Orinda Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Orinda, California.
- Location
- 11 Altarinda Road, Orinda, California 94563
- CMS Provider Number
- 055775
- Inspections on file
- 19
- Latest survey
- April 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Orinda Care Center, Llc during CMS and state inspections, most recent first.
A resident with post-polio syndrome reported missing clothing and money, and staff did not complete an inventory of her belongings upon admission as required by facility policy. The Social Services Director was aware of the missing items but could not confirm if reimbursement occurred or if an inventory was ever created, resulting in the resident's frustration.
Skilled nursing staff did not notify the physician when a resident with post-polio syndrome experienced hallucinations and attempted to leave the facility. Despite clear changes in mentation and behavior, there was no documentation of physician notification until after several days, when the resident was ultimately sent to the hospital for evaluation and treatment.
A resident with post-polio syndrome did not receive a dentist-recommended biopsy for a dental abscess, as there was no evidence the procedure was ordered or completed. The same resident also did not receive sufficient assistance from social services to obtain a new ID card needed for independent living, despite multiple attempts and documented barriers. These failures left the resident frustrated and without necessary support.
A resident with intact cognitive status reported insufficient supplies and an unclean room, with observations confirming white crumbs on the floor and personal items improperly stored. Staff interviews and inventory review revealed ongoing shortages of towels, linens, and mattress covers, forcing CNAs to use disposable wipes and leaving many beds unmade. The lack of essential supplies resulted in unsanitary and uncomfortable conditions, affecting residents' dignity, comfort, and safety.
A resident with limited mobility and moderate risk for pressure ulcers did not have a care plan in place, and a wound on the coccyx was initially misidentified as a skin tear rather than a stage 2 pressure ulcer, leading to delayed appropriate treatment. The same resident's foley catheter was changed to a larger size without a written physician's order, and both catheter sizes remained active in the treatment record, causing confusion among nursing staff.
The facility failed to follow food safety standards, as Cook1 prepared dessert without a beard net, exposing his beard. Additionally, five bowls of dry cereal and one bowl of white granulated powder were found unlabeled and undated in the kitchen, violating the facility's policies on food hygiene and storage.
The facility failed to ensure advance directives were offered or documented for eight residents, potentially compromising their healthcare wishes. Despite having policies in place, the facility did not document discussions or assistance regarding advance directives for residents with serious health conditions, as confirmed by staff interviews and record reviews.
Two residents were inaccurately assessed for tobacco use in their MDS assessments, despite being observed smoking daily. Interviews confirmed their long-term smoking habits, and the MDS Coordinator admitted to the coding error, which misrepresented their clinical status and risked inadequate person-centered care.
The facility failed to provide RN coverage for at least eight consecutive hours a day on 11 occasions, as confirmed by payroll records and the Administrator. This deficiency coincided with two resident falls when an RN was not available to perform post-fall assessments, highlighting a lapse in ensuring resident safety and well-being.
The facility failed to secure a medication cart, leaving it unlocked and unattended, and did not maintain proper temperature for refrigerated medications. An LVN admitted to not locking the cart, risking unauthorized access. The DON confirmed that medications were stored at incorrect temperatures, potentially compromising their effectiveness.
The facility violated HIPAA by allowing staff to use personal cell phones to exchange residents' PHI, including full names and clinical details, via the Signal app. Staff, including an LVN and the DON, used personal devices for communication, even when off duty, without ensuring encryption, posing a risk of privacy breach.
The facility failed to follow infection control practices, including not labeling Resident 11's nasal cannula tubing, not disinfecting a stethoscope between residents, and improperly transporting clean blankets. These actions were against the facility's policies and acknowledged by staff, posing a risk of cross-contamination.
A resident with multiple diagnoses, including cerebral palsy and quadriplegia, did not receive care with dignity when an LVN and a CNA failed to provide privacy during wound care treatment. The resident's buttocks were exposed with window blinds open and curtains undrawn, violating the resident's rights to dignity and privacy as per the facility's policy.
A resident with mild cognitive impairment and a progressive neurological condition was found with medications on the bedside table without an assessment for safe self-administration. The resident stated staff were aware of the self-administration, but the LVN and DON confirmed no IDT assessment was completed. Facility policy requires such assessments to ensure safety.
A facility failed to complete a quarterly MDS assessment for a resident, resulting in a lapse of over four months without an updated assessment. The MDSC acknowledged missing the assessment due in October, which placed the resident at risk for unidentified changes in health status and potentially inappropriate care.
A facility failed to accurately complete a resident's PASARR for serious mental illness, resulting in a negative Level I screening and no Level II evaluation. The resident, with diagnoses including epilepsy and major depressive disorder, was potentially deprived of necessary mental health services. The Admission Director admitted the oversight, which was against the facility's policy.
A facility failed to perform a PASARR for a resident with dementia, schizophrenia, and other mental health conditions, as required by policy. The absence of this assessment could lead to the resident not receiving necessary specialized services. The Admission Director confirmed the facility's responsibility to ensure the PASARR is completed correctly.
A resident with a left hand deformity refused to wear a prescribed splint, and the facility failed to provide an alternative treatment. The resident experienced pain when using his hand to wheel his wheelchair, and staff were unaware of his condition. Despite the resident's refusal since December, no alternative plan was developed, and the resident's doctor was not notified.
Two residents with limited ROM did not receive necessary exercises due to a lack of communication between the rehabilitation and nursing departments. Despite recommendations for a restorative program, the residents were not in the system to receive RNA services, leading to potential decline in their functional mobility.
A resident with an above-knee amputation and back pain requested a change in his Oxycodone administration from every six hours to every four hours. Despite being cognitively intact and communicating his needs, the nursing staff failed to follow up effectively with the doctor or among themselves, resulting in unrelieved pain and frustration for the resident.
A facility failed to establish parameters for Glargine insulin administration for a diabetic resident, leading to inconsistent insulin delivery over five months. The resident, aware of their condition, expected daily insulin as per physician orders, but the MAR showed irregular administration. The DON could not find insulin administration guidelines, and the Pharmacy Consultant admitted to missing this oversight.
A resident with a history of seizures was admitted to an LTC facility with a prescription for levetiracetam 1000 mg every 12 hours. The facility incorrectly transcribed the order as 100 mg/ml to be given as needed, leading to the resident receiving the wrong dosage for 22 days. This error resulted in multiple seizures, hospitalization, and the resident's death. The facility's failure to follow its medication reconciliation policy contributed to the adverse outcome.
Failure to Secure and Inventory Resident Belongings
Penalty
Summary
Facility staff failed to secure the belongings of a resident who was admitted with post-polio syndrome and was oriented to time and able to recall information accurately. The resident reported that underwear, other clothing items, and $53 stored in her bedside table had gone missing. She stated that she had informed multiple staff members, including the social worker, but only a partial effort was made to locate the missing items. The resident also discovered that the facility had not completed an inventory of her belongings upon admission, despite staff indicating they would check such a list. Interviews with the Social Services Director confirmed awareness of the missing items and that some clothing had been returned, but there was uncertainty regarding reimbursement for the lost money and whether an admission inventory had been completed. Review of the medical record showed no documented inventory of the resident's belongings. Facility policies required that personal belongings and clothing be inventoried and documented upon admission and updated as necessary, but this was not done in this case.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Skilled nursing staff failed to notify the physician of a significant change in condition for a resident who was admitted with post-polio syndrome and had previously been oriented to time and place. The resident experienced a sudden onset of hallucinations, including seeing snakes under the bed and believing bugs were crawling in the room, as well as an attempt to elope from the facility. Despite these notable changes in mentation and behavior, there was no documentation that the physician was notified during the initial episodes. The Director of Nursing confirmed that staff did not inform the physician about the resident's hallucinations, which are recognized as a potential sign of infection. The facility's clinical protocol required nurses to assess and report changes in cognitive and emotional status, but this was not followed. The physician was only notified after several days, at which point the resident was sent to the hospital for further evaluation and treatment.
Failure to Provide Dental Follow-Up and Social Services for Independent Living
Penalty
Summary
A deficiency occurred when the facility failed to provide medically-related social services to support a resident's dental health and ability to live independently. The resident, who had post-polio syndrome resulting in muscle weakness, was evaluated by a dentist who recommended an urgent biopsy for a dental abscess. However, there was no documentation that the biopsy was ever ordered or completed. Interviews with the Social Services Director (SSD) and Director of Nursing (DON) confirmed that the biopsy had not been arranged, and the resident stated the procedure was never done. Additionally, the resident expressed frustration about not receiving adequate assistance to obtain a new identification card, which was necessary for her goal of living independently. Although the SSD had initially made an appointment at the DMV, the resident still did not have a new ID card. The MDS RN attempted to help but encountered barriers due to missing documents and physical limitations, and reported these issues to the SSD. Documentation and interviews confirmed that the SSD did not follow up further, leaving the resident upset and without the necessary identification.
Failure to Provide Clean, Homelike Environment and Adequate Linen Supplies
Penalty
Summary
The facility failed to maintain a clean, orderly, and homelike environment for its residents, as evidenced by multiple observations and staff interviews. Resident rooms were found with a build-up of white crumbs on the floor, and personal items such as disposable briefs and pillows were piled on chairs at the bedside rather than being stored appropriately. One resident, who was cognitively intact according to their BIMS score, reported insufficient supplies and noted that their room had not been cleaned, with lunch trays and personal items still left out. Staff interviews revealed an ongoing shortage of essential linens and towels since December 2024, leading CNAs to use disposable dry wipes for resident care and struggle to find enough mattress covers. Observations of the linen closet and laundry area confirmed the lack of necessary supplies, with only a handful of towels and other linens available for a census of 46 residents. The monthly linen inventory further documented significant shortages in bath towels, wash cloths, bedspreads, blankets, and bath blankets. These deficiencies resulted in an unsanitary and uncomfortable environment, negatively impacting residents' dignity, comfort, and safety.
Failure to Accurately Assess Pressure Ulcer and Improper Foley Catheter Management
Penalty
Summary
A resident with a history of cord compression and a benign neoplasm of the pituitary gland was admitted with limited mobility and a moderate risk for pressure ulcers, as indicated by a Braden Scale score of 13. Despite this risk, there was no care plan in place to address the potential for pressure ulcer development. When a wound was identified on the resident's coccyx, the treatment nurse initially assessed it as a skin tear, despite the presence of thin skin and a darkened area. Two days later, a wound physician correctly identified the wound as a stage 2 pressure ulcer. Nearly four weeks later, the wound had progressed to a stage 4 pressure ulcer. The director of nursing confirmed that the initial assessment was incorrect and that no care plan had been developed for pressure ulcer prevention or management. Additionally, the resident had a foley catheter that was changed from size F16 to F18 without a written physician's order. The nurse practitioner verbally communicated the change, but the order was not properly documented, and the previous order for the F16 catheter was not discontinued. This resulted in both catheter sizes being listed in the treatment administration record, causing confusion among licensed nurses regarding which size to use. The resident expressed concern about staff competency in managing the foley catheter, and the director of nursing acknowledged the lack of proper documentation and order management.
Food Safety Standards Not Followed
Penalty
Summary
The facility failed to adhere to food safety standards as observed during a survey. Cook1 was seen preparing dessert without wearing a beard net, despite having a beard approximately one inch long. This was in violation of the facility's policy on employee hygiene and sanitary practices, which mandates the use of hair nets or caps and beard restraints when handling food. Cook1 was wearing a surgical mask, but his beard was still exposed, and he was unsure if a beard net was necessary with a mask on. Additionally, the facility did not properly label and date food items in the kitchen. Five bowls of dry cereal and one bowl containing white granulated powder were found unlabeled and undated in a kitchen cabinet. The Dietary Services Supervisor confirmed that all food should be labeled and dated, as per the facility's policy on food receiving and storage. The white granulated powder was identified as a food thickener, which also required labeling. These oversights posed a potential risk for food safety and could lead to foodborne illnesses among residents.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that advance directives were offered or documented for eight residents, potentially compromising their healthcare wishes in case of incapacitation. Residents 2, 11, 14, 18, 37, 38, 46, and 249 were identified as not having advance directives on file, and there was no documentation indicating that they or their representatives were asked about the existence of such directives. This oversight was confirmed through interviews with medical records staff and the Social Services Director, who acknowledged the absence of advance directives in the residents' records. Resident 2, for example, was admitted with multiple diagnoses including dementia and paranoid schizophrenia, yet there was no record of an advance directive being discussed or documented. Similarly, Resident 14, with conditions such as epilepsy and congestive heart failure, also lacked documentation of an advance directive. Interviews with responsible parties and staff revealed concerns about the facility's ability to honor residents' healthcare preferences without these directives in place. The facility's policy and procedure on advance directives, revised in 2013, mandates that residents be provided with information about their rights to make medical decisions and be offered assistance in establishing advance directives. However, the policy was not followed, as evidenced by the lack of documentation and staff admissions during interviews. This failure to adhere to policy and ensure advance directives were in place could lead to residents' healthcare wishes not being honored in critical situations.
Inaccurate Assessment of Tobacco Use in Residents
Penalty
Summary
The facility failed to accurately assess the tobacco use status of two residents, Resident 13 and Resident 23, during their comprehensive Minimum Data Set (MDS) assessments. Both residents were observed smoking daily on the facility's patio, yet their MDS assessments inaccurately indicated that they were not using tobacco. This discrepancy was confirmed through interviews with the residents, who both stated they had been long-term smokers, and with a Restorative Nursing Aid who supervised their smoking sessions and confirmed their smoking habits since admission. The MDS Coordinator acknowledged the error in coding the MDS assessments for both residents, which inaccurately reflected their clinical status. This failure to accurately assess and document the residents' tobacco use status placed them at risk for not receiving person-centered care tailored to their actual needs and habits.
RN Coverage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, resulting in a deficiency for a total of 11 days. This was confirmed through a review of the facility's Payroll Based Journal and acknowledged by the Administrator during an interview. The absence of an RN on specific dates was noted, and the Administrator admitted that this practice posed a risk to resident health, as Licensed Vocational Nurses (LVNs) do not possess the same level of knowledge and skills as RNs. Additionally, the lack of RN coverage coincided with two resident falls on days when an RN was not present to perform necessary post-fall assessments. The facility's assessment tool indicated the requirement for sufficient staffing with appropriate competencies to ensure resident safety and well-being, which was not met on the specified dates. The absence of an RN during these times potentially delayed necessary assessments and treatments, impacting the day-to-day care of residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmacy services policies and procedures, resulting in two significant deficiencies. Firstly, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended in the hallway, directly outside the dining and activity room. During an interview, the LVN admitted to not ensuring the cart was fully locked before leaving it unattended, acknowledging the risk of unauthorized individuals accessing the medications. Secondly, the facility did not maintain the required temperature range for refrigerated medications. Observations revealed that the refrigerator storing medications, including vaccines and insulin, was at 30 F, which is below the acceptable range of 36 F to 46 F. The Director of Nursing (DON) confirmed that medications stored outside the specified temperature parameters could be compromised and ineffective. Despite acknowledging the issue, the DON did not take corrective actions to address the improper storage conditions.
HIPAA Violation Due to Use of Personal Devices for PHI
Penalty
Summary
The facility failed to comply with the Health Insurance Portability and Accountability Act (HIPAA) by not safeguarding resident-identifiable information. Clinical and non-clinical staff, including the attending physician, nurses, nursing managers, and administrative personnel, used their personal cell phones to exchange residents' Protected Health Information (PHI) and confidential biographical details. This included using an app called Signal to send group text messages containing sensitive information such as residents' full names, dates of birth, and clinical details. The staff, including the Licensed Vocational Nurse (LVN) and Director of Nursing (DON), admitted to using their personal devices for these communications, even when off duty, without ensuring the app's encryption status. The facility's administration, including the Administrator (ADM) and Clinical Consultant (CC), acknowledged the risk of a potential breach of residents' PHI due to the use of personal devices. The facility's California Employee Handbook allowed the use of personal mobile devices for facility-related business but required strict compliance with confidentiality policies. However, the staff's practice of accessing and exchanging PHI on personal devices, even when not on the clock, posed a significant risk of a privacy breach. The facility's Policy and Procedure on confidentiality, dated 10/2017, emphasized safeguarding residents' personal and medical records, which was not adhered to in this instance.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control prevention practices in several instances. Resident 11's nasal cannula tubing was observed to be undated and unlabeled, which was against the facility's policy that required oxygen tubing to be changed and dated every seven days. This oversight was acknowledged by LVN 3, who admitted that without proper labeling, the nursing team could not determine when the tubing needed to be changed, potentially leading to infection. Resident 11 had multiple diagnoses, including asthma and chronic obstructive pulmonary disease, which could increase the risk of infection. Additionally, LVN 3 was observed using a stethoscope on multiple residents without cleaning and disinfecting it between uses, which was a breach of the facility's policy requiring disinfection of shared equipment between residents. The Infection Preventionist confirmed the risk of cross-contamination due to this practice. Furthermore, the Housekeeping Manager was seen transporting clean blankets without covering them, holding them against her clothing, which was contrary to the facility's policy that required clean linen to be protected from contamination during transport. This was acknowledged by both the Housekeeping Manager and the Infection Preventionist.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to provide care with dignity for a resident, identified as Resident 18, when two staff members did not ensure privacy during nursing care. Resident 18, who has multiple diagnoses including cerebral palsy, quadriplegia, and muscle wasting, was dependent on two or more helpers for dressing and movement. During an observation, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) were providing wound care treatment to Resident 18's left ischium. During this procedure, Resident 18's buttocks were fully exposed, and the window blinds were left open with the curtain not drawn, failing to provide necessary privacy. The LVN acknowledged that Resident 18 was not treated with dignity during the treatment, and the CNA admitted that Resident 18's rights were violated due to the lack of privacy. The Director of Staff Development (DSD) confirmed awareness of the incident and stated that the expectation was for staff to draw the curtain to ensure privacy during such procedures. The facility's policy on Resident Rights emphasizes treating all residents with kindness, respect, and dignity, including ensuring privacy during care.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure an assessment and evaluation for self-administration of medications was completed for a resident, identified as Resident 11. During an observation, it was noted that Resident 11 had a bottle of Nystatin powder, a cup filled with Pepto Bismol, and Sudafed Nasal Spray on the bedside table. Resident 11, who was admitted with multiple diagnoses including mild cognitive impairment and a progressive neurological condition, stated that staff were aware of the self-administration of these medications. However, there was no documented assessment by the Interdisciplinary Team (IDT) to determine if self-administration was safe and appropriate for Resident 11. The Licensed Vocational Nurse (LVN) acknowledged the presence of the medications on the bedside table but was unaware of any assessment for self-administration. The Director of Nursing (DON) confirmed that no IDT assessment had been completed for Resident 11 to evaluate the safety and appropriateness of self-administering medications. The facility's policy requires an IDT assessment to evaluate a resident's cognitive and physical abilities for safe self-administration and mandates that unauthorized medications found at the bedside be returned to the nurse in charge.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment in a timely manner for one of the sampled residents, identified as Resident 28. This assessment is crucial for tracking a resident's status between comprehensive assessments to ensure any gradual changes in their condition are monitored. Resident 28 was admitted to the facility, and the last assessment was completed on 7/28/24. However, the Minimum Data Set Coordinator (MDSC) did not complete the subsequent quarterly assessment due in 10/2024, resulting in a lapse of over four months without an updated assessment. During an interview and record review, the MDSC acknowledged the oversight, stating that the quarterly MDS assessment for Resident 28 was missed. This failure placed Resident 28 at risk for unidentified significant changes in health status, potentially affecting the appropriateness of care and services provided based on her current health condition.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening Resident Review (PASARR) for serious mental illness was accurately completed and sent to the appropriate state mental authority for a Level II evaluation and determination. The resident, who was admitted with diagnoses including epilepsy, major depressive disorder, delusional disorders, dementia, and congestive heart failure, had a Level I PASARR screening that incorrectly indicated no mental illness, resulting in a negative screening outcome. This error meant that a Level II Mental Health Evaluation was not conducted, potentially preventing the resident from receiving necessary mental health services. During an interview, the Admission Director acknowledged that it is the facility's responsibility to ensure the accuracy of Level I PASARR screenings. The facility did not notice the error in the resident's Level I PASARR, which might have led to the resident not receiving available services from the Department of Developmental Services Regional Center. The facility's policy on PASARR, revised in 2017, states that screenings should be completed timely and errors should be addressed by contacting the Department of Health Care Services.
Failure to Complete PASARR for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to perform a Pre-Admission Screening and Resident Review (PASARR) for a resident, which is a necessary assessment to determine if individuals with serious mental illness or intellectual/developmental disabilities require specialized services. This oversight was identified during a review of the resident's admission records and Minimum Data Set (MDS), which showed active diagnoses of dementia, paranoid schizophrenia, epilepsy, amnestic disorder, and cognitive communication deficit. Despite these significant mental health conditions, there was no evidence of a completed PASARR Level I assessment. During an interview, the Admission Director acknowledged the facility's responsibility to ensure the PASARR Level I is completed correctly. The absence of this assessment could result in the resident not receiving appropriate care and treatment services from the Department of Developmental Services Regional Center. The facility's policy mandates that the PASARR be completed and included in the resident's chart within five days of admission, a requirement that was not met in this case.
Failure to Provide Alternative Treatment for Resident's Hand Deformity
Penalty
Summary
The facility failed to provide an alternative treatment for a resident with a left hand deformity who refused to wear a prescribed splint. The resident, who had a history of plate implant surgery and was on contracture precautions, experienced pain when using his left hand to wheel his wheelchair. Despite the resident's refusal to wear the splint since December 2024, the facility did not notify the resident's doctor or develop an alternative plan to manage the resident's condition. Observations and interviews revealed that staff, including a CNA and an LVN, were unaware of the resident's left hand deformity and associated pain. The therapy progress notes indicated that the resident had declined the splint, but no further action was taken to address the resident's needs. This inaction resulted in the resident experiencing pain and a potential risk for skin breakdown while using his wheelchair.
Failure to Provide ROM Exercises for Residents
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises for two residents, Resident 6 and Resident 18, who were identified as having limited ROM. Resident 6, who was admitted with severe cognitive impairment and multiple diagnoses including cerebrovascular accident and muscle weakness, required maximal assistance with mobility. Despite recommendations for a restorative program upon discharge from occupational and physical therapy, Resident 6 did not receive the necessary ROM exercises. Similarly, Resident 18, who had multiple neurological conditions and was dependent on assistance for mobility, did not receive ROM exercises after being discharged from physical therapy without reaching maximum potential. The deficiency was attributed to a lack of communication between the rehabilitation and nursing departments, resulting in the failure to implement the Restorative Nursing Program for these residents. The Restorative Nurse Assistant confirmed that neither resident was in the system to receive RNA services due to the absence of a therapy referral. The Director of Rehabilitation and the Director of Nursing acknowledged the oversight and the potential for decline in the residents' functional mobility and ROM due to the lack of restorative care. The facility's policy indicated that residents should receive restorative nursing care to promote safety and independence, but this was not followed in these cases.
Failure to Address Resident's Pain Management Request
Penalty
Summary
The facility failed to adequately address a resident's request to change the frequency of his pain medication, resulting in unrelieved pain and feelings of frustration and unhappiness. Resident 249, who had an above-knee amputation and was experiencing back pain after a fall, requested that his Oxycodone medication be administered every four hours instead of every six hours. Despite being cognitively intact and able to communicate his needs, his request was not followed up effectively by the nursing staff. Licensed Vocational Nurse (LVN 1) documented the resident's request and notified the doctor but did not receive a response and failed to follow up further. Another nurse, LVN 3, also did not follow up with the doctor or communicate the resident's needs to other nurses due to being rushed at the end of her shift. The facility's policy on pain assessment and management was not adhered to, as the staff did not develop interventions consistent with the resident's needs, leading to the deficiency.
Lack of Insulin Administration Parameters for Diabetic Resident
Penalty
Summary
The facility failed to establish and implement clear parameters for the administration of Glargine insulin for a resident diagnosed with Type 2 diabetes mellitus with hyperglycemia. Over a period of more than five months, the resident received insulin inconsistently, with administration occurring on some days and not on others, despite similar blood glucose levels. The resident was aware of their diabetic condition and expected daily insulin administration, as per the physician's orders, which specified a daily bedtime dose of 10 units of Glargine insulin. Upon review, it was found that the Medication Administration Record (MAR) showed discrepancies in insulin administration, with the resident receiving insulin on certain days and not on others, even when blood glucose levels were comparable. The Director of Nursing (DON) was unable to locate any parameters guiding insulin administration for the resident, acknowledging the necessity of such parameters to mitigate risks of hyperglycemia or hypoglycemia. The facility's Pharmacy Consultant admitted to possibly overlooking the absence of these critical parameters, which are essential for providing clear instructions to nursing staff on when to administer or withhold insulin.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in severe consequences. Upon admission, the resident, who had a history of non-traumatic intracranial hemorrhage, malignant neoplasm of the brain, post-traumatic seizures, hemiplegia, and hemiparesis, was prescribed levetiracetam 1000 mg every 12 hours for seizure disorder. However, the Director of Staff Development incorrectly transcribed the order as 100 mg/ml, to be given as needed, which was not in line with the prescribed routine dosage. For 22 days, the nursing staff administered the incorrect dosage, leading to multiple seizures, hospitalization, and ultimately the resident's death. The facility's Medication Administration Records indicated that the medication was not given as prescribed, and there was no documentation to justify the change from as-needed to twice a day. The Clinical Consultant and Licensed Vocational Nurse acknowledged the error, and the Pharmacy Consultant admitted to missing the incorrect transcription during her monthly review. The facility's failure to accurately reconcile and transcribe the medication order upon admission, as outlined in their policy, directly contributed to the resident's adverse health outcomes. The resident experienced repeated seizures and was transferred between hospitals for continuous EEG monitoring, where the dosage was eventually corrected. Despite these efforts, the resident continued to have seizures and was transitioned to comfort-focused care before passing away.
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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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