential issues with medication effectiveness. In Medication Cart #1, an opened package of Albuterol Inhalation Solution for a resident with acute respiratory failure and other conditions was found without an open date label. This package contained four out of five plastic vials, and the Quality Assurance Nurse (QAN) acknowledged that the prescription label indicated an expiration date of seven days after opening. The absence of an open date label could result in the administration of expired medication. In Medication Cart #2, another opened package of Albuterol Inhalation Solution for a resident with COPD and other diagnoses was observed with an open date of 2/4/2025, but it was not discarded despite the expiration date being seven days after opening. The QAN confirmed that the package contained only one plastic vial left and stated that it would be discarded to prevent its use. The Director of Nursing (DON) emphasized the importance of labeling medications with open dates to avoid administering expired medications, as they would not be as effective.
Inaccurate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to accurately document a resident's discharge disposition on the discharge summary, resulting in inconsistent records for Resident 47. The resident was admitted with conditions including a nasal bone fracture, gait abnormalities, and type 2 diabetes mellitus. The resident had decision-making capacities and was scheduled for a left knee skin graft surgery. However, discrepancies were found in the documentation regarding the resident's discharge location. The nursing progress notes and the Minimum Data Set (MDS) indicated that the resident was discharged to a general acute hospital center (GACH), while the Physician's Discharge Summary incorrectly stated that the resident was discharged home. Interviews with the MDS Nurse and Medical Records Director (MRD) revealed that the MRD was responsible for auditing resident charts and ensuring accurate documentation. The MRD confirmed the inconsistency in the discharge location between the Physician's Discharge Summary and the MDS but admitted to not understanding the importance of matching documentation. The Director of Nursing emphasized the importance of accurate documentation for keeping all parties informed of resident updates and dispositions. The facility's policies on admission, transfer, discharge, and documentation stress the need for accurate and consistent record-keeping.
Failure to Maintain Walk-In Freezer in Good Operating Condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in good operating condition as per its policy and procedures. The deficiency was identified through observation, interview, and record review, revealing that the facility did not document temperature readings of the freezers both in the morning and evening as required. The facility's policy indicated that freezer temperatures should be recorded twice daily, but the Dietary Supervisor (DS) confirmed that temperatures were only logged once in the morning. Additionally, the temperature logs did not specify which thermometer was used, and only one thermometer reading was recorded for freezer number three, which was the walk-in freezer. During an inspection, the walk-in freezer was found to have a plastic curtain with water dripping down and condensation with visible water droplets on the ceiling. The temperature readings from different thermometers in the freezer varied significantly, with the outside thermometer reading 19 degrees Fahrenheit, the inside thermometer near the door reading 20 degrees Fahrenheit, and the thermometer at the back reading negative two degrees Fahrenheit. The Air Conditioning Technician (AC Tech) noted that the thermometer by the door would not provide an accurate reading due to heaters along the door, and the freezer had a cracked condensate line that needed repair. The facility's policy also required that each freezer have two visible thermometers and maintain a temperature of zero degrees Fahrenheit or lower. However, the Kitchen Manager (KM) stated that the facility only checked the temperature readings once a day and relied on the thermometer in the back of the walk-in freezer, as the other thermometer was broken. The DS and Administrator (ADM) acknowledged that the facility was not following its policy and procedures, which could potentially put residents at risk for foodborne illness or contamination due to improper freezer maintenance.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control policy and the local public health department's recommendations, leading to deficiencies in managing COVID-19. During an unannounced visit, it was observed that the facility did not have a procedure to screen visitors for COVID-19 symptoms before entering. The Administrator and a Licensed Vocational Nurse confirmed that visitors were only required to log in and wear a facemask, without any symptom screening or antigen testing. The facility also failed to conduct biweekly PCR testing for all residents and staff as instructed by a public health nurse and a county physician. The Administrator stated that the testing could not be initiated because the medical director, whose signature was required, was on vacation and unreachable. Additionally, the facility's breakrooms were not equipped with necessary infection control supplies such as hand sanitizers, facemasks, and wipes, and did not adhere to occupancy limits or ventilation recommendations. Furthermore, the rehabilitation room was observed to be overcrowded, with more people than allowed and without proper mask usage or social distancing. The Infection Preventionist admitted to not ensuring compliance with the recommendations, including signage for mask changes and the availability of masks in breakrooms. The facility also faced challenges in acquiring air purifiers due to supply shortages, contributing to the inadequate infection control measures.
Failure to Implement Wheelchair Sensor Pad Alarm for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a wheelchair sensor pad alarm was placed on the wheelchair of a resident who was assessed as high risk for falls. The resident, who had difficulty walking, hemiplegia, and hemiparesis, was admitted and readmitted to the facility with a physician's order to use a sensor pad in bed and in a wheelchair to prevent unassisted movement. The resident's care plan also included the use of a sensor pad as a safety precaution. However, the resident was found lying on the floor in the dining room, indicating that the sensor pad was not in use. Interviews and record reviews revealed that the resident's wheelchair sensor pad was often unplugged or missing, as noted by a family member on multiple occasions. The Director of Staff Development confirmed that the sensor alarm was not applied to the resident's wheelchair during a visit. The Director of Nursing acknowledged that the facility's failure to implement the care plan interventions could expose residents to accidents, such as falls, which could lead to serious injuries. The facility's policy on fall management emphasized the importance of providing an environment free of accident hazards and adequate supervision to prevent accidents.
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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