North Park Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Tracy, California.
- Location
- 2586 Buthmann Ave, Tracy, California 95376
- CMS Provider Number
- 555245
- Inspections on file
- 32
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at North Park Post-acute during CMS and state inspections, most recent first.
A resident with severe dementia, documented wandering risk, and an active wander guard order eloped during the night through an unalarmed and unlocked laundry exit door located outside the main patient care area. The resident’s care plan identified elopement risk and called for frequent checks, redirection, and use of a wander guard, but on the night of the incident the resident was left in an activities room under CNA supervision while the assigned nurse assisted an x-ray technician and then went on break. No door alarms sounded, and staff discovered the resident missing only after the roommate inquired about her whereabouts. Police later located the resident in a nearby private home, and EMS transported the resident to a hospital, where an acute NSTEMI and acute altered mental status were diagnosed.
A resident was issued a 30-Day Notice of Discharge/Eviction for denial of payment while a Medi-Cal application was still pending, despite facility staff being aware of the pending status and regulations prohibiting discharge under these circumstances. Staff interviews and documentation confirmed the facility's knowledge of the application, and the resident's right to remain was not upheld.
A resident with diabetes experienced severe hypoglycemia and seizures due to the facility's failure to monitor blood glucose levels and manage her diabetic condition properly. The resident's insulin regimen was changed without ensuring BG monitoring orders were in place, leading to a critically low blood sugar level and hospitalization.
The facility failed to maintain food safety and sanitation standards, with issues such as a dietary aide not wearing a hairnet, wet nesting of glasses and containers, expired yogurt available for consumption, and improper dishwasher sanitization. Additionally, dust and debris were found in utensil drawers and on kitchen surfaces, and dented cans were stored improperly, posing risks to resident safety.
A resident in an LTC facility received a lower dose of Lorazepam than prescribed, resulting in significant medication errors. The resident was supposed to receive 1 mg every six hours, but instead received 0.5 mg on multiple occasions, which was incorrectly documented as the full dose. The DON confirmed the error, and the facility's medication administration policies were not followed.
The facility failed to document COVID-19 vaccination education for several residents, as confirmed by the Infection Preventionist and the DON. The facility's policy requires education on vaccine benefits, risks, and side effects before offering it, but this was not documented in the residents' medical records.
The facility failed to ensure safe insulin use for two residents with diabetes. One resident's insulin order lacked parameters for high blood sugar, and frequent high readings were not addressed or reported to the MD. Another resident's insulin use was not monitored by blood sugar measurements. Facility policies on diabetes management were not followed, and staff interviews revealed a lack of awareness and action regarding these issues.
The facility failed to maintain a homelike environment for two residents. One resident had a black rubber strip in her room, posing a tripping hazard, while another had broken blinds. The strip was installed due to broken tiles and had been in place for over a year, with staff acknowledging it as a hazard. The blinds were missing a section, and the resident expressed a desire for replacement. Facility policies emphasize maintaining a dignified and orderly environment, which was not upheld.
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, a medication cart contained an outdated Lantus insulin pen, and at the North station, a treatment cart stored an opened bottle of Sterile Sodium Chloride intended for single use. These lapses were acknowledged by the nursing staff and the Director of Nursing.
The facility failed to document education for immunizations for two residents. One resident's Influenza vaccination record lacked documentation of education, and another resident's records for both Influenza and Pneumococcal vaccines were missing education documentation. The facility's policies require that education about the benefits and potential side effects of vaccines be provided and documented in the resident's medical record.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to inadequate care. One resident with skin integrity issues did not have a care plan initiated until eight days post-admission. Another diabetic resident lacked a care plan, resulting in a fall due to low blood sugar, hospitalization, and seizures. The DON confirmed the absence of necessary care plans, which are crucial for effective treatment and monitoring.
A resident with diabetes was admitted to a facility without proper orders for blood glucose monitoring or emergency diabetic medication. The attending physician did not provide necessary instructions, and the nursing staff failed to implement hospital orders. This oversight resulted in the resident experiencing severe hypoglycemia, leading to a fall, hospitalization, and new onset seizures.
The facility failed to follow its medication administration policy for three residents. An LPN did not sign off medications at the time of administration, another LPN administered morning medications late, and a third LPN left the medication cart unattended with medications on top. These actions were confirmed through record reviews and staff interviews.
Elopement of Cognitively Impaired Resident Through Unalarmed Laundry Exit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent an elopement for a resident with severe cognitive impairment and known wandering risk. The resident was admitted with encephalopathy, delirium, gait and mobility abnormalities, need for assistance with personal care, and dementia. A Brief Interview for Mental Status (BIMS) score of 1 indicated severe impairment in thinking and memory. The resident’s care plan, initiated months earlier, identified risk for wandering or elopement related to exit-seeking behavior, a focus on wanting to go home, dementia, and aimless wandering, with goals to prevent elopement and maintain safety. Interventions included frequent checks of the resident’s whereabouts, redirection when approaching exit doors, assessment for a wander/elopement alarm, and application of a wander guard as ordered. An active order for wander guard placement due to exit-seeking behavior was in place. On the night of the incident, documentation showed that the resident was last seen by the night shift CNA walking up and down the hallway at approximately 2:35 a.m., and the resident’s roommate later came out to inquire about the resident when she was no longer in the room. Staff then determined the resident was not in the building and began searching the premises. The assigned nurse (LN 3) reported being responsible for 30 residents that shift and stated that around 1:50 a.m. she accompanied an x-ray technician to assist with other residents, leaving the resident under the supervision of the CNA in the activities room because the resident did not want to remain in bed. LN 3 remained with the x-ray technician until about 2:30 a.m. and then took her scheduled lunch break, assuming the resident remained under CNA supervision. LN 3 later became aware the resident was missing when the roommate asked about her whereabouts and initially believed the resident was still in the building because no door alarm had sounded. Interviews and record review revealed that the resident eloped through a laundry room exit door that was not alarmed and that a second laundry door, which was supposed to be locked from the inside when staff left the area, had been left unlocked. The Administrator stated that prior to the elopement, all exit doors except the laundry door were alarmed, and that staff had forgotten to lock the second laundry door on the night of the incident. The Interdisciplinary Team note documented that the resident, who was alert and ambulatory at the time of exiting, left through a door that did not have an alarm and was outside the patient care area, and that the wander guard did not alarm for this door. Police records indicated that officers responded to a missing person call, searched the surrounding area, and later received a call from a community member reporting an unknown female in her home wearing a yellow gown; officers identified this person as the resident. Due to extreme cold weather, the resident’s age, and health conditions, EMS transported the resident to a hospital, where she was diagnosed with an acute NSTEMI and acute altered mental status, with elevated troponin and treatment including heparin and cardiac monitoring. Facility policies on wandering, elopement prevention and management, and safety and supervision of residents required identification of residents at risk for unsafe wandering or elopement, inclusion of detailed monitoring plans in the care plan, provision of adequate supervision, and maintenance and utilization of electronic monitoring and door alarm systems when deemed appropriate. Policies also described that a missing resident is considered a facility-wide emergency and outlined notification procedures for the Administrator, DON, legal representative, physician, and law enforcement if a resident is not located. Despite these policies and the resident’s documented risk factors and care plan interventions, the resident was able to leave the building through an unalarmed and unlocked laundry exit without staff knowledge, remained missing for several hours during nighttime and early morning hours, and was ultimately found offsite and transported to the hospital, where an acute cardiac injury (NSTEMI) was diagnosed.
Improper Discharge Notice Issued During Pending Medi-Cal Application
Penalty
Summary
The facility failed to comply with transfer and discharge requirements when it issued a 30-Day Notice of Discharge/Eviction to a resident and the resident's responsible party due to a denial of payment, despite the resident having a pending Medi-Cal application. Documentation in the social services notes confirmed that the facility was aware the Medi-Cal application was under review at the time the notice was issued. The responsible party also acknowledged that the application was still pending and not yet active. Interviews with facility staff, including the Social Service Director and Social Services Assistant, confirmed that the resident had a right to remain in the facility while the Medi-Cal application was pending or under appeal. The Administrator later confirmed that Medi-Cal coverage was approved retroactively. Reference to state advocacy guidance indicated that facilities are prohibited from discharging residents with timely Medi-Cal applications pending eligibility determination, and that an appeal suspends a finding of nonpayment. The issuance of the discharge notice under these circumstances constituted a failure to meet regulatory requirements.
Failure to Monitor Diabetic Resident Leads to Severe Hypoglycemia and Seizures
Penalty
Summary
The facility failed to provide quality care to Resident 596, a diabetic patient, who experienced a series of critical events due to inadequate monitoring and management of her condition. Resident 596 was admitted with a diagnosis of diabetes and was on insulin and oral anti-diabetic medications. However, the admitting nurse did not include blood glucose (BG) testing parameters in the resident's orders, and the attending physician did not ensure BG monitoring orders were in place after changing the resident's insulin regimen. This oversight led to a lack of BG monitoring, which is crucial for managing diabetes effectively. On 9/20/24, Resident 596 suffered an unwitnessed fall due to critically low blood sugar levels, resulting in injuries and seizures. The licensed nurse on duty failed to implement emergent nursing interventions to assess the resident's BG level after the fall and did not inform Emergency Medical Services (EMS) of the resident's diabetic status or her last insulin dose. Consequently, Resident 596 was found with a blood glucose level of 20, significantly below the normal range, and was admitted to the intensive care unit (ICU) for treatment of severe hypoglycemia and seizures. The attending physician acknowledged the system failure, admitting that she did not write orders for BG monitoring or a sliding scale for insulin administration. The physician also recognized the risk of death, seizures, or hypoglycemic events due to the lack of proper diabetic management. The facility's policies and procedures for managing diabetes and medication administration were not followed, contributing to the resident's critical condition and subsequent hospitalization.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service and safety, as evidenced by multiple deficiencies observed in the kitchen area. A dietary aide was seen not wearing a hairnet, which is essential to prevent hair from contaminating food. Additionally, drinking glasses and food containers were found wet nested, a practice that can promote bacterial growth. Clean fruit cups were stored under a dishwasher with water dripping onto them, and expired yogurt was available for resident consumption, all of which pose significant risks to food safety. The dishwasher was not functioning within the required parameters, with its water temperature below the necessary 120 degrees Fahrenheit and the parts per million of the dishwashing solution below the accepted standard. This failure in maintaining proper sanitization levels could compromise the cleanliness of dishes used by residents. Furthermore, two utensil drawers contained dust and debris, and two dented cans of corn were found in the food storage area, both of which are against the facility's sanitation policies. The kitchen environment itself was not maintained in a sanitary condition, with three fans in the food preparation area and the counter above the stove top covered in dust and debris. These conditions could lead to contamination of food prepared for the 89 residents receiving meals from the facility. The facility's policies on sanitization and food storage were not followed, as evidenced by these observations, which could potentially lead to foodborne illnesses among residents.
Medication Administration Error for Anti-Anxiety Medication
Penalty
Summary
The facility failed to administer an anti-anxiety medication, Lorazepam, correctly to a resident, resulting in significant medication errors. The resident was prescribed Lorazepam 1 mg to be taken every six hours for agitation with behaviors, starting from late April 2024. However, during May and September 2024, the resident received a lower dose of 0.5 mg on multiple occasions, which was incorrectly documented as 1 mg in the Medication Administration Record (MAR). Specifically, the resident received the incorrect dose 18 times in May and once in September, as evidenced by discrepancies between the Controlled Drug Record (CDR) and the MAR. The Director of Nursing confirmed that the resident did not receive the medication as ordered by the physician, acknowledging the administration of only half the prescribed dose. The facility's policies on controlled medication administration and specific medication administration procedures were not followed, as the documentation did not accurately reflect the amount administered. This failure in adhering to the facility's guidelines and physician's orders had the potential to cause increased anxiety and emotional distress for the resident.
Failure to Document COVID-19 Vaccination Education
Penalty
Summary
The facility failed to provide documented evidence of education regarding COVID-19 vaccinations for four sampled residents and one unsampled resident. During a review of the clinical records, it was found that the records for these residents did not contain documentation indicating that education on the benefits, risks, and potential side effects of the COVID-19 vaccine was provided. This lack of documentation was confirmed during an interview with the Infection Preventionist, who acknowledged that the section titled 'Education Provided to Resident/Family' was not checked in the medical records of the affected residents. The Director of Nursing explained that providing education to residents before administering or refusing a vaccination is crucial as it gives them sufficient information about the medication, including its risks and benefits, allowing them to make an informed decision. The facility's policy on COVID-19 vaccination, revised in October 2023, mandates that residents and staff be educated about the vaccine before it is offered, and that the resident's medical record should include documentation of this education. However, this policy was not adhered to in the cases of the identified residents.
Failure to Ensure Safe Insulin Use for Diabetic Residents
Penalty
Summary
The facility failed to ensure the safe use of insulin for two residents with diabetes, leading to potential unsafe insulin and antidiabetic drug use. Resident 1's insulin order lacked parameters for addressing high blood sugar levels, and there was no documentation of additional treatments or interventions despite frequent high blood sugar readings. The medical doctor was not notified of these high readings, and the resident's care plan, which required notification of the doctor for blood sugar levels above 400, was not followed. Interviews with staff and the medical doctor revealed a lack of awareness and action regarding the resident's high blood sugar levels. Resident 596's diabetic medication and insulin use were not monitored by blood sugar measurements, indicating a failure in monitoring and managing the resident's diabetes. The facility's policies on managing diabetes and medication administration were not adhered to, as evidenced by the lack of intervention for high blood sugar levels and the absence of a sliding scale for insulin administration. The Director of Nursing acknowledged that the nursing staff should have contacted the doctor to obtain parameters for managing blood sugar variations.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, Resident 382 and Resident 3, as observed during a survey. For Resident 382, the floor tiles in her room were replaced with a black rubber strip, which was not uniform with the rest of the rooms and posed a tripping hazard. The Responsible Party for Resident 382 expressed concerns about the strip, having tripped over it in the past. The Maintenance Director confirmed the strip was installed due to broken tiles and had been in place for over a year. The Certified Nurse Assistant also noted the strip as a potential hazard, especially for wheelchairs. The Administrator and Director of Nursing were unaware of the strip's presence and acknowledged it was not in line with the facility's homelike environment policy. For Resident 3, the deficiency involved broken blinds in her room, which had been missing a section for some time. Resident 3 expressed a desire for the blinds to be replaced, describing them as looking "shaggy." The Director of Staff Development and the Director of Nursing both confirmed that blinds should be well-fitting and not broken to maintain a homelike environment. The facility's policies on resident rights and maintenance emphasize the importance of maintaining a dignified and orderly environment, which was not upheld in these instances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, Medication Cart #4 contained an outdated Lantus insulin pen, which had been opened and was beyond its use date of 28 days after opening. This was acknowledged by Licensed Nurse 5 during an inspection. Additionally, at the North station, the treatment cart stored an opened bottle of Sterile Sodium Chloride, which is intended for single use and should have been discarded after use. Licensed Nurse 6 confirmed that the bottle should have been disposed of. The Director of Nursing acknowledged these findings, stating that the insulin pen should have been discarded after 28 days and that single-use products should be discarded after use. The facility's policy on medication storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedure. These lapses in medication storage practices could result in residents receiving expired or unusable medications.
Failure to Document Vaccine Education for Residents
Penalty
Summary
The facility failed to provide documented evidence of education for immunizations to two residents, Resident 14 and Resident 23. For Resident 14, the Influenza vaccination record dated 9/29/23 did not have the education box checked, and the Infection Preventionist (IP) confirmed there was no documentation of education provided regarding the vaccine. Similarly, for Resident 23, the Influenza vaccination record dated 12/13/23 also lacked documentation of education, and the IP acknowledged this omission. The facility's policy requires that education about the benefits and potential side effects of the influenza vaccine be provided and documented in the resident's medical record. Additionally, Resident 23's record for the Pneumococcal Polysaccharide (PPSV 23) vaccine, dated 5/6/21, also did not have the education box checked, and the IP confirmed the absence of documented education. The Director of Nursing (DON) emphasized the importance of providing education to residents before administering or refusing a vaccination to ensure they have sufficient information about the risks and benefits. The facility's policy mandates that education about the pneumococcal vaccine be provided and documented, and any refusal of the vaccine should be recorded in the resident's medical record.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents, leading to significant deficiencies in care. Resident 545 was admitted with multiple diagnoses, including enterocolitis due to C. Diff, dementia, and generalized muscle weakness. Despite the presence of redness in the right groin, left groin, and perirectal area upon admission, the baseline care plan addressing these skin integrity issues was not initiated until eight days later. This delay in care planning was confirmed by the Director of Nursing (DON) during a review of the resident's medical records. Resident 596, who was admitted with a diagnosis of diabetes, did not have a diabetic baseline care plan developed to manage her condition and medications, including insulin and oral antidiabetic drugs. The admitting nurse failed to enter the necessary orders for hypoglycemia and hyperglycemia protocols. As a result, Resident 596 experienced a fall due to low blood sugar, leading to hospitalization and subsequent adverse events, including seizures. The DON confirmed that a diabetic care plan was not in place, which was crucial for directing the care of the resident. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to meet the resident's immediate needs. However, the lack of timely care plans for both residents resulted in inadequate monitoring and management of their conditions. The DON acknowledged the importance of care plans in creating a pathway of care and ensuring effective treatment, which was not achieved in these cases.
Failure in Diabetic Care Management Leads to Resident Hospitalization
Penalty
Summary
The attending physician (AP) failed to provide necessary orders for routine blood glucose monitoring and adequate oversight for a diabetic resident, identified as Resident 596. Upon admission, the resident had a diagnosis of diabetes and was receiving multiple medications for its management. However, the admitting orders from the hospital, which included instructions for blood glucose monitoring and parameters for notifying the physician in case of significant changes, were not implemented by the facility. The AP did not include these orders in the resident's Order Summary Report, nor did they provide orders for emergency diabetic medication administration or parameters for managing hypoglycemia or hyperglycemia. The nursing staff, under the direction of Licensed Nurse (LN) 3, failed to ensure the admitting orders were accurately entered into the system. Although LN 3 stopped the NPH insulin as per the AP's verbal instructions, there were no written orders to guide the nursing staff on blood glucose monitoring or emergency interventions. The AP's notes, which were faxed to the facility days later, did not include necessary orders for managing the resident's diabetes effectively. Consequently, the resident's blood glucose levels were not monitored adequately, and no emergency protocols were in place to address potential hypoglycemic or hyperglycemic events. As a result of these oversights, Resident 596 experienced a severe hypoglycemic event, leading to a fall and subsequent hospitalization. The resident was found with a critically low blood glucose level and suffered new onset seizures, which were attributed to the severe hypoglycemia. The facility's Medical Director and Director of Nurses acknowledged the lack of appropriate orders and monitoring, highlighting the risk posed to the resident due to the absence of a structured diabetes management plan.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to follow its policy and standards of practice for medication administration for three residents. Licensed Nurse (LN) 2 did not sign off medications at the time of administration for Residents 1, 2, and 3. Medications for these residents were signed off hours after they were due, which was confirmed through a review of the Medication Administration Audit Report (MAAR) and interviews with LN 2 and other staff members. LN 2 admitted to administering medications on time but signing them off later when she had time, which contradicts the facility's policy and places residents at risk for medication errors. Additionally, LN 6 administered morning medications late to Resident 1. The MAAR indicated that medications scheduled for 7 AM were administered between 8:56 AM and 9:04 AM. LN 6 confirmed during an interview that the medications were passed late. The Director of Nurses (DON) emphasized the importance of timely medication administration to ensure the therapeutic effect of the medications. Furthermore, LN 4 left the medication cart unattended with medications on top during a medication pass. This occurred when LN 4 was interrupted by a resident's family member. LN 4 acknowledged the mistake and explained the importance of securing medications to prevent unauthorized access. The DON reiterated the importance of securing medications to ensure resident safety. The facility's policy mandates that medications be administered within one hour of their prescribed time and that the medication cart be kept closed and locked when out of sight.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
