Oakpark Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tujunga, California.
- Location
- 9166 Tujunga Canyon Blvd, Tujunga, California 91042
- CMS Provider Number
- 055360
- Inspections on file
- 27
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakpark Healthcare Center during CMS and state inspections, most recent first.
Three residents at risk for pressure ulcers had their low air loss mattresses (LALMs) set incorrectly, with settings not matching their actual weights as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff and the DON confirmed the improper settings, which were identified through observation and record review.
Several residents at high risk for falls did not receive physician-ordered safety interventions, including floor mats, bed alarms, and personal alarms, as observed and confirmed by staff. Additionally, an LPN left medications unattended and out of eyesight at a bedside, contrary to facility policy. The DON acknowledged these lapses and their potential impact on resident safety.
The facility did not ensure that a resident received oxygen therapy according to physician orders, with one resident receiving a higher flow rate than prescribed. Additionally, three residents' oxygen tubing and humidifiers were not labeled with the date of last change as required by facility policy, and staff could not confirm when the equipment was last changed. These deficiencies were identified through observation, record review, and staff interviews.
Two residents experienced medication errors when one did not receive prescribed medications within the required time frame and another received eight crushed medications mixed together via g-tube, contrary to facility policy. These actions resulted in a medication error rate of 24.39%, significantly above the acceptable threshold.
Three residents experienced significant medication errors: one did not have insulin injection sites rotated as required, another did not receive carvedilol and pancrelipase at the prescribed times with meals, and a third received eight crushed medications mixed together via g-tube instead of each being administered separately with water flushes. These actions were contrary to physician orders and facility policy, as confirmed by staff and the DON.
Surveyors found that several opened food items, including ice cream, sweet relish, creamy Italian dressing, whole egg mayonnaise, and unsalted margarine, were not labeled with use by or expiration dates as required by facility policy. Both the Dietary Supervisor and DON confirmed that proper labeling was not followed, potentially affecting nearly all residents.
A CNA and an LVN failed to wear isolation gowns while providing high-contact care to two residents on enhanced barrier precautions for MDRO colonization and indwelling device use. Both staff members provided care—dressing and gastrostomy tube medication administration—without the required PPE, despite facility policy and signage indicating the need for gown and glove use during such activities.
A nurse entered a resident's room multiple times without knocking while administering medication, despite facility policy requiring staff to knock and request permission before entry. The resident had severe cognitive impairment and required significant assistance with daily activities. This action was confirmed by the nurse and acknowledged by the DON as a violation of the resident's right to dignity and privacy.
A resident with a history of COPD, UTI, and atrial fibrillation, who required substantial assistance and had moderately impaired cognition, tested positive for ESBL-producing E. coli. Despite lab confirmation and initiation of antibiotics and contact precautions, staff did not develop a comprehensive, person-centered care plan to address the resident's change in condition, as required by facility policy.
A resident with multiple diagnoses, including Parkinsonism and dementia, experienced an unanticipated change of condition involving right shoulder pain. Although a stat X-ray was ordered, the resident's pain care plan was not reviewed or revised by the interdisciplinary team as required by facility policy. The DON confirmed the care plan was not updated following the change of condition.
Two residents did not receive care in accordance with professional standards: one received repeated insulin injections in the same abdominal site despite a care plan and policy requiring site rotation, and another was given amiodarone despite blood pressure readings below the physician-ordered hold parameters. Facility staff and documentation confirmed these failures to follow established protocols.
A resident with cognitive and mobility impairments was found in bed without access to a call light, which was on the floor, preventing the resident from signaling for assistance. The DON confirmed this was against facility policy, which requires call lights to be within reach to ensure timely response to resident needs.
The facility failed to maintain the dignity of three residents by not knocking before entering their rooms. CNAs entered the rooms of residents with various medical conditions without knocking, despite acknowledging the importance of this action. The DON confirmed that knocking is required to respect residents' dignity, as per the facility's policy.
The facility failed to provide a private space for resident council meetings, as required by its policy. Meetings were held in the activity room with other residents and staff present, which compromised privacy. The Activity Director confirmed the lack of a designated private area, acknowledging the need for such a space to uphold residents' rights.
A facility failed to document non-pharmacological interventions before administering opioid pain medication to a resident with prostate cancer and impaired cognition. Despite a physician's order for as-needed medication, the facility did not record any attempts to use alternative pain management methods, as required by their policy. This oversight occurred over several days, potentially increasing the risk of adverse side effects.
The facility failed to administer blood pressure medications within prescribed parameters for a resident with multiple cardiovascular conditions, leading to potential adverse effects. Additionally, there was a discrepancy between the Medication Count Sheet and the Medication Administration Record for another resident receiving pain medication, highlighting documentation issues. These deficiencies were contrary to the facility's medication administration policy.
A resident with breast and bone cancer, requiring moderate assistance, was found without access to her call light, which was on the floor. The facility's policy requires call lights to be within reach to ensure timely assistance, but this was not adhered to, as confirmed by a CNA and the DON.
A resident with Parkinsonism and neurocognitive disorder experienced a fall, but the LTC facility failed to notify the resident's responsible party and physician as required by policy. The MDS Nurse confirmed the lack of documentation for these notifications, despite the care plan's directive to inform both parties. This oversight could have affected treatment decisions.
A facility failed to ensure a window screen was properly affixed in a resident room, creating a half-inch gap. This was observed during a facility tour and confirmed by the ADON, who noted the potential hazard of insect entry. The room was occupied by three residents, and the facility's maintenance policy requires safe and operable conditions.
A facility failed to develop a person-centered care plan for a resident's antibiotic use, despite the resident having a physician's order for fosfomycin to treat a urinary tract infection. The resident, who required supervision and partial assistance for ADLs, had no care plan addressing the antibiotic therapy, which was confirmed by the Infection Preventionist Nurse. This was contrary to the facility's policy requiring comprehensive care plans for each resident.
Two residents in the facility were found with long, untrimmed fingernails, indicating a failure to provide necessary assistance with personal hygiene. One resident, with conditions such as dementia, had dirty nails with black substances, while another resident, with heart failure and mobility issues, reported not being offered nail trimming services. The DON and a CNA acknowledged the oversight, emphasizing the importance of maintaining nail hygiene to prevent infection.
The facility failed to conduct post-fall evaluations for two residents identified as high risk for falls, following incidents where they experienced falls. Despite the facility's policy requiring such evaluations, there was no documented evidence of rehabilitation assessments being conducted. The Rehabilitation Director was unaware of the facility's fall policies, leading to non-compliance with the required procedures.
A facility failed to document a post-dialysis assessment for a resident with end-stage renal disease, as required by their care plan. The resident's Dialysis Communication Record lacked documentation for cognitive status, vital signs, and access site assessment post-dialysis. The DON confirmed the absence of documentation and highlighted the importance of these assessments for resident safety. This oversight represents a failure to follow the facility's policy for caring for residents with end-stage renal disease.
The facility failed to adhere to infection control protocols in two cases: a CNA did not wear PPE when entering a droplet isolation room, and a resident's nasal cannula tubing was found touching the floor. These actions were against the facility's policies and posed a risk of infection spread.
Incorrect LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) were set correctly according to residents' weights for three residents who were at risk for or had a history of pressure ulcers. For one resident with dementia, muscle wasting, and moderate cognitive impairment, the LALM was set at 350 lbs, while the resident's actual weight was 119 lbs. The physician's order required the LALM to be checked for proper placement and function every shift, but this was not done, as confirmed by the nurse and the Director of Nursing (DON). Another resident with severe cognitive impairment and muscle wasting had an LALM set at 50 lbs, despite a sticker on the device indicating it should be set between 100-150 lbs for the resident's actual weight of 128 lbs. The nurse confirmed the setting was incorrect and that the LALM was being used for pressure ulcer prevention. The DON acknowledged that the LALM should be set according to the resident's weight and that failure to do so could negatively affect the resident's skin. A third resident with dementia, difficulty walking, and epilepsy had an LALM set at 320, while the resident's weight was 108 lbs and a sticker on the device indicated the correct setting should be 100. Both the registered nurse and the treatment nurse confirmed the setting was incorrect and explained that improper settings could cause discomfort and increase the risk of pressure injury. Facility policy and the manufacturer's guide both required LALMs to be set according to the resident's weight, and staff interviews confirmed that this was not consistently done.
Failure to Implement Fall Prevention Interventions and Safe Medication Practices
Penalty
Summary
The facility failed to implement physician-ordered fall prevention interventions and safe medication administration practices for several residents at high risk for accidents. One resident with chronic obstructive pulmonary disease, dementia, and left-sided weakness was identified as high risk for falls and had a physician's order and care plan for a floor mat to be placed on the right side of the bed. However, during observation, no floor mat was present, and the assigned CNA confirmed never seeing one at the bedside. The DON acknowledged that the absence of the floor mat increased the resident's risk for complications from falls. Another resident with Parkinsonism, ataxic gait, and severe cognitive impairment had a physician's order for a personal alarm to be applied while in bed and in a wheelchair, with monitoring every shift. Despite documentation indicating staff monitored the alarm, observation revealed the resident in a wheelchair without any alarm device attached. The activity assistant confirmed the absence of the alarm, and the DON stated that staff did not follow the physician's order, which could result in recurrent falls and injuries. A third resident with encephalopathy, muscle wasting, and dementia, also at high risk for falls, had a physician's order and care plan for a bed alarm following an unwitnessed fall. Observation found the resident asleep in bed without a bed alarm, and the CNA confirmed its absence. The DON stated the importance of the bed alarm for alerting staff to unassisted transfers. Additionally, a nurse was observed leaving medications unattended and out of eyesight at a resident's bedside while retrieving equipment, which the nurse later verified. The DON stated that medications should not be left unattended to prevent unauthorized access and accidental ingestion. Facility policies reviewed supported the need for these interventions and safe practices.
Failure to Follow Physician Orders and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. One resident was observed receiving oxygen at a rate greater than 5 liters per minute via nasal cannula, despite the physician's order specifying administration at 2 liters per minute as needed, with titration up to 5 liters per minute to maintain oxygen saturation at or above 92%. The registered nurse present was unsure of the correct oxygen flow rate and confirmed that the resident was receiving more than the ordered amount. The Director of Nursing also confirmed that staff are required to follow physician orders for oxygen administration. Additionally, the facility did not ensure that oxygen tubing and humidifiers for three residents were labeled with the date and time of the last change, as required by both physician orders and facility policy. Observations and interviews revealed that the oxygen tubing and humidifiers in use for these residents lacked proper labeling, and staff were unable to confirm when the equipment was last changed. The facility's policy and care plans for these residents specified that oxygen tubing should be changed weekly and labeled accordingly. The residents involved had significant medical histories, including dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure, and other chronic conditions requiring continuous or as-needed oxygen therapy. The lack of adherence to physician orders and facility protocols regarding oxygen administration and equipment maintenance was confirmed through staff interviews, record reviews, and direct observation.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by 10 medication errors out of 41 observed opportunities, resulting in an error rate of 24.39%. Two residents were directly affected by these errors. For one resident with a history of malignant neoplasm of the pancreas, hypertensive heart disease with heart failure, and difficulty walking, the facility did not administer carvedilol and pancrelipase within the prescribed time frame. The physician's orders specified that carvedilol should be given with breakfast and dinner, and pancrelipase with meals, both within a one-hour window of the scheduled time. However, the medications were not administered as ordered, and the resident reported not receiving them with breakfast as required. The nurse involved acknowledged the delay and confirmed it was outside the facility's policy for timely medication administration. Another resident, who had severe cognitive impairment, Parkinsonism, gastrostomy status, and a history of urinary tract infections, received eight crushed medications mixed together and administered at once via a gastrostomy tube. Facility policy required that each medication be crushed and administered separately, with a water flush between each to prevent drug interactions and tube clogging. The nurse administering the medications confirmed that she did not follow this protocol and instead gave all medications together in one dose. The DON also confirmed that this was not in accordance with facility policy and that medications should be given separately through the g-tube. Both incidents were confirmed through observation, interviews with staff, and review of medical records and facility policies. The facility's own policies defined these actions as medication errors, as they were not in accordance with physician orders, manufacturer specifications, or accepted professional standards. The errors were acknowledged by the staff involved and the DON, and the facility's documentation supported that the medications were not administered as required.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in three distinct instances. For one resident with type two diabetes mellitus and severe cognitive impairment, staff did not rotate insulin injection sites as required. Documentation showed repeated administration of insulin in the same area of the abdomen over multiple days, despite care plan interventions and facility policy mandating site rotation. Both the LVN and DON confirmed that injection sites were not rotated, which was acknowledged as a medication administration error according to facility policy. Another resident with a history of pancreatic cancer and hypertensive heart disease did not receive prescribed medications, carvedilol and pancrelipase, at the times ordered by the physician. The resident reported not receiving these medications with breakfast as required, and the MAR confirmed administration times did not align with physician orders. The LVN and DON both stated that administering medications outside the prescribed timeframe is considered a medication error, and facility policy requires medications to be given within one hour of the scheduled time unless otherwise specified. In a third instance, an LVN was observed mixing eight crushed medications together and administering them all at once via a gastrostomy tube to a resident with parkinsonism and severe cognitive impairment. Facility policy and the LVN's own statements indicated that each medication should be administered separately with a water flush between each to prevent drug interactions and tube clogging. The DON confirmed that the medications were not administered correctly, as per facility policy, which defines such actions as a medication error.
Failure to Label and Date Opened Food Items in Storage
Penalty
Summary
Surveyors observed that the facility failed to store food items in accordance with professional standards for food service safety. Specifically, two open boxes of ice cream in the freezer, as well as one gallon each of sweet relish, creamy Italian dressing, whole egg mayonnaise, and one pound of unsalted margarine in the walk-in refrigerator, were not labeled with use by or expiration dates. The Dietary Supervisor confirmed during interviews that these items should have been labeled and acknowledged that the absence of proper labeling could affect residents' safety. The Director of Nursing also stated in an interview that food items should be labeled with use by and expiration dates to prevent spoilage. A review of the facility's policies confirmed that all frozen and opened food items are required to be labeled and dated according to storage guidelines. These deficiencies had the potential to affect 45 out of 46 residents in the facility.
Failure to Use Required PPE During High-Contact Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistant (CNA) 3 failed to wear an isolation gown while dressing a resident who was on enhanced barrier precautions (EBP) due to colonization with ESBL-producing E. coli. The resident had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, and required substantial assistance with activities of daily living. Despite signage indicating EBP and facility policy requiring gown and glove use for high-contact care activities such as dressing, CNA 3 was observed providing care without the required personal protective equipment. CNA 3 stated she was unaware of the resident's EBP status and the need to wear an isolation gown during care. A Licensed Vocational Nurse (LVN) also failed to don a gown while administering medications via a gastrostomy tube to another resident on EBP for a history of multidrug-resistant organism (MDRO) colonization and indwelling device use. The resident had severe cognitive impairment and required maximal assistance for most activities of daily living. The LVN confirmed not wearing a gown during the medication administration, despite a physician's order and facility policy specifying the need for gown and glove use during high-contact care activities, including device care for residents on EBP. Interviews with the Infection Preventionist and Director of Nursing confirmed that both staff members should have worn isolation gowns during these high-contact care activities, as required by facility policy and the residents' precaution status. The facility's policy, last reviewed in October 2024, clearly outlined the use of enhanced barrier precautions, including gown and glove use for residents with MDROs or indwelling devices during high-contact care activities such as dressing and device care.
Failure to Knock Before Entering Resident Room Violates Dignity Policy
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to knock on a resident's door before entering the room on multiple occasions while administering medication. This was directly observed during a medication pass, and LVN 1 confirmed in an interview that she did not knock prior to entering the resident's room. The Director of Nursing (DON) stated that staff are expected to knock before entering residents' rooms to respect their privacy and dignity, as the facility is considered the residents' home. The resident involved had been admitted and readmitted to the facility with diagnoses including Parkinsonism and was assessed as having severely impaired cognitive skills, requiring maximal assistance with most activities of daily living. The facility's policy on dignity, last reviewed in October 2024, requires staff to knock and request permission before entering residents' rooms to promote residents' sense of well-being and respect their private space. The failure to follow this policy resulted in a violation of the resident's right to dignity and respect.
Failure to Develop Care Plan for Resident with ESBL-Positive UTI
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who tested positive for extended spectrum beta-lactamase (ESBL) producing Escherichia coli (E. coli). The resident, who had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, was readmitted to the facility and required substantial assistance with activities of daily living due to moderately impaired cognition. Despite laboratory results confirming a urinary tract infection with ESBL-producing E. coli and the initiation of antibiotic therapy and contact precautions, there was no evidence that an interdisciplinary team (IDT) care plan meeting was conducted to address this change in condition. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's policy required the development of a care plan in response to such changes in a resident's condition. Review of the resident's records and care plans from the relevant period showed that this requirement was not met, resulting in a failure to document and implement a care plan tailored to the resident's new diagnosis and needs.
Failure to Update Care Plan After Change of Condition
Penalty
Summary
The facility failed to update and revise a resident's care plan following a change of condition for one of three sampled residents reviewed under the Accidents care area. The resident, who had diagnoses including Parkinsonism, ataxic gait, and unspecified dementia, experienced right shoulder pain that was not anticipated. The resident's Minimum Data Set indicated severely impaired cognitive skills and required varying levels of staff assistance for daily activities. On the date of the change of condition, a stat X-ray was ordered for the resident's right shoulder. Despite the change of condition and the new physician order, the resident's care plan for pain, which had been initiated earlier, was not reviewed or revised to reflect the new development. The Director of Nursing confirmed that the care plan was not updated after the change of condition, even though facility policy requires care plans to be reviewed and updated after significant changes in a resident's condition. The failure to update the care plan was identified during a review of records and interviews with facility staff.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate instances involving medication administration. In the first instance, a resident with type 2 diabetes, unspecified dementia, and dependence on renal dialysis received repeated insulin injections in the same area of the abdomen, specifically the left lower quadrant, over multiple days. The resident's care plan specifically required rotation of insulin injection sites to prevent skin discoloration and tissue damage, and the facility's policy also mandated site rotation. Despite these directives, the Medication Administration Record (MAR) showed that staff administered insulin in the same location repeatedly, and both the LVN and DON confirmed that site rotation did not occur as required. In the second instance, another resident with a history of compression fracture, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease was prescribed amiodarone with specific hold parameters: the medication was to be withheld if the resident's systolic blood pressure (SBP) was less than 100 mm Hg or if the pulse was less than 60. The MAR indicated that the resident received amiodarone on two occasions when the SBP was below the prescribed threshold. The DON confirmed that the medication should not have been administered under these circumstances and that the medication should have been held and documented as such according to facility policy. Both deficiencies were confirmed through interviews and record reviews with facility staff, including the DON and LVN. The facility's own policies and procedures, as well as the residents' care plans and physician orders, were not followed in these cases, resulting in medication administration practices that did not meet professional standards of quality.
Call Light Not Accessible to Resident with Mobility and Cognitive Impairments
Penalty
Summary
A deficiency was identified when a resident with a history of encephalopathy, cerebrovascular disease, hemiplegia, and hemiparesis affecting the left dominant side was observed lying in bed without access to their call light, which was found on the floor. The resident was cognitively impaired and required moderate assistance from staff for transfers, toileting, dressing, and bathing, as documented in their Minimum Data Set. During an observation with the DON, it was confirmed that the call light was not within the resident's reach, contrary to facility policy, which requires that call lights be accessible to residents when in bed. The DON acknowledged that the lack of access to the call light could result in delayed care. The facility's policy also emphasizes the importance of ensuring timely responses to residents' needs by keeping call lights accessible.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to maintain the dignity and respect of three residents by not knocking before entering their rooms. This deficiency was observed during a survey where Certified Nursing Assistants (CNAs) entered the rooms of three residents without knocking. Resident 29, who was admitted with heart failure, atrial fibrillation, and dementia, required moderate assistance with daily activities. Resident 30, with Parkinsonism and neurocognitive disorder, had intact cognitive skills and required supervision or assistance with daily activities. Resident 33, with heart failure and a history of falls, required substantial assistance with personal hygiene. The CNAs acknowledged their failure to knock and recognized the importance of doing so to show respect. The Director of Nursing confirmed that staff are expected to knock and introduce themselves before entering a resident's room to uphold the residents' dignity. The facility's policy on dignity, revised in February 2022, mandates that each resident should be cared for in a manner that promotes their well-being and self-esteem, which includes knocking and requesting permission before entering a resident's room. The failure to adhere to this policy was identified as a deficiency that could potentially affect the residents' self-esteem and self-worth.
Lack of Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to implement its policy and procedure for the resident council by not providing a private space for meetings. This deficiency was identified during an interview with the Activity Director (AD), who stated that resident council meetings are held monthly in the activity room. However, the AD acknowledged that the meetings are not private, as other residents and staff who are not part of the council are present in the room, engaging in activities such as coloring or drawing. The AD admitted that the facility lacks a designated private area for these meetings, which is necessary for maintaining residents' privacy and rights. The facility's policy, titled 'Resident Council,' indicates that the care center should support the formation of a resident council and provide a private space for meetings. The policy also assigns responsibility to a staff member, often the Activities Director or social service designee, to organize, facilitate, and record the minutes of the meetings. Despite this policy, the facility did not ensure a private meeting space, potentially violating the residents' rights to hold private council meetings.
Failure to Document Non-Pharmacological Interventions Before Administering Opioids
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed opioid pain medication to a resident. This deficiency was identified for one of the 14 sampled residents, who had been diagnosed with malignant neoplasm of the prostate and had moderately impaired cognition, requiring maximum assistance for most activities of daily living. The resident had a physician's order for oxycodone with acetaminophen to be administered every six hours as needed for severe pain. However, the facility did not document any non-pharmacological interventions prior to administering the medication on multiple occasions. The Director of Nursing confirmed that from early June to mid-June, the resident received the prescribed pain medication without any documented attempts of non-pharmacological interventions. The facility's policy on pain assessment and management, revised in March 2020, emphasized the importance of identifying pain and developing interventions consistent with the resident's needs, which could include non-pharmacological methods. The lack of documentation and adherence to this policy led to the deficiency, potentially increasing the resident's risk of adverse side effects from the medication.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that licensed nurses administered blood pressure medications within the prescribed parameters for one of the residents. Resident 16, who was admitted with diagnoses including atrial fibrillation, cardiomegaly, hypertension, and hypotension, had specific physician's orders for medications such as Amiodarone, Metoprolol, and Midodrine, with instructions to hold the medications if certain blood pressure or heart rate thresholds were not met. However, the review of the Medication Administration Record (MAR) revealed that these medications were administered even when the resident's blood pressure was below the specified parameters, contrary to the physician's orders. Additionally, the facility did not ensure that the Medication Count Sheet (MCS) coincided with the MAR for another resident. Resident 5, who had severely impaired cognition and required maximum assistance, had an order for hydrocodone-acetaminophen for severe pain. The MCS indicated that the medication was administered on two occasions, but these administrations were not documented in the MAR. This discrepancy was acknowledged by the Registered Nurse and the Director of Nursing, who emphasized the importance of documenting administered controlled substances in both records to prevent medication errors and ensure accurate pain management. The facility's policy on administering medications, which requires medications to be administered as prescribed and documented appropriately, was not followed in these instances. The Director of Nursing confirmed that medications should be held or administered according to the physician's order and that proper documentation is crucial to avoid potential medication errors and ensure continuity of care.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a device used by residents to signal their need for assistance from staff. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including breast cancer and bone cancer. The resident had intact cognition and required moderate assistance for some activities of daily living. The resident's care plan included interventions to place belongings within reach and to remind the resident to use the call light for help. During an observation, the resident was found awake in bed and stated she did not know where her call light was. The call light was observed on the floor, and a Certified Nursing Assistant confirmed it should have been within reach. The Director of Nursing emphasized the importance of having call lights accessible to residents to ensure timely responses to their needs. The facility's policy on answering call lights also indicated that call lights should be accessible to residents when in bed, from the toilet, shower, or floor.
Failure to Notify Responsible Party and Physician After Resident Fall
Penalty
Summary
The facility failed to adhere to its policy on notifying a resident's responsible party and physician following a change in condition, specifically after a fall incident involving a resident. The resident, who was admitted with diagnoses including Parkinsonism, neurocognitive disorder with Lewy bodies, and emphysema, experienced a fall. Despite the facility's policy requiring notification of the resident's physician and responsible party in such events, there was no documented evidence that these notifications were made. This oversight was identified during a review of the resident's progress notes, which lacked any indication that the responsible party and physician were informed of the fall. The resident's care plan explicitly stated the need to notify the physician and family member in the event of a fall. However, the MDS Nurse confirmed that the required notifications were not documented, highlighting a lapse in following the facility's procedures. The facility's policy, revised in 2017, mandates prompt notification of changes in a resident's condition to the attending physician and responsible party. The failure to notify could have impacted the resident's treatment decisions, as the physician might have needed to order additional interventions following the fall.
Window Screen Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure that the window screen in one of the resident rooms was properly affixed to the frame, resulting in a gap or opening from top to bottom measuring half an inch. This deficiency was identified during an initial facility tour and room observation, where it was noted that the room was occupied by three residents. The Assistant Director of Nursing (ADON) confirmed the observation during a subsequent interview and acknowledged that the gap could pose a potential hazard by allowing insects to enter the room. The facility's policy on maintenance service, which was last reviewed in October 2023, indicates that the maintenance department is responsible for maintaining the building in a safe and operable manner at all times.
Failure to Develop Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident's antibiotic use, which was identified as a deficiency. The resident, who was initially admitted in September 2022 and readmitted in September 2023, had diagnoses including muscle weakness, urinary tract infection, and gastro-esophageal reflux disease. The resident's Minimum Data Set (MDS) indicated they had the capacity to make themselves understood and required supervision and partial assistance for activities of daily living. A physician's order dated March 2024 prescribed fosfomycin for urinary tract infection prophylaxis, with a dosage change in June 2024. However, there was no care plan developed to address the antibiotic therapy. During an interview and record review with the Infection Preventionist Nurse (IPN), it was confirmed that there was no care plan for the resident's antibiotic use, despite the facility's policy requiring a comprehensive, person-centered care plan for each resident. The IPN acknowledged that a care plan should have been developed to state the goal of treatment and the interventions to achieve those goals, and it should be periodically evaluated. The absence of a care plan for the antibiotic therapy was identified as a failure to deliver necessary care and services, as per the facility's policy.
Failure to Provide Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with nail trimming for two residents, leading to a deficiency in maintaining personal hygiene. Resident 23, who was admitted with conditions including hypertension, chronic obstructive pulmonary disease, and dementia, required moderate assistance with personal hygiene. Observations revealed that Resident 23 had long, dirty fingernails with black substances underneath, indicating a lack of grooming services. The Director of Nursing (DON) acknowledged the issue, stating that the nursing staff is responsible for ensuring residents are clean and well-groomed, including nail care. Similarly, Resident 33, who was admitted with heart failure, atrial fibrillation, and mobility issues, also had long, untrimmed fingernails. Despite requiring assistance with personal hygiene, Resident 33 reported that no one had offered to trim his nails. A Certified Nursing Assistant (CNA) confirmed the oversight, attributing it to the resident's recent readmission. The DON reiterated that both licensed nurses and CNAs are responsible for maintaining residents' nail hygiene to prevent infection and ensure cleanliness.
Failure to Conduct Post-Fall Evaluations
Penalty
Summary
The facility failed to implement its fall policy by not conducting post-fall evaluations for two residents, placing them at risk of not receiving appropriate care after fall incidents. Resident 29, admitted with conditions including heart failure, atrial fibrillation, and dementia, was identified as high risk for falls. Despite a fall occurring on 3/12/2024, there was no documented evidence of a rehabilitation evaluation being conducted post-fall, as confirmed by both the Director of Nursing and the Physical Therapy Assistant during interviews and record reviews. Similarly, Resident 30, with diagnoses including Parkinsonism, neurocognitive disorder with Lewy bodies, and emphysema, was also identified as high risk for falls. After a fall on 3/21/2024, where the resident was found slid down on a mat next to the bed, there was no documented rehabilitation assessment conducted. The Rehabilitation Director admitted to not being aware of the facility's fall policies and instead followed the company's protocols. The facility's policy, which requires a post-fall evaluation by a nurse or physical therapist, was not adhered to in these cases.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident, identified as Resident 5, who required dialysis services. Resident 5 was admitted to the facility with diagnoses including end-stage renal disease, dependence on renal dialysis, and diabetes mellitus. The resident's care plan, initiated upon readmission, specified that vital signs should be taken pre- and post-dialysis. However, a review of the Dialysis Communication Record revealed that the post-dialysis assessment was not documented, leaving sections for cognitive status, vital signs, and access site assessment blank. During an interview and record review, the Director of Nursing confirmed the absence of documented evidence for the post-dialysis assessment. The DON emphasized the importance of these assessments to ensure resident safety and monitor any deviations from baseline conditions. The facility's policy on the care of residents with end-stage renal disease mandates care according to recognized standards, which includes thorough post-dialysis assessments. The lack of documentation for Resident 5's post-dialysis assessment represents a failure to adhere to these standards, potentially placing the resident at risk for complications.
Infection Control Lapses in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control practices in two instances. In the first instance, a Certified Nursing Assistant (CNA 4) did not don the required personal protective equipment (PPE) before entering a droplet isolation room for a resident diagnosed with parainfluenza virus. Despite signage indicating droplet precautions, CNA 4 entered the room without gloves, gown, and goggles, stating that he was only in the room for a short period. This action was contrary to the facility's policy, which mandates wearing a mask, gown, and gloves for droplet precautions to prevent the spread of infection. In the second instance, a resident's nasal cannula tubing was observed touching the floor, which poses a risk of contamination. The resident, who required oxygen therapy due to congestive heart failure and atrial fibrillation, had severely impaired cognition and needed moderate assistance with daily activities. The CNA present acknowledged the tubing was on the floor and indicated she would replace it. The facility's policy and CDC guidelines emphasize keeping medical equipment off the floor to prevent bacterial contamination. Both deficiencies highlight lapses in adhering to established infection control protocols, which are critical in preventing cross-contamination and ensuring resident safety. The Director of Nursing confirmed the importance of following PPE protocols and keeping medical equipment off the floor to minimize infection risks.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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