Pacific Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1323 17th Street, Santa Monica, California 90404
- CMS Provider Number
- 555054
- Inspections on file
- 30
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pacific Post Acute during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions was discharged to an unsafe and unsanitary home environment without adequate support or proper discharge planning. The facility did not follow its discharge policy, failed to involve the IDT or the resident's POA in planning, and did not provide timely notice to the Ombudsman. As a result, the resident was left alone, sustained injuries, and required hospitalization.
The facility failed to properly dispose of medications in Medication room [ROOM NUMBER], as observed by surveyors. The pharmaceutical waste bin was found open, containing intact loose medication tablets, capsules, and other medications in their original packaging. LVN and RN confirmed that the medications were not disintegrated as per facility policy, allowing for potential misuse and diversion. The DON and Administrator acknowledged the improper disposal, which did not adhere to the facility's procedures.
The facility failed to follow its infection control policy by not labeling personal hygiene items in a shared bathroom used by four residents. Unlabeled toothbrushes, emesis basins, body soap, and toothpaste were found, posing a risk of infection spread. The residents had various medical conditions and required assistance with personal hygiene. The facility's policy emphasized standard precautions, which were not followed.
A resident in an LTC facility was left in soiled incontinence briefs and not repositioned in a timely manner, leading to feelings of discomfort and neglect. Despite having sufficient staff, CNAs prioritized meal tray distribution over immediate care needs, and the resident's requests were perceived as demanding. The facility's policies on maintaining resident dignity were not upheld.
A resident in an LTC facility experienced neglect when CNAs failed to provide timely incontinence care and repositioning, leaving her to eat with a soiled brief. Despite the facility not being short-staffed, CNAs prioritized meal tray distribution over the resident's immediate needs, leading to feelings of frustration and helplessness. The facility's policies on infection control and call light response were not properly followed, resulting in neglect of the resident's care needs.
A resident experienced neglect and frustration due to two CNAs' lack of competency in providing timely and respectful care. The resident was left waiting for incontinence care while CNAs prioritized other tasks, leading to feelings of discomfort and neglect. Misunderstandings about infection control rules and failure to seek assistance contributed to the deficiency.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with cerebrovascular accident and hemiplegia was observed with the call light out of reach, despite care plans indicating its necessity. Another resident with Parkinson's disease and muscle weakness was unable to reach the call light, which was wrapped around a siderail. Staff confirmed the importance of accessible call lights for safety and timely assistance.
The facility failed to ensure proper food labeling and storage in the kitchen, as observed by surveyors. Bags of peas and carrots in the walk-in freezer were not dated or labeled, and cheese and waffles in the overflow freezer had incorrect labeling. The Dietary Manager acknowledged these issues, which could affect 42 medically compromised residents receiving food from the kitchen.
The facility did not meet the required 80 square feet per resident in three rooms, with Rooms #9, 16, and 28 providing less space than required. Despite this, residents and staff reported adequate space for mobility and care, and a room waiver was submitted. The DON confirmed measures were taken to ensure the variance did not affect resident care.
A resident was not readmitted to the facility after hospitalization despite available beds, due to a lack of follow-up by the Admission/Business Development staff and the Director of Nursing. The resident, who required maximal assistance and had moderately impaired cognitive skills, remained in the hospital longer than necessary, contrary to the facility's Bed Hold Notice Upon Transfer policy.
A resident with a history of fracture, dysphagia, and atrial fibrillation was diagnosed with a UTI after exhibiting confusion and behavioral changes. Despite the diagnosis and antibiotic treatment, the facility failed to develop a comprehensive care plan to address the resident's UTI, as required by their policy. The Director of Nursing confirmed the absence of a care plan, highlighting a deficiency in meeting the resident's needs.
A resident was transferred from a skilled nursing facility without timely notification to the resident, their representative, or the Ombudsman. The resident, who was cognitively intact and required assistance with daily activities, was discharged to another facility with a hospice evaluation. The facility's Discharge Planner claimed the resident agreed to the transfer, but there was no documented evidence of such discussions. The Ombudsman was notified only on the day of discharge, contrary to the facility's policies.
The facility failed to provide advance written notice of room changes for three residents, violating their rights. A resident with intact cognitive skills experienced multiple incompatible roommate changes without notification, affecting her well-being. Two other residents with cognitive impairments and behavioral issues were also involved in room changes without proper notice. The facility did not adhere to its policy requiring advance notice and documentation of room changes.
A resident's grievances about disruptive roommates were not documented or addressed by the facility, despite being known to staff and management. The resident, who required moderate assistance for daily activities, experienced sleep disturbances due to roommates' behaviors, but no grievance form was completed, violating the facility's policy.
A resident with COPD and major depressive disorder experienced issues with incompatible roommates, affecting her sleep and well-being. Despite reporting these issues, the facility failed to document or address her concerns, violating policies requiring social services to coordinate necessary referrals and services.
A resident's emergency contact reported that staff did not answer phone calls and were rude during a late-night visit. Despite multiple concerns being raised about the resident's care, the Social Service Director did not initiate a grievance report, violating the facility's policy on addressing grievances.
Failure to Ensure Safe and Orderly Discharge Planning
Penalty
Summary
The facility failed to provide an effective and safe discharge for a resident with complex medical needs, resulting in the resident being discharged to an unsafe home environment without adequate support or preparation. The facility did not follow its own discharge planning policy and procedure, as the interdisciplinary team (IDT) did not ensure that the discharge destination met the resident's health and safety needs or preferences. The care plan for discharge was not properly implemented, and the discharge summary lacked input and recommendations from the IDT, with sections left blank and signed off by a staff member who did not provide the required education or assessment. The resident had significant medical conditions, including Parkinson's disease, a recent above-knee amputation, diabetes, chronic kidney disease, and major depressive disorder. The resident required moderate assistance with activities of daily living, used a wheelchair, and had a non-weight bearing order on the left lower extremity. The resident's home environment was documented as cluttered, unsanitary, and lacking caregiver support, with the only available support being a power of attorney (POA) who lived an hour away and was not regularly present. Despite these factors, the facility discharged the resident home with only a home health agency referral, without confirming the adequacy of support or the safety of the environment. The discharge notice was not provided to the resident's representative or Ombudsman in a timely or understandable manner, and the POA was not included in discharge planning meetings. The facility staff did not coordinate with the IDT or verify the resident's home situation, and Adult Protective Services was not contacted despite the apparent risks. As a result, the resident was left alone at home for several days, was found on the floor with injuries, and required hospitalization. The facility's failure to follow its discharge planning process and ensure a safe transition led directly to the resident's harm.
Improper Disposal of Medications in Medication Room
Penalty
Summary
The facility failed to properly dispose of medications in a manner that prevents retrieval, as observed in Medication room [ROOM NUMBER]. During an inspection, it was found that the pharmaceutical waste bin was open and contained a mixture of intact loose medication tablets and capsules, medications in manufacturer bottles, creams/ointments, and unopened and unused suppositories and patches in their original packaging. Licensed Vocational Nurse (LVN) 3 and Registered Nurse (RN) 1 confirmed that the medications were disposed of in their original form without any liquid poured over them to disintegrate the medications, contrary to the facility's policy and procedures. The Director of Nursing (DON) and the Administrator acknowledged that the medications in the pharmaceutical waste bin were not disposed of properly, allowing for easy access, retrieval, and potential re-use. The facility's policies and procedures, as reviewed, indicated that outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to procedures for medication disposal. However, the facility failed to adhere to these procedures, increasing the potential for accidental misuse and diversion of medication, and exposure to harmful substances.
Infection Control Deficiency Due to Unlabeled Personal Hygiene Items
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not labeling personal hygiene items in a shared bathroom used by four residents. During an observation, it was noted that two toothbrushes, two emesis basins, two bottles of body soap, and one toothpaste were found unlabeled in the shared bathroom. This oversight was confirmed by a Certified Nurse Assistant/Restorative Nurse Assistant, who acknowledged that such items should not be left unlabeled as it could lead to the spread of infection among residents. The residents involved had various medical conditions, including major depression disorders, protein-calorie malnutrition, gastro-esophageal reflux disease, immunodeficiency, type 2 diabetes mellitus, and dementia, among others. The Minimum Data Set assessments indicated that these residents required varying levels of assistance with personal hygiene and had intact or moderately impaired cognitive skills for daily decision-making. The facility's policy, revised in December 2024, emphasized the importance of following standard precautions for infection prevention and control, which was not adhered to in this instance.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident 390, by not providing timely incontinence care and repositioning assistance. On multiple occasions, Resident 390 was left in soiled incontinence briefs for extended periods, including a specific incident where the resident had to wait 40 minutes for care. This delay occurred because CNA 3 prioritized passing meal trays over attending to the resident's immediate needs, despite the facility not being short-staffed. The resident expressed feelings of discomfort, frustration, and neglect due to these delays and the manner in which the staff communicated with her. Additionally, Resident 390's requests for repositioning were not promptly addressed. CNA 4, who was responsible for the resident's care at another time, delayed repositioning the resident after returning from a break, assuming that the resident could wait. The resident's frequent use of the call light and requests for assistance were perceived as demanding by the staff, leading to further delays in care. The staff's failure to respond promptly to the resident's needs and their elevated tone of voice contributed to the resident feeling disrespected and treated like a child. The facility's policies and procedures emphasize the importance of maintaining resident dignity and responding to requests for assistance in a timely manner. However, the actions and inactions of the staff, including not asking for help when needed and not prioritizing the resident's immediate care needs, resulted in a failure to uphold these standards. Interviews with the Director of Nursing and the Administrator confirmed that the facility had sufficient staff to address the resident's needs and that the infection control concerns cited by CNA 3 were not valid reasons for delaying care.
Neglect in Resident Care Due to Delayed Incontinence Management
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the actions of CNAs who did not provide timely incontinence care and repositioning. The resident, who was unable to walk and care for herself, reported feeling upset, frustrated, helpless, and neglected due to the delay in care. On one occasion, the resident had to wait up to 40 minutes to be cleaned after a bowel movement, during which time she was left to eat with a soiled incontinence brief. The CNAs involved did not prioritize the resident's request for care, citing other duties such as passing meal trays. Interviews with staff revealed that CNA 3 did not clean the resident immediately due to an incorrect belief that infection control rules prohibited incontinence care during meal tray distribution. The Director of Staff Development and the Director of Nursing confirmed that there was no such rule, and proper handwashing would suffice to address infection control concerns. Additionally, the facility was not short-staffed, and CNA 3 could have asked for assistance to ensure the resident's needs were met promptly. The resident's care plan indicated a need for regular checks and assistance with toileting, which was not adhered to. The facility's policy on call light response was also not followed, as the resident's requests were not addressed in a timely manner. The Director of Nursing and the Administrator acknowledged that the failure to provide immediate care constituted neglect, as it did not meet the resident's needs for comfort and safety, potentially leading to physical and emotional distress.
Inadequate CNA Competency Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs) had the necessary competencies to provide care in a respectful and timely manner, which affected Resident 390. During an observation and interview, Resident 390 expressed feelings of sadness and frustration due to being told by CNAs in a harsh tone that she would need to wait for incontinence care. On one occasion, Resident 390 requested a change of her incontinence brief after a bowel movement, but CNA 3 prioritized passing meal trays over providing immediate care, leading to Resident 390 feeling uncomfortable and neglected. CNA 4 described Resident 390 as demanding and stated that call lights were answered in the order they were activated, with no complaints from other residents. CNA 4 did not seek assistance from other staff, assuming they were busy, and emphasized that Resident 390's requests were not emergencies. CNA 3 believed there was an infection control rule preventing them from providing incontinence care while passing meal trays, which led to confusion about prioritizing tasks. CNA 3 admitted to needing further training on handling such situations. The Director of Staff Development (DSD) clarified that there was no infection control rule prohibiting incontinence care during mealtime and emphasized the importance of proper handwashing. The DSD and Director of Nursing (DON) both highlighted the need for CNAs to be competent in their duties, respectful, and protective of residents' dignity. The facility's policy and job description for CNAs outlined the expectation for staff to treat residents with dignity and respect, and to perform their duties in accordance with established policies and procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which had the potential to delay their care. Resident 21, who was admitted with diagnoses including cerebrovascular accident, hemiplegia with left-sided weakness, and muscle weakness, was observed with the call light out of reach on multiple occasions. The resident's care plan indicated the need for the call light to be within reach due to communication issues and fall risk. Despite this, observations showed the call light was either hanging from the bed or placed under a pillow, making it inaccessible. Interviews with staff confirmed the importance of having the call light within reach to prevent delays in care and potential injuries. Similarly, Resident 390, who had diagnoses including Parkinson's disease, diabetes mellitus, and muscle weakness, was observed unable to reach the call light while sitting in a wheelchair. The call light was wrapped around the bed's siderail, approximately three feet away from the resident. The resident's care plan also emphasized the need for the call light to be within reach due to fall risk. Staff interviews reiterated the necessity of ensuring call lights are accessible to residents to facilitate communication and maintain safety. The facility's policy on call light accessibility and timely response was not adhered to in these instances.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Specifically, the surveyors found that bags of peas and carrots in the walk-in freezer were not dated or labeled. The Dietary Manager (DM) acknowledged that the cook had just opened these bags but forgot to label them with the date they were opened and the use-by date. The DM emphasized the importance of labeling food to prevent the use of expired items and to avoid serving food that could cause illness to residents. Additionally, the surveyors observed that cheese and waffles in the overflow freezer were not correctly labeled and dated. The cheese had a use-by date that should have been updated when it was moved to the freezer, and the waffles had an incorrect open date and use-by date. The DM admitted that the dates on these items were labeled incorrectly. The facility's policy and procedure on food safety and storage, which requires proper labeling, dating, and monitoring of refrigerated food, was not followed, potentially affecting 42 medically compromised residents who received food from the kitchen.
Facility Fails to Meet Space Requirements in Three Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in three rooms, specifically Rooms #9, 16, and 28. Observations and interviews revealed that these rooms did not meet the federal regulation for space per resident, with Room #9 providing 74.48 square feet per resident, Room #16 providing 71.91 square feet per resident, and Room #28 providing 78.79 square feet per resident. Despite this, residents and staff reported that there was adequate space for mobility and care, and a room waiver request was submitted indicating that the rooms were in accordance with the residents' special needs and provided enough space for dignity and privacy. The Director of Nursing confirmed the existence of a room waiver and stated that measures were taken to ensure the room variance did not adversely affect resident care.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following hospitalization, despite having available beds, in accordance with its Bed Hold Notice Upon Transfer policy. The resident, who had been admitted to the facility with diagnoses including metabolic encephalopathy, chronic embolism, and thrombosis, required maximal assistance for activities of daily living and had moderately impaired cognitive skills. After being transferred to a general acute care hospital for further evaluation, the resident was ready for discharge back to the facility. However, the facility did not facilitate the resident's timely readmission. The Admission/Business Development (AD/BD) staff received the referral for the resident's readmission but was out of town and failed to follow up upon returning. The Director of Nursing (DON) was unaware of the resident's continued hospitalization and did not follow up with the hospital when beds became available. The facility's policy requires that residents be allowed to return unless specific conditions are met, none of which applied in this case. The failure to readmit the resident resulted in the resident remaining in the hospital longer than necessary.
Failure to Implement Comprehensive Care Plan for UTI
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who experienced a change in condition due to a urinary tract infection (UTI). The resident, who was admitted with diagnoses including a fracture of the left ilium, dysphagia, and paroxysmal atrial fibrillation, was found to be confused and acting out, which led to a urinalysis being ordered. The resident was subsequently diagnosed with a UTI and prescribed antibiotics. Despite this change in condition, no care plan was developed to address the UTI diagnosis and the associated treatment. The facility's policy requires the development of a comprehensive, person-centered care plan for each resident, which includes measurable objectives and timeframes to meet the resident's needs. However, a review of the resident's electronic and paper health records confirmed the absence of such a care plan. The Director of Nursing acknowledged that no care plan was created for the resident's UTI diagnosis, which is a deficiency in meeting the facility's policy and potentially impacts the resident's health and safety.
Failure to Provide Timely Notification of Transfer and Discharge
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer and discharge to a resident, as well as to the resident's representative and the State Long Term Care Ombudsman. This deficiency was identified for one resident who was transferred from Skilled Nursing Facility 1 to another facility. The resident, who had been at the facility for over two years and considered it home, was not given adequate notice or documentation of the transfer, leading to feelings of anxiety and distress. The resident, who was cognitively intact and required assistance with activities of daily living, was discharged to another skilled nursing facility with a hospice evaluation. The discharge was reportedly initiated by the facility's Discharge Planner, who claimed that the resident had agreed to the transfer. However, there was no documented evidence of any discussions or requests from the resident for a discharge. The Social Services Director and the Director of Nursing were also unaware of any prior desire from the resident to be discharged, and the Ombudsman was only notified on the day of the discharge. The facility's policy and procedures for discharge planning emphasize the importance of documenting the resident's discharge goals and needs, as well as providing education to the resident and family prior to discharge. In this case, the facility did not adhere to its own policies, as there was no documentation of the resident's desire to be discharged, and the Ombudsman was not informed in a timely manner. This lack of communication and documentation resulted in the resident being transferred without the necessary protections and support.
Failure to Provide Advance Notice for Room Changes
Penalty
Summary
The facility failed to uphold residents' rights by not providing advance written notice of room or roommate changes for three residents, as required by their policy. Resident 1, who had intact cognitive skills and required moderate assistance for daily activities, experienced multiple roommate changes without proper notification. The resident expressed dissatisfaction with previous roommates due to their behavioral issues, which affected her sleep and well-being. Resident 2, with moderately impaired cognitive skills and requiring maximal assistance, was involved in the room change process without receiving the necessary advance notice. Similarly, Resident 3, who had moderate to total dependence on staff for daily activities and exhibited behavioral issues such as aggressiveness and sundowning, was also part of the room change without proper notification. Interviews with staff revealed that these residents had behavioral issues that contributed to the incompatibility with Resident 1. The Director of Nursing acknowledged the lack of documentation and adherence to the facility's policy regarding room changes. The facility's policy stated that residents and their representatives should receive advance written notice of room changes, including the reasons for the change, in a language and manner they understand. However, this procedure was not followed, leading to the deficiency in promoting residents' rights.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances for a resident, violating their right to have grievances resolved without discrimination or reprisal. The resident, who was cognitively intact and required moderate assistance for activities of daily living, had repeatedly expressed concerns about incompatible roommates who exhibited disruptive behaviors, such as yelling and screaming at night. These disturbances affected the resident's sleep and well-being, and the resident had informed the staff and management about these issues. Despite the resident's vocal complaints, no grievance form was completed to document these concerns. Interviews with staff, including two Licensed Vocational Nurses and the Director of Nursing, confirmed that the resident's grievances were known but not formally recorded or addressed. The facility's grievance policy mandates that grievances be documented and resolved, but in this case, the grievance forms were not updated, leading to a failure in addressing the resident's concerns adequately.
Failure to Provide Necessary Social Services Referrals
Penalty
Summary
The facility failed to provide necessary social services referrals for a resident, leading to a deficiency in care. The resident, who was admitted with chronic obstructive pulmonary disease, major depressive disorder, and muscle weakness, had intact cognitive skills and required moderate assistance for activities of daily living. Despite having a care plan goal to improve mood and reduce symptoms of depression and anxiety, the resident experienced issues with incompatible roommates who exhibited disruptive behavior, affecting her sleep and well-being. The resident reported these issues to the staff, but no documented actions were taken to address her concerns. During an interview, the Director of Nursing acknowledged that the facility's grievance forms and room change notifications were not updated, indicating a failure to follow established policies. The facility's policy required social services to coordinate resident referrals and collaborate with nursing staff to arrange necessary services. However, the lack of documentation and follow-up on the resident's grievances and room change requests demonstrated a failure to meet the resident's medically related emotional and social needs, as outlined in the facility's job description for the Social Service Designee.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure prompt attempts were made to resolve grievances for a resident, violating the resident's responsible party's right to have grievances addressed and resolved. The resident, who was admitted with diagnoses including cerebral infarction, dysphagia, and major depressive disorder, had severely impaired cognition and required maximal assistance for activities of daily living. On one occasion, the resident's emergency contact visited the facility at 1:00 a.m. and found that staff did not answer phone calls and were rude and unprofessional. The emergency contact reported the incident to the management, but no grievance report was initiated by the Social Service Director, despite multiple concerns being raised previously about the resident's care. The facility's policy and procedures on resident and family grievances state that grievances should be addressed without discrimination or reprisal, and the Grievance Official should take steps to resolve the grievance and record the actions taken. However, the Social Service Director admitted to not following the grievance procedure, even though she was aware of the incidents and concerns raised by the resident's emergency contact. This failure to follow the grievance policy resulted in the resident's grievances not being promptly addressed or resolved, as required by the facility's own policies.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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