Monterey Palms Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Desert, California.
- Location
- 44610 Monterey Avenue, Palm Desert, California 92260
- CMS Provider Number
- 555403
- Inspections on file
- 33
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Monterey Palms Health Care Center during CMS and state inspections, most recent first.
A resident with post-stroke hemiplegia and moderate cognitive deficit alleged that a CNA hit his elbow away while providing perineal care and became upset when the CNA responded by calling him a liar and challenging his accusation. The CNA later admitted becoming angry and telling the resident he was lying about being hit. This interaction conflicted with facility policy and training that direct staff not to argue with residents, to use professional de-escalation techniques, and to walk away and give residents space when they become angry or accusatory.
Two residents did not receive their prescribed IV antibiotics as ordered, with doses being missed, given late, or not documented, and there was no evidence that the physician or pharmacy were notified when medications were unavailable. Nursing staff and the DON confirmed that medication administration and documentation did not follow facility policy.
Three residents with complex medical conditions did not have their medication administrations accurately documented, with multiple instances of late intravenous antibiotic and antifungal doses recorded in the MAR. Nursing staff and the DON confirmed that documentation did not always reflect the actual time of administration, contrary to facility policy requiring timely and accurate charting.
The facility failed to ensure proper food safety and sanitation practices. A dietary aide did not follow guidelines for testing sanitizer concentration, risking improper sanitization. A cook inadequately cleaned a prep counter after handling raw chicken, and another cook failed to monitor the cooling process of roast meat, risking foodborne illness. These deficiencies affected all residents receiving food from the kitchen.
The facility failed to adhere to dietary guidelines and portion control, impacting residents' nutritional needs. Dietary staff did not follow the Cooks spreadsheet for portion sizes, leading to incorrect servings of pureed foods. Additionally, recipes were not followed, affecting the consistency and flavor of meals. Residents on specific diets received inappropriate food items, and salad dressing was served without measuring, potentially affecting calorie and nutrient intake.
The facility failed to provide appetizing and properly tempered food, affecting seven residents. Multiple residents reported cold and unappetizing meals, with staff confirming issues such as lack of seasoning and delayed meal service. The facility's policy required tasting and quality checks, which were not adhered to, leading to this deficiency.
The facility failed to maintain a sanitary environment and adhere to food safety standards. Wet kitchen equipment, dust accumulation, and build-up on equipment were observed, posing contamination risks. Improper food storage and labeling practices were noted, along with unsanitary conditions such as a worn cutting board and cracked tiles. Personal items were stored inappropriately, and a staff member did not follow proper cleaning procedures after handling raw chicken, increasing the risk of foodborne illnesses.
A facility failed to create a care plan for a resident with a new diagnosis of pulmonary emboli on anticoagulant therapy. The resident, with moderate cognitive impairment, was readmitted with a prescription for Eliquis, but no care plan was documented to address the condition or medication management. The DON acknowledged the oversight, which was contrary to the facility's policy requiring an acute condition care plan.
A resident with cerebral infarction and end-stage renal disease was found with dirty fingernails, indicating a failure in maintaining proper hygiene. The facility's policy required daily nail care, but the routine was limited to Sundays. The infection preventionist and CNA acknowledged the oversight, and the DON confirmed the established routine, highlighting a deficiency in adhering to the care plan for maintaining resident dignity and comfort.
A resident was found with an outside pharmacy's Simvastatin medication at her bedside without a self-administration assessment, and expired Daptomycin IVPB bags were stored in the medication room refrigerator for another resident. The facility's policies on medication storage and self-administration were not followed, leading to potential risks for residents.
A resident was served a turkey sandwich despite documented preferences for cottage cheese and a dislike for turkey. The meal ticket indicated these preferences, but the resident did not receive the preferred food. The Dietary Manager confirmed the importance of honoring food preferences to prevent nutritional deficiencies. This incident reflects a failure to adhere to the facility's policies on serving foods and nutrition care.
The facility failed to properly dispose of garbage and refuse, as observed when dumpster lids were not closed and trash was found on the ground. The Dietary Services Supervisor and Registered Dietitian acknowledged the issue, which could attract pests and cause infection control problems. The facility's policy requires dumpster areas to be clean and lids closed.
A facility failed to follow infection control measures for a resident with contact isolation precautions. Staff members entered the resident's room without wearing appropriate PPE, and one CNA used non-disposable equipment without proper disinfection. Interviews revealed a lack of understanding of infection control policies among staff, despite the resident's need for contact isolation due to an ESBL infection.
A resident with a history of stroke and Parkinson's disease was found unable to reach her call light, which was wrapped around the siderail, during a complaint investigation. The CNA confirmed the call light was not within reach, contrary to the resident's care plan and facility policy, which required call lights to be accessible to prevent falls.
The facility failed to ensure timely responses to call lights, as evidenced by two residents experiencing delays of up to an hour, leading to unmet care needs and feelings of embarrassment. Staff interviews and observations confirmed that call lights should be answered within 3-5 minutes, but this standard was not consistently met.
The facility failed to ensure that two out of three trash dumpster lids were securely closed, potentially attracting pests and creating an unsanitary environment. Staff acknowledged the importance of keeping lids closed, but the lids were sometimes left open because they were heavy and hard to close.
Failure to Treat Resident with Dignity During Dispute Over Alleged Hitting During Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a CNA verbally responded inappropriately after the resident alleged being hit during care. The resident, who had hemiplegia/hemiparesis following a stroke and a BIMS score of 12 indicating moderate cognitive deficit, reported that while receiving perineal care he asked the CNA for a wipe and, when he reached for it, the CNA hit his elbow out of the way. The resident stated it was more than a push and that when he told the CNA, "You hit my elbow," the CNA yelled, "You're a liar." The resident reported that the CNA became mad at him, which upset and angered the resident. Progress notes indicated hospice staff reported the resident’s statement that the CNA hit his elbow while providing care. In a subsequent interview, the CNA acknowledged that during perineal care, when the resident asked, "Why did you hit me?" he became "a little angry" and told the resident, "You're lying," and further stated that he went out of his way for the resident and accused the resident of lying about being hit. The administrator, who serves as the abuse coordinator, stated that staff receive abuse training and that when a resident becomes angry or accusatory, staff are expected to walk away, give the resident space to calm down, and report to the charge nurse, and that the CNA should not have engaged with the resident by calling him a liar. Facility policy on Mood and Behavior Management Techniques directs staff not to argue with residents, to detach from resident agitation, and, if unsuccessful, to walk away and wait before re-approaching, which was not followed in this interaction.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of residents by not administering medications in accordance with physician orders for two residents. One resident, who was alert and oriented and had diagnoses including bacteremia, diabetes, and hypertension, reported receiving his antibiotic at inconsistent times. Review of his records showed that a scheduled dose of cefazolin was administered late and another dose was not documented as given. The Medication Administration Record (MAR) confirmed these discrepancies, and there was no evidence that the missed or late doses were communicated to the physician as required. Another resident, admitted with diagnoses including pneumonia, congestive heart failure, stroke, and end stage renal disease, had a physician order for vancomycin to be administered on specific days. The MAR indicated that two scheduled doses were not administered, with one dose noted as unavailable. Interviews with nursing staff and the Director of Nursing confirmed that medications were not given on time, not properly documented, and that neither the physician nor the pharmacy were notified when medication was unavailable. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for administration to be recorded immediately, which was not followed in these cases.
Failure to Accurately Document Medication Administration Times
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, specifically regarding the accurate documentation of medication administration for three residents. For one resident with bacteremia, diabetes, and hypertension, the Medication Administration Record (MAR) showed multiple instances where the scheduled 7 a.m. dose of intravenous cefazolin was administered late, with times ranging from over an hour to more than three hours past the scheduled time. Despite these delays, the MAR sometimes included comments indicating the medication was given on time, while other entries noted the late administration. The resident reported receiving antibiotics late or early at times. Another resident with septicemia, congestive heart failure, and a history of stroke had a physician's order for daily intravenous ceftriaxone at 9:00 a.m. The MAR indicated that on two occasions, the medication was administered more than an hour late. Similarly, a third resident with Crohn's disease, ileocecal resection, and an ileostomy had a physician's order for daily intravenous fluconazole at 9:00 p.m., but the MAR showed the medication was administered over an hour late on one occasion. Interviews with the RN and DON confirmed that the MARs reflected late administration times, and both acknowledged that medication administration should be documented accurately and timely, with the MAR reflecting the actual time of administration. Facility policies reviewed stated that charting should be factual, accurate, and timely, and that medications should be administered within 60 minutes of the scheduled time, with immediate documentation following administration.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services, as evidenced by several observations and interviews. Dietary Aide 2 did not adhere to the manufacturer's guidelines for testing the Quaternary sanitizer, which is crucial for sanitizing food contact surfaces. Instead of dipping the test strip for the required 10 seconds, DA 2 only dipped it for 1 second, potentially leading to a false reading of the sanitizer concentration. This deviation from protocol was confirmed by the Registered Dietitian, who emphasized the importance of following the manufacturer's guidelines to ensure proper sanitization. Additionally, Cook 2 did not follow the proper cleaning procedures after preparing raw chicken. The prep counter was observed with pink chicken juice, and CK 2 only used sanitizing wipes to clean the surface, rather than following the necessary steps of washing, rinsing, air drying, and sanitizing. This improper cleaning method was identified as a hazard for foodborne pathogens by the Registered Dietitian, who reiterated the importance of adhering to the facility's cleaning procedures to prevent contamination. Furthermore, Cook 1 demonstrated a lack of understanding of the proper cooling process for food. CK 1 began cooling roast meat from 140 degrees F and stored it in the refrigerator, checking the temperature only after 14 hours. The Registered Dietitian explained that the cooling process should involve monitoring the temperature every 2 hours to ensure it reaches 70 degrees F within 2 hours and 40 degrees F within an additional 4 hours. The failure to monitor the cooling process properly posed a food safety risk, as it could allow bacteria or viruses to grow on the roast meat, potentially leading to foodborne illness for the residents.
Failure to Follow Dietary Guidelines and Portion Control
Penalty
Summary
The facility failed to ensure that the menus, recipes, and Cooks spreadsheet were followed, resulting in deficiencies in meeting the nutritional needs of residents. On two separate occasions, dietary staff did not adhere to the specified portion sizes for pureed food items as outlined in the Cooks spreadsheet. Specifically, on January 27, 2025, CK 1 used incorrect scoop sizes for pureed beef pot pie and cauliflower, and on January 28, 2025, CK 2 used incorrect scoop sizes for pureed chicken and white rice. This led to residents on pureed diets receiving incorrect amounts of food, potentially affecting their nutritional intake. Additionally, the preparation of pureed cauliflower on January 27, 2025, did not follow the standardized recipe, resulting in a runny consistency that was not appealing or appetizing. CK 1 added unmeasured hot water to the cauliflower, which diluted its nutritional value. The facility's policy emphasized the importance of using standardized recipes to ensure meals are attractive and provide necessary nutritive value, which was not adhered to in this instance. Further deficiencies were observed when CK 2 failed to add margarine and seasoning to buttered corn, affecting the flavor and potentially decreasing residents' meal intake. Moreover, dietary staff served ice cream instead of chilled pears to residents on low fat, low cholesterol, and cardiac diets, contrary to the Cooks spreadsheet instructions. Lastly, the Dietary Services Supervisor served salad dressing without measuring, which could lead to incorrect calorie and nutrient intake. These actions demonstrate a lack of adherence to established procedures and policies, potentially impacting the nutritional well-being of the residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing appetizing and palatable food at appropriate temperatures according to residents' preferences. This deficiency was identified for seven out of 89 sample residents. Multiple residents reported that the food was often cold and unappetizing. Specific instances included Resident 96 stating the food was cold most of the time, Resident 43 expressing the need for warm and timely dinner service, and Resident 82 describing the food as terrible and cold. Additionally, Resident 84 mentioned cold eggs, and Resident 23 noted that the food was often cold and did not taste well. Resident 99 also expressed dissatisfaction with the food. Observations and interviews with staff further confirmed these issues. During a test tray evaluation, the Registered Dietician (RD) confirmed that the Buttered Corn and Lemon Pepper Chicken lacked flavor and seasoning. The Dietary Service Supervisor (DSS) acknowledged that scrambled and pureed eggs were served cold, with temperatures recorded at 101 F and 100 F, respectively. The DSS attributed the cold food to delays in passing meal trays. The facility's policy required cooks to taste all food before serving to ensure adequate seasoning and quality, and for the DSS and RD to routinely check prepared food for portion control, seasoning, quality, and correct consistency. However, these procedures were not followed, leading to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to professional standards for food service and safety. Observations revealed that kitchen equipment was improperly stored while still wet, which could lead to the transmission of microorganisms. Dust accumulation was noted on several surfaces, including door frames and vents in the walk-in refrigerator, posing a risk of food contamination. Additionally, there was a significant build-up on various kitchen equipment, such as the blender, ice machine, and storage shelves, which were not cleaned and sanitized as required. Food storage practices were also found to be inadequate. Two opened tortillas were left exposed to the air in the walk-in refrigerator, and ground beef was placed for defrosting without proper labeling. These practices could compromise food quality and safety, increasing the risk of foodborne illnesses. Furthermore, a strainer with brown spots, possibly rust, was observed, and cracked tiles in the dishwashing area presented potential hazards for contamination and pest attraction. Personal items were improperly stored in the kitchen's storage area, and a cutting board was found to be worn and unsanitary. Additionally, a staff member failed to follow proper cleaning procedures after preparing raw chicken, using only sanitary wipes instead of the required wash, rinse, and sanitize steps. These deficiencies collectively posed a significant risk of foodborne illnesses to the facility's residents, who are a medically vulnerable population.
Failure to Develop Care Plan for Resident with Pulmonary Emboli
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a new diagnosis of pulmonary emboli who was on anticoagulant treatment. The resident, identified as having moderate cognitive impairment and lacking the capacity to make medical decisions, was readmitted to the facility with a diagnosis of pulmonary emboli and a new prescription for Eliquis, an anticoagulant medication. Despite the resident's condition and treatment requirements, there was no documented evidence of a care plan addressing the signs and symptoms of pulmonary emboli or the management of the anticoagulant therapy. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing (DON) and the MDS Coordinator. The DON acknowledged that a care plan specific to the resident's new diagnosis and medication was not developed, despite the facility's policy requiring an acute condition plan of care to be created when an acute condition is identified. This oversight had the potential to delay necessary care and services, placing the resident at risk for further complications related to their condition and treatment.
Failure to Maintain Resident's Fingernail Hygiene
Penalty
Summary
The facility failed to maintain the cleanliness and proper hygiene of a resident's fingernails, which was observed during a survey. The resident, who had a history of cerebral infarction with left-sided weakness, osteomyelitis, and end-stage renal disease requiring hemodialysis, was found with blackish material under the fingernails of the right hand. The resident expressed a desire to have the nails cleaned, indicating that they had been in this condition for some time. The facility's infection preventionist and a CNA acknowledged the need for nail cleaning, noting that the resident's nails should have been cleaned before hemodialysis treatment. The facility's policy indicated that nail care should include daily cleaning and regular trimming to prevent infections and promote circulation. However, the facility had established a routine where nail cleaning and shaving were scheduled only on Sundays. This routine was confirmed by the Director of Nursing, who stated that CNAs were responsible for checking and maintaining the cleanliness of all residents' nails. The deficiency in providing necessary care and services for the resident's fingernail hygiene was identified as a failure to adhere to the facility's policy and the resident's care plan, which aimed to provide assistance in activities of daily living to maintain comfort and dignity.
Improper Medication Storage and Expired Antibiotics Found
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, as evidenced by two separate incidents involving residents. In the first incident, a resident was found with a bottle of Simvastatin medication from an outside pharmacy at her bedside. The resident, who was alert but with some confusion, stated she intended to take the medication in the evening. The medication was not part of the facility's supply, and there was no record of a medication self-administration assessment for the resident prior to the discovery. Interviews with the LVN and QA nurse confirmed that the medication should not have been at the resident's bedside, as it was not dispensed by the facility's pharmacy. In the second incident, three expired Daptomycin antibiotic IVPB bags were found in the medication room refrigerator for another resident. The bags had expired several days prior to the observation, and the RN acknowledged that the expired medications should have been discarded. The IP nurse and DON confirmed that licensed nurses were responsible for ensuring expired medications were not stored and that administering expired antibiotics could result in ineffective treatment. The facility's policies on medication storage and self-administration were reviewed, indicating that medications should be stored properly and that assessments should be conducted to determine a resident's capability for self-administration. However, these policies were not followed, leading to the potential for residents to self-administer medication without monitoring and to receive expired or ineffective medications.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, as evidenced by an incident involving a resident who was served a turkey sandwich despite having a documented dislike for turkey and a preference for cottage cheese. During an observation, it was noted that the resident's meal ticket clearly indicated these preferences, yet the resident was observed eating a turkey sandwich. The resident expressed that she did not like turkey sandwiches but chose not to mention it to the staff. The Restorative Nurse Assistant confirmed that the resident did not receive cottage cheese as preferred and did not like the turkey sandwich. The Dietary Manager acknowledged the importance of honoring residents' food preferences and offering alternatives, noting that failure to do so could lead to decreased food intake, weight loss, and nutritional deficiency. The facility's policy on serving foods requires the use of meal tickets to ensure tray accuracy and adherence to resident preferences. Additionally, the facility's nutrition care policy mandates that resident food preferences be documented and identified on tray cards, with appropriate substitutions offered for dislikes. This incident highlights a lapse in following these established procedures, potentially compromising the resident's nutritional and medical status.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on January 27, 2025. During an inspection of the dumpster area outside the back kitchen, it was noted that the lids of a white recycle dumpster and one of the black trash dumpsters were not closed. Additionally, trash items such as used gloves, forks, napkins, and opened cut boxes were found scattered on the floor surrounding the dumpsters. The Dietary Services Supervisor confirmed the presence of trash on the ground and acknowledged that the dumpster lids needed to be closed at all times to prevent pest attraction and infection control issues. Further interviews with the Registered Dietitian reinforced the necessity of keeping dumpster lids closed to minimize odors and prevent pest attraction and infection control problems. The facility's Policy and Procedure on Pest Control, dated 2018, mandates that dumpster areas be kept clean and sanitized, with trash receptacles covered at all times and dumpster lids closed. The failure to adhere to these procedures was identified as a deficiency by the surveyors.
Inadequate Infection Control Practices for Contact Isolation
Penalty
Summary
The facility failed to adhere to infection control measures for a resident requiring contact isolation precautions. Multiple staff members were observed entering and exiting the resident's room without wearing the appropriate personal protective equipment (PPE). Specifically, a Certified Nursing Assistant (CNA) entered the room to answer a call light and provide water without wearing a gown, gloves, or mask. Another CNA entered the room to perform vital sign monitoring without using a disposable blood pressure cuff or wearing PPE, and incorrectly used bleach wipes for hand hygiene upon exiting the room. Interviews with staff revealed a lack of understanding and adherence to the facility's infection control policies. One CNA incorrectly believed that PPE was only necessary for direct patient care and not for brief interactions, and was unable to articulate the proper method for disinfecting equipment. In contrast, a Licensed Vocational Nurse (LVN) correctly stated that PPE should be worn whenever entering a room with contact precautions. The resident in question was admitted with a urinary tract infection and had a physician's order for contact isolation due to an ESBL infection in the urine. The facility's policy required the use of PPE and dedicated equipment for residents under contact precautions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that basic accommodations of needs were provided when a resident's call light was not within reach. During an unannounced visit for a complaint investigation, it was observed that a resident, who was sitting in a wheelchair at the foot of her bed, had her call light wrapped around the right siderail, making it inaccessible. The resident confirmed in an interview that she was unable to reach her call light and could not call for help. A Certified Nursing Assistant (CNA) also acknowledged that the call light was not within reach and stated that call lights should be accessible to residents in wheelchairs. The resident involved had a medical history of cerebral infarction (stroke) and Parkinson's disease, and her care plan indicated an increased susceptibility to falling, with a specific approach to keep the call light within reach. The facility's policy on call lights also required that they be placed within the resident's reach when leaving the room.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, as evidenced by the experiences of two residents who required assistance with activities of daily living (ADLs). Resident 1, who had diagnoses including glioblastoma, left-sided hemiplegia, and muscle wasting, reported that call light response times were often over 30 minutes and sometimes up to an hour, particularly during evening or night shifts. On one occasion, Resident 1 did not receive assistance in time and soiled herself, leading to feelings of embarrassment and humiliation. Resident 5, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), muscle wasting, and congestive heart disease, also reported similar delays in call light responses, sometimes up to an hour. Both residents had documented capacity to make decisions and were aware of their needs for assistance. During the survey, it was observed that call lights were not answered promptly. For instance, Resident 5 activated her call light at 2:00 p.m., and it was not answered until 2:10 p.m. by a Certified Nursing Assistant (CNA). Interviews with facility staff, including CNAs, a Physical Therapy Assistant (PTA), and a Registered Nurse (RN), confirmed that call lights should be answered within 3-5 minutes to prevent accidents and assist with resident needs. The facility's policy documents also indicated that call lights should be answered in a timely manner to meet residents' needs and uphold their dignity. However, the observed delays in response times indicated a failure to adhere to these policies, potentially compromising resident care and dignity.
Failure to Securely Close Trash Dumpster Lids
Penalty
Summary
The facility failed to ensure that two out of three trash dumpster lids were securely closed, which had the potential to attract pests, insects, and vermin, creating an unsanitary environment for the residents. During an unannounced visit, one dumpster near the kitchen was observed with its lid open and flies flying in and out, while another dumpster near the property line was also found with its lid open and filled with broken-down cardboard. The Administrator, Director of Nursing, Janitor, Dietary Supervisor, Director of Maintenance, Housekeeper, and Housekeeping Supervisor all acknowledged the importance of keeping the dumpster lids closed to prevent pests and odors. The facility's document titled 'Pest Control' indicated that dumpster lids should be kept closed to maintain cleanliness and prevent pest infestations. The 2022 FDA Food Code also mandates that refuse, recyclables, and returnables be stored in covered receptacles to be inaccessible to insects and rodents. Despite these guidelines, the dumpster lids were left open, posing a risk to the sanitary conditions of the facility. Interviews with various staff members revealed that the dumpster lids were sometimes left open because they were heavy and hard to close.
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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