Pacific Villa, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3501 Cedar Avenue, Long Beach, California 90807
- CMS Provider Number
- 056313
- Inspections on file
- 33
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Pacific Villa, Inc during CMS and state inspections, most recent first.
A resident with major depressive disorder and moderate cognitive impairment reported being struck and expressed fear, indicating a psychosocial change in condition. Despite facility policy requiring physician notification and care plan updates for such changes, staff did not notify the physician or update documentation, citing the resident's history of similar statements. The omission was acknowledged by nursing leadership, and the resident's psychological evaluation reflected ongoing distress.
A resident with major depressive disorder and moderate cognitive impairment reported being struck and expressed ongoing fear, indicating a psychosocial change in condition. Despite staff awareness of the incident and facility policy requiring care plan review after such changes, the care plan was not updated to address the resident's new needs. This resulted in the resident's psychosocial concerns and safety issues not being incorporated into their care plan.
A resident with severe cognitive impairment and a history of schizophrenia poured water on another resident's face while she was receiving ADL care, causing distress and a sensation of drowning. The incident occurred when the CNA briefly left the room, and prior conflicts between the two residents had been observed. The DON was not aware of the incident, but facility policy prohibits abuse by anyone, including other residents.
A resident with intact cognition and dependent on staff for ADLs reported to a CNA that another resident with schizophrenia and severe cognitive impairment poured water on her face, causing distress. The CNA did not report the allegation to the DON or ADM as required by facility policy, resulting in the incident not being reported to CDPH or the ombudsman and preventing a timely investigation.
A treatment nurse failed to wear a gown while providing wound care to a resident with chronic osteomyelitis and peripheral vascular disease who was on enhanced barrier precautions (EBP). Despite clear physician orders and facility policy requiring gown and glove use for high-contact activities like wound care, only gloves were used. Staff interviews confirmed that gowns should have been worn during such care.
A resident with moderate cognitive impairment experienced new right hip pain and decreased mobility, later found to be a hip fracture of unknown origin. Staff did not escalate the change in condition to the DON or order diagnostic imaging, and the injury was not reported to the state agency as required by facility policy. The deficiency resulted from lack of communication and failure to follow reporting procedures for injuries of unknown origin.
A resident with moderate cognitive impairment and no prior mobility issues developed new right hip pain and decreased range of motion, requiring increased assistance with daily care. The CNA notified the LVN, who assessed the resident and informed the physician, but did not escalate the change in condition to the DON or initiate further investigation. The resident was later found to have a right hip fracture after transfer to a hospital, but the injury was not reported to the state agency or investigated as required by facility policy.
A resident with a history of orthopedic aftercare, epilepsy, and bipolar disorder experienced new right hip pain and decreased range of motion, requiring increased assistance with ADLs. The LVN assessed the resident but did not report the change of condition to the DON, as required by facility policy. The resident was later found to have a right hip fracture after being transferred to a hospital, and the incident was classified as an injury of unknown origin due to lack of timely reporting and assessment.
Two residents with psychiatric diagnoses, both requiring supervision while smoking, were left unsupervised on the patio and became involved in an argument that escalated to physical abuse, resulting in injury. One resident had exhibited escalating behaviors throughout the night, including yelling and demanding cigarettes, but staff did not notify a physician or provide additional monitoring. Facility policies requiring supervision and behavioral monitoring were not followed, leading to the incident.
Two residents, both requiring supervision while smoking due to mental health diagnoses and behavioral concerns, were left unsupervised on the patio during nighttime hours. Despite facility policies mandating direct supervision and restricted access to smoking materials, both residents accessed cigarettes and smoked without staff oversight. One resident, exhibiting aggressive behavior, assaulted the other during this unsupervised period, resulting in physical injury. Staff interviews confirmed lapses in monitoring and supervision, directly leading to the incident.
A resident with multiple medical and cognitive conditions was struck on the face by another resident, resulting in a laceration and swelling. After returning from the hospital, staff did not perform or continue neurological checks to monitor for signs of neurological decline, despite acknowledgment from nursing staff and the DON that such monitoring was necessary following the incident.
The QAPI committee did not address or develop corrective plans for identified deficiencies related to abuse and smoking supervision after a facility-reported incident. The DON confirmed these issues were not included in the QAPI agenda, and the ADM stated they would be reviewed in a future meeting. Facility policy requires a systematic approach to performance improvement, but this was not followed, resulting in repeated deficiencies.
During a Covid-19 outbreak, four staff members, including a CNA, housekeeper, LVN, and the Administrator, were observed not wearing masks in various areas of the facility, despite the facility's policy and reminders from leadership. The facility's Covid-19 Mitigation Plan required all staff to wear PPE, including facemasks, when Covid-19 cases were present, but staff non-compliance was observed and acknowledged by leadership. The outbreak involved two residents who tested positive for Covid-19.
The facility failed to cover three outside grey garbage dumpsters, as confirmed by the DON and ADM. The facility's policies require dumpsters to have tightly fitting lids to prevent attracting pests. This deficiency was observed during a survey.
A resident with severe cognitive impairment was assaulted by her roommate, who also had cognitive impairments, in an LTC facility. The assault occurred while the resident was asleep, resulting in a contusion that required hospital evaluation. The facility's failure to monitor and protect residents from harm led to this deficiency.
The facility failed to discard expired food items, including chicken, salads, and vegetables, found in the refrigerator during a survey. Staff interviews confirmed that the food was outdated and should not have been stored, violating the facility's policies. The Dietary Manager and Director of Nursing acknowledged the risks of foodborne illnesses from consuming expired food.
The facility failed to accurately document advance directives for five residents, leading to potential conflicts with their healthcare wishes. Deficiencies included missing signatures and incomplete documentation, as identified through interviews and record reviews. Staff emphasized the importance of accurate documentation to ensure residents' preferences are respected.
The facility failed to accurately document PASARR screenings for five residents, leading to potential inappropriate placements and delays in needed services. Residents with mental illnesses and cognitive impairments did not receive necessary Level II screenings due to unresponsiveness and oversight by staff, despite facility policies requiring such evaluations.
A facility failed to provide adequate range of motion (ROM) care for three residents, leading to deficiencies in their care plans and physician orders. One resident did not receive passive range of motion (PROM) exercises for both arms and ankles, while another did not receive PROM for elbows, wrists, hands, knees, and ankles, and had improperly positioned hand towels. A third resident did not receive PROM for the left hand. Observations and interviews revealed that these omissions were due to documentation errors, nervousness, and forgetfulness.
The facility failed to maintain infection control practices for four residents. A resident's humidifier was not changed weekly, risking bacterial growth. Another resident on Enhanced Barrier Precautions did not receive care with the required PPE. Additionally, two residents did not receive proper hand hygiene precautions before eye drop administration, violating facility policy.
A resident's call light was found inaccessible, wrapped around the bed rails, causing distress and inability to call for assistance. The resident, with multiple health conditions, required extensive assistance. Staff interviews confirmed the expectation for call lights to be within reach, and the facility's policy supported this requirement.
A resident's bed in an LTC facility was found to be malfunctioning, unable to adjust and leaning to one side, posing a safety risk. Despite the resident's moderate cognitive impairment and need for assistance, the issue persisted for three months. Facility staff, including a CNA, LVN, and Maintenance Supervisor, confirmed the malfunction and acknowledged the safety risk, highlighting a failure to adhere to the facility's bed maintenance policy.
A resident with severe cognitive impairment and multiple diagnoses, including COPD and bipolar disorder, did not receive proper fingernail care, resulting in long and dirty nails. Despite the resident's dependency on staff for personal hygiene, the CNA did not clean the nails, citing refusal without documentation. Interviews with staff revealed a lack of adherence to the facility's policy on nail care, which emphasizes the importance of grooming to maintain residents' self-esteem.
A resident with a history of schizophrenia and other conditions was observed with redness and swelling on the right eye and cheek, which was not documented or reported by the CNA or LVN. The facility's policies require immediate reporting and documentation of skin concerns, which was not followed, leading to a failure in providing necessary care and treatment.
The facility's Restorative Nursing Aide (RNA) staff failed to competently perform range of motion (ROM) exercises and apply splints for three residents with limited mobility. Observations revealed incomplete execution of physician-ordered exercises, with RNAs admitting to oversights and nervousness. The facility had not provided recent in-service training on these tasks, potentially impacting residents' ROM and function.
The facility failed to administer medications as per physician orders, affecting several residents. A resident did not receive risperidone as prescribed, and there was an error in administering calcium with vitamin D. Another resident's docusate sodium order lacked clarity, posing risks of improper treatment. Additionally, discrepancies in the Controlled Drug Record for Vimpat and lorazepam were noted, with the LVN failing to document administration immediately, increasing the risk of medication errors and potential misuse.
A facility failed to monitor a resident's behavior while on Risperdal for psychosis, risking unnecessary medication use. The resident, with severe cognitive impairment and auditory hallucinations, was not monitored for medication effectiveness, contrary to the care plan and facility policy. Staff confirmed the lack of monitoring, acknowledging the risk of unnecessary medication.
A medication error rate of 7.14% was observed in an LTC facility when an LVN failed to administer risperidone and incorrectly gave a combination of calcium with vitamin D instead of separate doses. The resident involved had a history of cognitive impairment and multiple medical conditions. The facility's policy emphasizes the importance of following physician orders and verifying medications against the MAR.
The facility failed to properly store and label medications, leading to deficiencies in medication management. Bisacodyl suppositories and brimonidine eye drops were stored incorrectly, and expired medications were not removed from the Central Supply Room. Additionally, several medications in the carts lacked proper labeling, affecting multiple residents and increasing the risk of medication errors.
A facility failed to document complete RNA treatment records for a resident with limited ROM and mobility. The RNA treatment record for October was incomplete for PROM exercises to the right leg, despite physician orders. The resident, with multiple diagnoses, refused PROM for the right leg, which was not documented. The DMR confirmed the record's incompleteness, highlighting the risk of contractures. The DON stressed the need for accurate records to ensure proper care.
The facility failed to create comprehensive care plans for two residents, one with a history of fabricating stories and another with facial redness and swelling. The absence of specific care plans for these issues was acknowledged by staff, highlighting a risk of delayed care and treatment.
The facility failed to record therapy start and end dates on the MDS for three residents, resulting in incomplete data submission. Residents received therapy for various conditions, achieving significant progress, but the MDS lacked necessary documentation. Interviews revealed staff were unaware of the requirement to include these dates.
A resident was not readmitted to the facility after hospitalization despite available beds, due to a misunderstanding of infection control requirements. The resident, who contracted Candida auris at the hospital, was refused readmission based on the facility's belief that no isolation beds were available. However, guidelines indicated that residents with MDROs do not require single-person rooms. This resulted in the resident staying at the hospital for 11 days before being transferred to another facility.
Failure to Notify Physician and Update Care Plan After Resident's Reported Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for one of three sampled residents after the resident reported being struck and expressed fear, indicating a psychosocial change. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported to the ombudsman that an unknown black male struck him in the stomach. The incident was communicated to facility staff, including an LVN, RNS, and the DON, but there was no documentation of physician notification or care plan review and update in response to the reported allegation. Interviews with staff revealed that the LVN did not notify the physician or document the incident, believing it was unnecessary due to the resident's history of making similar statements. The RNS and DON both acknowledged that a report of being struck and expressing fear constitutes a change in condition, including a psychosocial change, and that facility policy requires physician notification, documentation, and care plan review and update. However, these actions were not taken for the resident in question. A review of the resident's psychological consultation indicated ongoing feelings of unsafety and persecution based on race. The facility's policy and procedure on changes in a resident's condition or status requires prompt notification of the resident, attending physician, and representative of changes in medical or mental condition. Despite this, the required notifications and documentation were not completed following the resident's report of being struck and expressing fear.
Failure to Update Care Plan After Resident's Psychosocial Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident following a reported change in condition. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported being struck by an unknown individual and expressed ongoing fear for his safety. Despite this significant psychosocial change, there was no documentation that the resident's care plan was reviewed or updated to address his new needs. Interviews with facility staff, including an LVN, RN Supervisor, and the Director of Nursing, confirmed that they were made aware of the resident's allegation and recognized it as a change in condition requiring care plan review and revision. However, the care plan was not updated after the incident was reported. Staff acknowledged that this omission could result in the resident's needs not being addressed, including unresolved fear and psychosocial distress. A psychological consultation further documented the resident's feelings of being unsafe and persecuted, yet these concerns were not reflected in the care plan. Review of facility policy indicated that care plans should be reviewed and revised for residents experiencing a status change, but this procedure was not followed in this case.
Failure to Protect Resident from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident with a history of schizophrenia and severe cognitive impairment poured water on her face while she was receiving assistance with activities of daily living (ADLs). The affected resident, who was dependent on staff for ADLs and had intact cognition, reported feeling like she was drowning as the water covered her face and entered her mouth and throat. Witnesses, including another resident, described the act as intentional and distressing, and noted that staff were present in the room during previous verbal altercations between the two residents. The certified nursing assistant (CNA) providing care to the affected resident had left the room briefly, during which time the incident occurred. Upon returning, the CNA found the resident crying and soaked, and was informed of the water being poured. The CNA also reported prior incidents of conflict between the two residents, including verbal aggression and disputes over personal belongings. The Director of Nursing (DON) was unaware of the incident at the time of the interview but acknowledged that such an act would be considered abuse according to facility policy, which states that residents must not be subject to abuse by anyone, including other residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents. One resident, who was cognitively intact and dependent on staff for activities of daily living (ADLs), reported to a CNA that another resident, who had severely impaired cognition and a diagnosis of schizophrenia, poured water on her face while she was receiving care. The affected resident described feeling as though she was drowning and was observed crying with her upper body soaking wet. The CNA stated that upon returning to the room, she found the resident in distress and was informed of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse to the DON or ADM, the CNA did not report the allegation to the appropriate personnel. The DON confirmed she was unaware of the incident and had not been informed by the CNA. As a result, the incident was not reported to the California Department of Public Health (CDPH) or the ombudsman, preventing a timely investigation and risking the loss or forgetting of critical information.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a treatment nurse provided wound care to a resident with chronic osteomyelitis and peripheral vascular disease without wearing a gown, despite the resident being on enhanced barrier precautions (EBP) due to an open wound. The nurse was observed wearing gloves only while performing wound care on the resident's left plantar foot, even though an EBP sign was posted outside the resident's room and the physician's order specified the use of EBP for this resident. The nurse later stated she was unaware that a gown was required for wound care under EBP. Interviews with the infection control nurse and the director of nursing confirmed that staff are expected to wear gowns and gloves during high-contact care activities, such as wound care, for residents on EBP. The facility's policy also indicated that personal protective equipment, including gowns, is necessary during high-contact activities involving skin openings requiring dressings. The failure to follow these protocols was directly observed and confirmed through staff interviews and record review.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who experienced a significant change in condition, specifically right hip pain and decreased range of motion, which was later diagnosed as a right hip fracture. The resident, who had moderate cognitive impairment and no prior functional limitations in range of motion, was found by a CNA to be unable to move his right leg and required increased assistance with activities of daily living. The CNA notified the LVN, who assessed the resident but did not observe visible bruising or swelling and administered Tylenol for pain. The LVN did not escalate the change in condition to the Director of Nursing (DON) or recommend further assessment, such as an X-ray, and only informed the resident's physician, who ordered additional pain medication but no diagnostic imaging. The resident was subsequently transferred to a general acute care hospital for an unrelated incident, where a right hip fracture was discovered several days later, necessitating surgery. Upon the resident's readmission to the facility, the DON became aware of the hip fracture and, upon review, determined that the injury was of unknown origin, as neither staff nor the resident could explain how it occurred. The facility's policy required that injuries of unknown origin be reported to the state agency immediately, but this was not done because the DON was not informed of the initial change in condition or the injury at the time it occurred. Interviews with staff revealed that the LVN did not consider the resident's complaints and decreased mobility to be significant enough to warrant supervisor notification or further investigation. The DON confirmed that, according to facility policy, the injury should have been reported to the state agency as soon as it was discovered, but this did not happen due to a lack of communication and awareness among staff. The failure to report the injury of unknown origin constituted a deficiency in the facility's abuse, neglect, and exploitation reporting procedures.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have a right hip fracture. The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was noted to have moderate cognitive impairment but no prior functional limitations in range of motion. On the morning in question, the resident complained of right hip pain radiating to the knee and was unable to perform activities of daily living without assistance, which was a change from his baseline. The certified nursing assistant (CNA) observed that the resident could not move his right leg and required two people to assist with care, prompting the CNA to notify the charge nurse (LVN). The LVN assessed the resident, noted the new pain and decreased range of motion, but did not observe any bruising or swelling. The LVN administered Tylenol and informed the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. The LVN did not report the change in condition or the new symptoms to the director of nursing (DON), as required by facility protocol. The resident was subsequently transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later. Upon the resident's return to the facility, the DON became aware of the hip fracture and recognized it as an injury of unknown origin. The DON confirmed that the incident was not reported to the state agency as required by both facility policy and regulation, and no investigation was conducted into the cause of the injury. Facility policies reviewed indicated that all injuries of unknown origin must be reported immediately and thoroughly investigated, but these steps were not followed in this case.
Failure to Report Change of Condition Results in Delayed Identification of Hip Fracture
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to demonstrate competency in recognizing and reporting a change of condition (COC) for a resident who developed new right hip pain and decreased range of motion (ROM). The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was previously able to ambulate and perform activities of daily living (ADLs) independently. On the morning in question, the resident was unable to move his right leg, required increased assistance from a certified nursing assistant (CNA), and reported significant pain. The CNA notified the LVN, who assessed the resident but did not observe bruising or swelling and attributed the pain to a possible minor cause, administering Tylenol and informing the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. Despite the resident's new symptoms and decreased ROM, the LVN did not report the COC to the Director of Nursing (DON), who was the supervisor on duty. The facility's policy and the LVN's job description required that such incidents or unusual occurrences be reported to supervisory staff for further assessment and investigation. The DON later stated that had she been informed, she would have conducted a comprehensive assessment and recommended further diagnostic evaluation, such as an X-ray. The lack of communication prevented timely intervention and a thorough investigation into the cause of the resident's symptoms. Subsequently, the resident was transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later, necessitating surgery. Upon readmission to the facility, the DON became aware of the fracture and reviewed the records, confirming that the LVN had not reported the initial COC. The incident was classified as an injury of unknown origin, as the cause was unwitnessed and unexplained, and the resident was unable to provide an account of how the injury occurred.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision and Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse when two residents, both with significant psychiatric diagnoses, were left unsupervised and engaged in an altercation on the facility patio. Both residents had documented requirements for supervision while smoking, as indicated in their Smoking Assessment Forms, and were supposed to be monitored at all times during smoking activities. Despite these requirements, the residents were able to access the patio unsupervised during the early morning hours, outside of the scheduled smoking times, and became involved in an argument that escalated to one resident physically assaulting the other, resulting in a cut and swelling to the victim's lip. Prior to the incident, one of the residents exhibited escalating behaviors, including yelling, demanding cigarettes, pacing the hallways, and expressing paranoid thoughts about being given methamphetamine. These behaviors were observed by nursing staff throughout the night, but the resident's physician was not notified, and no additional monitoring or intervention was implemented. The assigned CNA was unaware of the residents' whereabouts during her shift and did not recall the altercation, despite being responsible for their care. Staff interviews confirmed that residents were not supposed to smoke at night and that supervision protocols were not followed. Facility policies required staff to supervise residents during smoking, maintain control of smoking materials, and monitor residents with behavioral issues. However, these policies were not adhered to, as evidenced by staff statements and documentation. The lack of supervision and failure to address escalating behaviors directly led to the unsupervised altercation and subsequent injury. The incident was deemed avoidable by facility leadership, who acknowledged that proper supervision and behavioral management were not provided.
Failure to Supervise Residents During Smoking Results in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that two residents, both assessed as requiring supervision while smoking, were adequately monitored while smoking on the patio during the early morning hours. Both residents had documented mental health diagnoses, with one having moderately impaired cognitive skills and fluctuating decision-making capacity, and the other with intact cognition but a history of aggressive behavior. Facility records, including Smoking Assessment Forms and care plans, specified that both residents must be supervised at all times while smoking and required the use of protective non-flammable aprons. Despite these requirements, both residents were left unsupervised on the patio, outside of the scheduled smoking times, and were able to access cigarettes without staff oversight. On the night in question, one resident exhibited escalating aggressive behavior, repeatedly requesting cigarettes from staff, pacing the hallways, and making threats. Staff interviews confirmed that there were no scheduled smoking breaks during the night shift, and that residents were not supposed to have cigarettes or lighters in their possession. However, both residents managed to access the patio and smoke unsupervised. During this time, an altercation occurred between the two, resulting in one resident being punched multiple times in the face and sustaining a cut and swelling on the lip. The incident was reported by the injured resident upon re-entering the facility, and staff observed visible injuries. Interviews with facility staff, including CNAs, LVNs, the Director of Staff Development, and the DON, revealed a lack of awareness and supervision regarding the residents' whereabouts and activities during the night. Staff acknowledged that supervision was required for both residents while smoking, and that the incident could have been prevented with proper monitoring. Facility policies reviewed also confirmed the requirement for direct supervision of residents with restricted smoking privileges. The failure to supervise these residents while smoking and to monitor aggressive behavior directly led to the altercation and resulting injury.
Failure to Monitor Neurological Status After Resident Assault
Penalty
Summary
The facility failed to monitor a resident for signs and symptoms of neurological decline after the resident was struck on the face by another resident. The affected resident had a history of human immunodeficiency virus disease, morbid obesity, schizophrenia, and bilateral knee contractures, and was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills. After the incident, the resident was found with a five-centimeter laceration above the left eyebrow, minimal bleeding, and swelling. The resident was transferred to a general acute care hospital and later returned to the facility the same day. Despite the incident and the resident's return from the hospital, staff did not continue neurological checks or monitor the resident's neurological status. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments were not performed after the resident's return, even though such monitoring was recognized as necessary due to the potential for serious brain injury following facial trauma. The lack of post-incident neurological monitoring constituted the identified deficiency.
QAPI Committee Failed to Address Abuse and Supervision Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to address, maintain, and develop an effective plan to correct identified problems related to abuse and accident following a facility-reported incident. Despite the identification of deficiencies concerning abuse and smoking supervision during an investigation, these issues were not included in the QAPI/QA Committee agenda. The Director of Nursing (DON) acknowledged that the problems were not addressed in the QAPI meeting and stated that the facility holds meetings every three months, with the last meeting not covering the identified concerns. The DON also recognized the importance of QAPI in preventing reoccurrences of abuse and ensuring a safe environment for residents, as well as the need for adequate staff supervision. The Administrator (ADM) confirmed that issues of abuse, smoking, and supervision were not reviewed in the previous QAPI meeting but indicated plans to include them in the next meeting. A review of the facility's policy and procedure for the QAPI Change Process showed that the facility is expected to use a systematic approach to performance improvement, including developing corrective action plans and tracking performance after identifying root causes. However, the committee did not follow these procedures after the deficiencies were identified, resulting in repeated deficient practices related to abuse and supervision.
Failure to Enforce Mask Use During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff consistently wore masks during a Covid-19 outbreak, as required by its own Covid-19 Mitigation Plan and the most recent California Department of Public Health PPE guidance. Observations on multiple occasions revealed that four out of ten sampled staff members, including a Certified Nursing Assistant (CNA) responsible for Covid-19 screening, a housekeeper, a Licensed Vocational Nurse (LVN), and the Administrator, were not wearing masks in various areas of the facility. The CNA stated she did not believe mask-wearing was mandatory during the outbreak, while the LVN admitted to not wearing a mask due to discomfort from heat. The Administrator acknowledged forgetting to wear a mask in the nursing station, and the housekeeper was observed vacuuming without a mask in the lobby. Interviews with facility leadership, including the Infection Preventionist Nurse (IPN), Housekeeping Supervisor (HKS), Director of Nursing (DON), and Administrator, confirmed awareness of the Covid-19 outbreak and the expectation that all staff should wear masks. The IPN reported that reminders were given to staff during morning huddles, but some staff may have perceived Covid-19 as a normal illness and did not adhere to mask protocols. The DON and HKS both stated that mask-wearing was necessary to prevent the spread of infection, especially given the vulnerability of the resident population. A review of the facility's Covid-19 Mitigation Plan Manual indicated that all staff should wear recommended PPE, including facemasks, when Covid-19 cases are identified in the facility. Despite this policy, staff non-compliance with mask-wearing was observed and acknowledged by both staff and leadership during interviews. The failure to follow established infection control practices occurred while two residents were confirmed positive for Covid-19, and the outbreak had been ongoing since at least 5/28/2025.
Uncovered Garbage Dumpsters
Penalty
Summary
The facility failed to ensure that three outside grey garbage dumpsters were covered, as observed during a survey. During an observation and interview with the Director of Nursing (DON), it was confirmed that the dumpsters were uncovered and without their lids. The DON acknowledged that the lids should be on when not in use to prevent attracting unwanted animals and pests. Additionally, the Administrator (ADM) confirmed that the facility staff are aware of the requirement to keep the dumpsters covered. A review of the facility's undated policies and procedures indicated that garbage and refuse containers should be covered when not in use, and dumpsters should have tightly fitting lids to prevent the accumulation of garbage outside the dumpsters.
Resident Assaulted by Roommate Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from physical assault by another resident, resulting in a deficiency. The incident involved Resident 1, who was assaulted by her roommate, Resident 2, while under the facility's care. Resident 1, who had severe cognitive impairment due to unspecified dementia and schizophrenia, was asleep in her bed when Resident 2 attacked her unprovoked, hitting her with a fist and then a shoe. This assault led to Resident 1 sustaining a contusion on her left upper and lower eyelid, necessitating a transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 2, who also had cognitive impairments due to unspecified dementia, anxiety disorder, and paranoid schizophrenia, was observed by a Certified Nursing Assistant (CNA) hitting Resident 1. The CNA witnessed the assault and reported it to the Director of Nursing (DON), who confirmed the injury upon entering the room. The facility's policy and procedure on abuse, neglect, and exploitation clearly state that residents must not be subject to abuse by anyone, including other residents, yet this policy was not effectively implemented to prevent the incident. The facility's failure to monitor and ensure the safety of Resident 1 led to the assault, as acknowledged by the Administrator, who stated that it was impossible to monitor all corners of the facility. This incident highlights a significant lapse in the facility's duty to protect its residents from harm, as outlined in their own policies. The deficiency was identified through interviews and record reviews conducted by surveyors, who documented the events leading to the assault and the subsequent medical evaluation and treatment of Resident 1.
Failure to Discard Expired Food in Facility
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator was not outdated, as observed during a survey. Various food items, including chicken, seasoned hash brown potatoes, potato salad, macaroni salad, tomatoes, bread, lettuce, and freezer-burned meat, were found to be stored past their expiration dates. These observations were confirmed during interviews with the Dietary Manager (DM) and other staff members, who acknowledged that the food was outdated and should not have been stored in the refrigerator. The facility's policy and procedures for food storage, which dictate that no food should be kept beyond its expiration date and that freezer-burned food must be discarded, were not followed. Interviews with the DM and the Director of Nursing (DON) highlighted the potential risks associated with consuming expired food, such as foodborne illnesses and compromised food quality. The DM explained that food is labeled with the date it is opened, and staff are expected to follow expiration dates to prevent foodborne illnesses. The DON emphasized that consuming expired food could lead to food poisoning and stomach sickness among residents. The facility's failure to adhere to its own policies and procedures for food storage and handling was evident in the observations and interviews conducted during the survey.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately document advance directives for five out of seven residents, which could potentially lead to conflicts with the residents' healthcare wishes. The deficiencies were identified through interviews and record reviews, revealing that the advance directive acknowledgments were either incomplete or lacked necessary signatures. For instance, Resident 5's advance directive was signed by the physician two years after the interdisciplinary team completed it, rendering it invalid. Similarly, Resident 21's advance directive lacked a decision on whether to formulate an advance directive and was missing a physician's signature. Resident 36's advance directive acknowledgment was incomplete, lacking a witnessed signature, a physician's dated signature, and documentation of the resident's mental condition and prognosis. The document also failed to indicate whether the resident's mental condition was consistent with the advance directive. Resident 65's acknowledgment was missing a physician's signature and did not document discussions about the resident's diagnoses, prognosis, and mental condition. Additionally, Resident 68's acknowledgment did not indicate a choice regarding the formulation of an advance directive and lacked a physician's signature and acknowledgment of a durable power of attorney. Interviews with facility staff, including the Social Services Director and the Director of Nursing, highlighted the importance of accurately completing advance directives to ensure residents' preferences are respected. The facility's policy and procedure on advance directives require the Director of Nursing or designee to notify the attending physician for appropriate documentation in the resident's medical record. However, the deficiencies in documentation and oversight could lead to delays in care or treatment, as noted by the Registered Nurse Supervisor.
Inaccurate PASARR Documentation and Screening Deficiencies
Penalty
Summary
The facility failed to ensure accurate documentation of the Preadmission Screening and Resident Review (PASARR) for five residents, leading to potential inappropriate placement and delay of needed services. Resident 19 was admitted with schizophrenia and anemia, and although the Minimum Data Set (MDS) indicated cognitive intactness and delusions, the PASARR Level I screening was negative despite the presence of a mental illness and psychotropic medication prescription. Resident 21, with schizophrenia and bipolar disorder, had a positive Level I screening requiring a Level II screening, which was not completed due to unresponsiveness from facility staff. Resident 45, diagnosed with schizophrenia, bipolar disorder, and major depressive disorder, also had a positive Level I screening requiring a Level II screening, which was not completed. Resident 65, with dementia and schizophrenia, required a Level II screening due to a positive Level I screening, but this was missed by the Infection Preventionist Nurse (IPN). Resident 84, with hyperlipidemia and type 2 diabetes, was taking antipsychotic medication, yet the PASARR Level I screening inaccurately indicated no serious mental illness or psychotropic medication use. Interviews with the IPN and Director of Nursing (DON) highlighted the importance of accurate PASARR documentation and completion of Level II screenings when indicated, to ensure residents receive appropriate care. The facility's policy stated that individuals with mental disorders or intellectual disabilities should only be admitted if deemed appropriate by the state authority, and any new or possible serious mental disorders should prompt a Level II review. However, the facility failed to adhere to these guidelines, resulting in the deficiencies noted.
Failure to Provide Adequate Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited range of motion (ROM) and mobility, as observed through various deficiencies in their care plans and physician orders. Resident 5 did not receive passive range of motion (PROM) exercises for both arms from December 1 to December 19, 2024, despite physician orders and care plans indicating the need for such exercises five times per week. Additionally, PROM was not provided to Resident 5's ankles on December 19, 2024, as required. Observations revealed that Resident 5's joints were in a flexed position, and the resident was unable to fully extend both elbows or straighten both legs. Interviews with staff confirmed the omission of PROM exercises due to a transition to a new electronic documentation system. Resident 20 also did not receive the necessary PROM exercises for elbows, wrists, hands, knees, and ankles, as outlined in the care plan and physician orders. The resident's hand towels were not positioned correctly, and PROM was not performed prior to applying hand rolls and ankle splints. Observations showed that Resident 20's joints were in a flexed position, and the resident had visible tremors and unclear speech. Interviews with staff indicated that PROM exercises were not performed due to nervousness and oversight, and the hand towels did not stay in place due to the positioning of the resident's fingers. Resident 68 did not receive PROM exercises for the left hand, despite care plans and physician orders specifying the need for such exercises to maintain ROM and prevent contractures. Observations showed that Resident 68 had limited ROM in the left shoulder and elbow, and the resident was able to perform active range of motion (AROM) exercises with the right arm. Interviews with staff confirmed the omission of PROM exercises for the left hand, which was attributed to forgetfulness. The facility's policy and procedure for preventing decline in ROM emphasized the importance of moving each joint through its ROM, which was not consistently implemented for these residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices for four residents, leading to potential risks of infection. For Resident 73, the humidifier was not changed weekly as required, which could lead to bacterial growth and potential infection. The humidifier was dated 12/8/2024, and staff interviews confirmed the importance of changing it weekly to prevent infections. The facility's policy indicated that respiratory therapy equipment should be changed every 72 hours or as per the manufacturer's recommendation, which was not adhered to in this case. Resident 20, who was on Enhanced Barrier Precautions (EBP) due to having a G-tube, did not receive care with the appropriate Personal Protective Equipment (PPE). During a session of passive range of motion exercises and application of splints, the staff member did not wear a protective gown, which is required for high-contact activities under EBP. Interviews with staff confirmed that a gown should be worn during such activities to prevent infections, especially for residents with indwelling devices like G-tubes. For Residents 27 and 54, the facility failed to implement proper hand hygiene precautions before administering eye drops. The Licensed Vocational Nurse (LVN) did not wash hands or change gloves after touching various surfaces and before administering eye drops, which is against the facility's policy. The policy requires hand hygiene before and after medication administration to prevent contamination and ensure resident safety. Interviews with the LVN and the Director of Nursing confirmed the importance of hand hygiene in preventing infections during medication administration.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. Resident 42, who was part of a random sample of 20 residents, was observed to have their call light wrapped around the back of the bed rails, making it inaccessible. This observation was made during an interview with the resident, who expressed distress and difficulty in reaching the call light. The resident had been admitted with multiple diagnoses, including hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The Minimum Data Set (MDS) indicated that the resident had intact cognitive skills but required extensive assistance for various daily activities. Interviews with facility staff, including a Certified Nurse Assistant (CNA), a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed the expectation that call lights should always be within reach of residents. The CNA admitted to forgetting to place the call light within reach after attending to the resident. Both the LVN and DSD emphasized the importance of having the call light accessible to ensure residents can call for assistance, especially in emergencies. The facility's policy on answering call lights also stipulated that call lights should be within easy reach when residents are in bed or confined to a chair.
Resident's Bed Malfunction Poses Safety Risk
Penalty
Summary
The facility failed to ensure that a resident's bed was not broken, which had the potential to put the resident at risk for accidents while in bed. The resident, who was admitted with diagnoses including hypertensive heart, psychosis, glaucoma, and muscle weakness, was found to have a bed that did not function properly. The bed was unable to go up and down and was leaning to the left side. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported the issue to nurses and maintenance staff multiple times over a period of three months. Observations and interviews with facility staff, including a CNA, LVN, and the Maintenance Supervisor, confirmed the bed's malfunction and the potential safety risk it posed. The Maintenance Supervisor acknowledged the entry in the maintenance report log indicating the bed's malfunction and admitted that residents should not have broken beds due to safety concerns. The facility's policy required regular inspections and maintenance of bed equipment, but this was not adhered to in this case, leading to the deficiency.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for Resident 29, who was observed to have long and dirty fingernails on multiple occasions. Resident 29, who has severe cognitive impairment and requires extensive assistance with activities of daily living (ADLs), was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and bipolar disorder. Despite the resident's dependency on staff for personal hygiene, the Certified Nursing Assistant (CNA) did not clean the resident's nails, citing the resident's refusal, which was not documented or reported to the charge nurse as required. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that there was a lack of adherence to the facility's policy and procedure regarding nail care. The LVN acknowledged that treatment nurses are trained to assist with trimming residents' fingernails, but this was not done for Resident 29. The DON confirmed that CNAs are responsible for cleaning and cutting nails during ADLs and emphasized the importance of documenting care refusals. The facility's policy on quality of care and dignity indicates that residents should be groomed according to their preferences to maintain self-esteem and self-worth.
Failure to Monitor and Treat Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident, who had redness on the right side of the cheek, was monitored and received appropriate treatment. The resident, who had a history of schizophrenia, major depressive disorder, gastro-esophageal reflux disease, and hypertensive heart disease, was observed with redness and swelling to the right eye and a small bump with redness below the right eye. Despite the resident reporting a bug bite to the nursing staff, the Certified Nursing Assistant (CNA) who noticed the redness did not document or report it. Similarly, the Licensed Vocational Nurse (LVN) observed the redness but did not complete a change of condition report, notify the doctor, or update the care plan, assuming the redness was caused by the resident's glasses. The Registered Nurse Supervisor and the Director of Nursing confirmed that there was no documentation of a skin inspection, assessment, care plan, or change of condition for the resident's redness. The facility's policy requires nursing assistants to report any skin concerns immediately and for licensed nurses to document changes in condition and notify the doctor. The lack of documentation and communication regarding the resident's skin condition represents a failure to provide necessary care and treatment, as outlined in the facility's policies and procedures.
Inadequate Competency in Restorative Nursing Aides
Penalty
Summary
The facility failed to ensure that its Restorative Nursing Aide (RNA) staff were competent in providing range of motion (ROM) exercises and applying splints to residents with limited mobility. This deficiency was observed in three residents, each with specific physician orders and care plans that were not fully adhered to by the RNA staff. Resident 5, diagnosed with muscle wasting and dementia, was supposed to receive passive range of motion (PROM) exercises to both legs, including the ankles, followed by the application of knee splints. However, during an observation, the RNA staff failed to perform PROM on the ankles, which was acknowledged by the RNA as an oversight. Resident 20, with diagnoses including epilepsy and Alzheimer's disease, had physician orders for PROM exercises to both arms and legs, along with the application of hand rolls and ankle splints. During an observation, the RNA staff did not perform PROM on several joints, including elbows, wrists, hands, knees, and ankles, before applying the splints and hand rolls. The RNA admitted to feeling nervous, which contributed to the incomplete execution of the prescribed exercises. Resident 68, who had hemiplegia and hemiparesis following a cerebral infarction, was to receive active range of motion (AROM) exercises on the right arm and PROM on the left arm. The RNA staff demonstrated AROM exercises incorrectly on the left side and failed to perform PROM on the left hand. Interviews with the Director of Rehabilitation (DOR) and a Physical Therapist revealed that the RNA staff had not received recent in-service training on ROM exercises and splint application, with the last training sessions occurring several years prior. The Director of Nursing (DON) acknowledged that the lack of competency in RNA staff could lead to a decline in residents' ROM and function.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and professional standards of practice, affecting several residents. For Resident 54, the facility did not administer risperidone as prescribed, which is crucial for managing psychosis. Additionally, there was an error in administering a combination of calcium with vitamin D instead of separate doses, leading to potential medication errors. The Licensed Vocational Nurse (LVN) involved acknowledged the mistake and the importance of following physician orders to prevent negative health impacts. Resident 440's case involved a lack of clarity in the physician's order for docusate sodium, a medication used for constipation. The order did not specify the dose and frequency, which posed a risk of overtreatment or undertreatment, potentially leading to diarrhea and dehydration. The LVN recognized the need for clarification with the physician to ensure safe administration. The Director of Nursing (DON) confirmed that the staff should have sought clarification to prevent such risks. For Residents 23 and 13, there were discrepancies in the Controlled Drug Record (CDR) for Vimpat and lorazepam, both controlled substances. The LVN failed to document the administration of these medications immediately, leading to inconsistencies in the medication count. This oversight increased the risk of medication errors and potential misuse or diversion of controlled substances. The DON emphasized the importance of immediate documentation to maintain accurate tracking of controlled substances.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the behaviors of a resident who was prescribed psychotropic medication, specifically Risperdal, for psychosis manifested by auditory hallucinations. The resident, who was admitted with severe cognitive impairment and a diagnosis of psychosis, was dependent on activities of daily living and lacked the capacity to make decisions. Despite the care plan indicating the need to monitor and document the effectiveness and side effects of Risperdal, there was no evidence of behavior monitoring related to the resident's auditory hallucinations. Interviews with facility staff, including an LVN, RN supervisor, and the Director of Nursing, confirmed the absence of behavior monitoring for the resident's use of Risperdal. The staff acknowledged that without monitoring, it was impossible to determine the medication's effectiveness, potentially leading to unnecessary medication use. The facility's policy required ongoing evaluation of the effects of psychotropic medications on residents, but this was not adhered to in the case of the resident in question.
Medication Error Rate Exceeds 5% Due to Administration Mistakes
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass for a resident, resulting in a medication error rate of 7.14%. The error involved the failure to administer risperidone, a medication prescribed for psychosis, and the incorrect administration of a combination of calcium with vitamin D instead of separate doses as per the physician's orders. This error was observed during a medication pass conducted by an LVN. The resident involved had a history of fluctuating cognitive capacity and required assistance with daily activities. The resident's medical conditions included hypertensive heart disease, Type 2 Diabetes Mellitus, vitamin D deficiency, anxiety disorder, and bipolar disorder. The resident's medication orders included risperidone, calcium, and vitamin D, among others, which were not administered correctly during the observed medication pass. The LVN acknowledged the mistake, stating that she did not administer risperidone and incorrectly gave a combination of calcium with vitamin D. The Director of Nursing confirmed that the nurse should have verified the medication orders to prevent such errors. The facility's policy on medication administration emphasizes the importance of following physician orders and verifying medications against the Medication Administration Record (MAR).
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. During an inspection, it was observed that bisacodyl suppositories were stored in a refrigerator at 42°F, contrary to the manufacturer's requirement of room temperature storage. Additionally, brimonidine tartrate ophthalmic solution was improperly stored in the refrigerator, and an opened Lantus Solostar pen was not discarded after 28 days, as required. These storage issues affected at least two residents, potentially compromising the safety and effectiveness of the medications. Further inspection revealed expired medications in the Central Supply Room, including zinc sulfate, vitamin D3, and hydrogen peroxide. These products were not removed despite being past their expiration dates, posing a risk to residents if used. The facility's failure to discard these expired items indicates a lack of adherence to proper medication management protocols. Additional deficiencies were found in the medication carts, where several medications, including Fiasp, Novolog, and latanoprost eye drops, were either expired or lacked proper labeling with open dates. This oversight affected multiple residents and increased the risk of medication errors. The facility's policies on medication storage and labeling were not followed, as evidenced by the presence of expired and improperly stored medications, which could lead to adverse health outcomes for residents.
Incomplete RNA Treatment Records for Resident's PROM Exercises
Penalty
Summary
The facility failed to ensure complete documentation of Restorative Nursing Aide (RNA) treatment records for a resident with limited range of motion and mobility. Specifically, the RNA treatment record for October 2024 was incomplete for the provision of passive range of motion (PROM) exercises to the resident's right leg, despite physician orders indicating that PROM should be provided to both legs five times per week. The RNA treatment record only included initials for PROM to the left leg, leaving the right leg section blank. The resident, admitted in August 2024, had diagnoses including dementia, bipolar disorder, anxiety disorder, and rhabdomyolysis. During an observation in December 2024, the resident refused PROM exercises for the right leg, which the RNA did not document for the entire month of October. The Director of Medical Records confirmed the incompleteness of the record, acknowledging the potential risk of contractures due to the lack of documented care. The Director of Nursing emphasized the importance of accurate medical records to ensure all treatments and care are provided and documented.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to potential delays in care and treatment. For one resident, who was admitted with diagnoses including bipolar disorder and major depressive disorder, the care plan did not address the resident's behavior of fabricating stories. Despite being moderately cognitively impaired and requiring substantial assistance with personal care, the care plan only focused on minimizing episodes of irritability related to anxiety. Both a Licensed Vocational Nurse and the Director of Nursing acknowledged the absence of a care plan addressing the resident's fabrication of stories, which is crucial for staff awareness and management of the resident's behavior. Another resident, admitted with schizophrenia, major depressive disorder, and hypertensive heart disease, exhibited redness and swelling on the right side of the face, including a small bump under the right eye. Despite these observations, there was no care plan documented to address these symptoms. A Licensed Vocational Nurse confirmed the lack of a care plan and expressed concern about the potential for infection, neglect, or hospitalization due to the absence of documented interventions. The Director of Nursing stated that licensed nurses are responsible for developing and implementing care plans to monitor and respond to changes in residents' conditions.
Incomplete MDS Documentation for Therapy Services
Penalty
Summary
The facility failed to accurately record the start and end dates of therapy services on the Minimum Data Set (MDS) for three residents, resulting in incomplete information being submitted to the Federal database. Resident 14, who was admitted with multiple diagnoses including type 2 diabetes mellitus and major depressive disorder, received occupational and physical therapy services. However, the MDS did not reflect the therapy start and end dates, despite the resident having completed therapy and achieved the highest level of functional independence. Similarly, Resident 21, admitted with conditions such as bipolar disorder and epilepsy, underwent occupational and physical therapy. The therapy aimed to improve activity tolerance and safety awareness, among other goals. Despite the completion of therapy and the resident reaching the highest practical level, the MDS failed to include the necessary therapy dates, leading to an incomplete assessment. Resident 26, who had contractures and other medical conditions, also received therapy services to enhance mobility and independence. The therapy was completed, and the resident achieved maximum potential, yet the MDS did not document the therapy dates. Interviews with the Director of Rehabilitation and the MDS Coordinator revealed a lack of awareness regarding the requirement to record these dates in the MDS, contributing to the deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite available beds, due to a misunderstanding of infection control requirements. The resident, who had been transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of abnormal lab results, was stabilized and deemed appropriate for transfer back to the facility. However, the facility refused readmission, citing a lack of available isolation beds due to the resident contracting Candida auris, a highly contagious yeast, at the hospital. This decision was made despite the facility's daily census indicating available male beds during the period in question. The facility's refusal to readmit the resident was based on the belief that they could not accommodate the resident's infection control needs. However, an All Facility's Letter indicated that residents with multidrug-resistant organisms (MDROs) do not require single-person rooms and can be managed with Enhanced Barrier Precautions. The facility's policy stated that residents should be readmitted upon the first availability of a bed, which was not adhered to in this case. Consequently, the resident remained at the hospital for 11 days before being transferred to another skilled nursing facility, leading to potential risks of confusion and disorientation due to displacement.
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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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