Palm Springs Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Springs, California.
- Location
- 277 S Sunrise Way, Palm Springs, California 92262
- CMS Provider Number
- 056229
- Inspections on file
- 42
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Palm Springs Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that LAL mattress pumps for four cognitively impaired residents with orders for LAL therapy were not set according to their weight-based indicators, despite yellow arrows placed on the pumps to show correct settings. Observations showed multiple pumps set to much higher weight or “Firm/Max” settings than indicated, resulting in overinflated surfaces. Interviews with an RN, the SAC, an LVN, and the DON confirmed that staff understood LAL pumps must be set by weight and checked at shift start and after care, yet the assigned LVN acknowledged not re-checking one resident’s pump after wound treatment and likely not checking another resident’s pump that day.
A resident with severe cognitive impairment and no decision-making capacity experienced an unwitnessed fall with injury. Facility records, including the SBAR, risk meeting notes, and progress notes, showed no documentation that the resident’s representative was notified, despite facility policy requiring notification of the representative for changes in condition and accidents. The Administrator, SAC, and DON all confirmed that the representative should have been notified at the time of the change in condition and that such notification should have been documented, but it was not.
Two residents with significant medical needs did not have siderails implemented or maintained according to their evaluations and physician orders. In one case, a resident with a history of seizures and ventilator dependence experienced a fall from bed after the siderail order was discontinued and not renewed, despite an evaluation indicating the need for siderails. In another case, a resident's siderail evaluation indicated the need for siderails, but there was a delay in obtaining the necessary physician order. Staff interviews confirmed that facility policy and expectations were not followed in both instances.
The facility did not ensure accurate documentation of controlled medication administration for two residents. In both cases, narcotic pain medications were removed from the medication cart and recorded on the narcotic sheet, but the administration was not documented on the MAR as required by facility policy. Staff interviews confirmed that the expected practice was not followed, resulting in incomplete medication records.
A resident with a history of respiratory failure and tracheostomy tested positive for CRPA, but staff failed to notify the IP or implement contact precautions as required by facility policy. The resident was not placed on appropriate isolation until nearly a month after the positive culture result, despite clear guidelines for immediate action.
The facility failed to service ventilators for eight residents by the due dates, as observed during an unannounced visit. The respiratory therapist confirmed the overdue maintenance and stated he was instructed to focus on blower hours instead. The administrator was unaware of the issue, and the residents involved had conditions requiring ventilator dependence.
The facility failed to follow infection control practices for respiratory equipment, affecting 12 residents. Equipment such as ventilator circuits, BVFs, and oxygen tubing were not changed or dated as per the facility's policy. Observations showed equipment was either undated or overdue for replacement. Staff interviews confirmed that night shift RTs were responsible for changing and dating equipment, but this was not consistently done, leading to deficiencies in infection control.
The facility failed to complete quarterly MDS assessments within the required timeframe for six residents. An interview and record review revealed that the assessments were overdue, with the last assessments conducted on August 4, 2024, and not completed by the November 4, 2024 deadline. The DON confirmed the oversight, which could impact the residents' quality of care and staff awareness of care needs.
The facility failed to ensure proper accountability and administration of controlled medications for several residents. Discrepancies were found between the Controlled Drug Records and Medication Administration Records, with doses signed out but not documented. Additionally, a resident received pain medication not indicated in the physician's order, highlighting a failure to adhere to prescribed orders. These issues were confirmed by the DON and Consultant Pharmacist, indicating deficiencies in pharmaceutical services.
The facility failed to maintain safe food storage and sanitation practices, as observed during a survey. A half-gallon carton of Mocha Mix and a Ziploc bag of shredded carrots lacked use-by-date labels, contrary to facility policy. Additionally, a sherbet container and black residue were found on the floor of the walk-in freezer, indicating inadequate cleaning. The Food Service Assistant and Director acknowledged these lapses in compliance with established procedures.
A facility failed to timely identify and implement trauma-informed care for a resident with PTSD. The resident, with a history of trauma and substance dependence, expressed sadness and a desire to discuss his PTSD. Despite being cognitively intact, there was no evidence that his psychosocial history and psychologist's evaluation were discussed by the IDT, nor was a trauma-informed care plan developed. The Social Service Director admitted to not discussing the psychologist's findings with the IDT, contrary to the facility's policy on trauma-informed care.
A resident received hydrocodone with acetaminophen (Norco) for pain without documented pain assessments before and after administration, as required by the facility's policy. Interviews with an LVN and the DON confirmed the necessity of documenting pain scores to evaluate medication effectiveness. The absence of documentation potentially led to unnecessary or ineffective pain management.
The facility failed to implement proper infection control practices, as a CNA did not wear PPE while caring for a resident on Enhanced Barrier Precautions (EBP), and two residents with indwelling medical devices were not placed on EBP. Staff interviews revealed a lack of awareness and implementation of EBP, despite facility policies requiring PPE use for residents with devices like urinary catheters and gastrostomy tubes.
A resident's call light was not within reach, as observed during an interview. The CNA and LVN confirmed the call light should be accessible to prevent falls and ensure assistance. The resident had a pelvic fracture and osteoporosis, requiring easy access to help.
A resident experienced an unwitnessed fall, and the facility failed to conduct a timely assessment or notify the physician. Despite CNAs reporting the incident to the LVN Charge Nurse, no immediate action was taken, and the incident was not documented in the medical record. The facility's policy requires notification and documentation of such events, which was not followed.
A resident with allergies to peanuts and tomatoes was given a tuna sandwich containing tomatoes. Despite informing the nursing staff and having established procedures to check diet cards for allergies, the resident received a meal with an allergen. This indicates a lapse in the facility's process for accommodating food allergies.
Improper Weight-Based Settings of Low Air Loss Mattresses
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper use and settings of low air loss (LAL) mattresses for four of six residents reviewed, despite physician orders and facility policy requiring licensed nurses to monitor function, proper setup, and placement. LAL mattresses in the subacute unit were equipped with pumps whose air pressure is set according to resident weight, with yellow arrows placed on each pump by the Subacute Unit Coordinator (SAC) to indicate the correct setting. The facility’s policy on low-air-loss therapy beds states that these beds inflate to specific pressures based on the height and weight of the patient. Surveyors observed multiple instances where the LAL pump settings did not match the indicated weight-based settings. For one resident weighing 117 lbs, the yellow arrow on the pump was placed between 80 and 160 lbs, but the dial was set at 400 lbs until RN 1 adjusted it to align with the arrow. For a second resident weighing 144 lbs, the yellow arrow was between 100 and 150 lbs, but the dial was set at 350 lbs on the “Firm” setting, which the SAC confirmed was incorrect. For a third resident weighing 150 lbs, the yellow arrow was between 80 and 160 lbs, but the dial was set at 400 lbs on the “Max” setting, which the SAC also verified was not correct. For a fourth resident weighing 183 lbs, the yellow arrow was at 200 lbs, but the pump was set at 285 lbs, which LVN 1 acknowledged was incorrect and resulted in an overinflated, hard surface. Interviews confirmed that staff were aware of the requirement to set LAL pumps according to resident weight and to verify settings. RN 1 and the SAC explained that the yellow arrows were placed to guide staff to the correct setting based on weight, and that proper settings help relieve pressure on the skin and minimize the risk of pressure ulcer development. The SAC stated it was her expectation that the assigned LVN check and verify LAL pump settings at the beginning of each shift. LVN 1 stated he checks his residents’ LAL pumps at the beginning and end of his shift and after resident care, and verified he was assigned to one of the residents with an incorrect setting; he reported that he had checked the pump earlier and believed it was correct, and acknowledged he did not re-check the setting after providing wound treatment. LVN 1 also stated he did not think he checked the fourth resident’s mattress setting that day and acknowledged he should have. All four residents had severe cognitive impairment and physician orders for LAL mattresses with licensed nurses to monitor function, proper setup, and placement.
Failure to Notify Resident Representative After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in condition following a fall. The resident, who had a traumatic subarachnoid hemorrhage after a motor vehicle accident, was admitted with severe cognitive impairment. A BIMS assessment dated January 17, 2025, showed severe cognitive impairment, and physician orders dated February 5, 2025, documented that the resident did not have capacity to make his own decisions. On February 5, 2026, the Administrator confirmed that the resident’s representative was responsible for making healthcare decisions due to the resident’s severe cognitive impairment. The facility’s policy on Changes in Resident Condition states that the resident’s representative is to be notified when changes in condition occur, including accidents involving the resident that result in injury and may require physician intervention. On May 16, 2025, at 1:10 a.m., an SBAR for change of condition documented that the resident had an unwitnessed fall and was found on the floor next to his bed, with a notation to notify the MD and call the representative in the morning. Risk Meeting Notes from later that morning, attended by the DON, recorded that the resident was status post fall with injury and specifically indicated that the resident representative was not notified. A review of the progress notes following the fall showed no documentation that the representative was notified. In interviews, the Subacute Coordinator and the DON both stated that notification to a resident’s representative should occur at the time of a change of condition and that the nurse should document the date and time of notification on the SBAR and in concurrent progress notes. Both verified that the SBAR, Risk Meeting Notes, and progress notes for this incident did not show that the resident’s representative was notified of the unwitnessed fall.
Failure to Implement and Maintain Siderails as Indicated by Evaluation and Physician Orders
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically regarding the use of siderails for two residents with significant medical needs. For one resident with a history of seizures and ventilator dependence, a siderail evaluation conducted on May 24, 2025, indicated the need for siderails as a safety precaution, and a physician order was obtained the same day. However, this order was discontinued the following day and not renewed prior to the resident experiencing a fall from bed on June 2, 2025. Staff interviews and record reviews confirmed that the resident was found on the floor without siderails in place, despite the evaluation indicating their necessity. The Unit Manager and DON both verified that the physician order for siderails was not in effect at the time of the fall, and staff could not explain why the order had been discontinued. For another resident with chronic respiratory failure and ventilator dependence, a siderail evaluation completed on March 13, 2025, indicated the need for siderails. However, there was no physician order for siderails until April 8, 2025, leaving a gap between the evaluation and the implementation of the safety intervention. Staff interviews confirmed that the expectation was for nursing staff to obtain a physician order for siderails immediately following a positive evaluation, but this did not occur in a timely manner for this resident. Facility policy required that nursing staff complete a siderail evaluation, obtain a physician order, and implement siderails when medically necessary. The failure to follow these procedures resulted in residents not having siderails in place as indicated by their assessments, and in one case, directly preceded a fall from bed. Staff interviews consistently acknowledged the expectation to check evaluations, obtain orders, and implement siderails, but these steps were not consistently followed.
Failure to Accurately Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accurate reconciliation and documentation of controlled medications administered to two residents. For one resident admitted with a right humerus fracture, physician orders indicated oxycodone was to be administered as needed for moderate to severe pain. However, review of the narcotic sheet and electronic Medication Administration Record (MAR) for May 2025 showed that oxycodone was removed from the medication cart on several occasions, but the administration was not documented on the MAR for multiple dates. Licensed staff confirmed that the expected practice was to sign both the narcotic sheet and the MAR when administering narcotics, but this was not consistently done. Similarly, another resident with a diagnosis including urinary tract infection had an order for acetaminophen-hydrocodone (Norco) as needed for pain. The narcotic sheet indicated that Norco was removed from the medication cart on several dates, but these administrations were not documented on the MAR. Interviews with staff, including the Infection Preventionist and the Director of Nursing, confirmed that facility policy required documentation on both the narcotic sheet and the MAR, which was not followed. The facility's policy on controlled substances outlined the need for immediate and accurate record-keeping, which was not adhered to in these cases.
Failure to Implement Timely Contact Precautions for CRPA-Positive Resident
Penalty
Summary
The facility failed to implement proper infection control precautions in accordance with its policy and procedure when a resident tested positive for carbapenem-resistant pseudomonas aeruginosa (CRPA) on March 28, 2025. The resident, who had a history of respiratory failure with tracheostomy and resistance to carbapenems, was not placed on contact isolation immediately after the positive sputum culture result was received. Although the medical doctor was notified and ordered no antibiotics, there was no documentation that the Infection Preventionist (IP) was informed of the CRPA result at that time. The resident remained without appropriate contact isolation for nearly a month, despite facility policy requiring immediate implementation of contact precautions for CRPA cases. Interviews with staff revealed that the registered nurse who received the culture result did not notify the IP or document the result in the progress notes. The IP only became aware of the CRPA result on April 22, 2025, after which the resident was moved and placed on contact and droplet precautions. The Director of Nursing confirmed that the culture result was received but not reviewed or acted upon until almost a month later. Facility policy, which adheres to CDC guidelines, mandates that residents colonized or infected with CRPA be placed on contact precautions to prevent transmission.
Failure to Service Ventilators on Time
Penalty
Summary
The facility failed to ensure that ventilators for eight residents were serviced by the due dates indicated on the labels and according to the manufacturer's recommendations. During an unannounced visit, it was observed that the ventilators for these residents had not undergone preventative maintenance (PM) as required. The service due dates for the ventilators had passed, with some being overdue by several months. The respiratory therapist (RT) confirmed that the ventilators had not been serviced and stated that he was instructed to focus on the blower hours (BH) instead of the due dates. The RT indicated that the ventilators should undergo PM yearly to ensure proper functioning and resident safety. However, he was told to consider the ventilators safe if they had not reached 30,000 BH. Despite this, the RT acknowledged that it was his responsibility to ensure the PM was conducted and had requested the maintenance from his supervisor and the respiratory company owner. The administrator (ADM) was unaware of the overdue PM and stated that the RN Sub-acute Coordinator and RT should ensure all ventilators are functioning and have undergone PM. The residents involved had various medical conditions, including anoxic brain damage, respiratory failure with tracheostomy, and dependence on ventilators. The lack of timely maintenance had the potential to increase the risk of infection and improper ventilation for these residents. The operating manual for the ventilators specified that regular maintenance inspections should be carried out at least every 12 months, which was not adhered to in this case.
Infection Control Deficiency in Respiratory Equipment Management
Penalty
Summary
The facility failed to adhere to its infection control practices for respiratory equipment, affecting 12 out of 14 residents. During an unannounced visit, it was observed that multiple pieces of respiratory equipment, such as ventilator circuits, bacterial viral filters (BVF), heat moisture exchangers (HME), and oxygen tubing, were not changed or dated according to the facility's policy. The respiratory therapist (RT) confirmed that equipment was supposed to be changed on a specific schedule and dated accordingly, but this was not consistently done. Observations revealed that several residents had equipment that was either undated or not changed as per the schedule. For instance, Resident 2 had oxygen tubing dated January 30, 2025, which should have been changed, and Resident 3 had a BVF filter dated January 21, 2025, which was overdue for a change. Similar issues were noted with other residents, where equipment was either undated or had dates indicating they were overdue for replacement. The RT acknowledged these discrepancies and stated that equipment should be dated when changed to ensure adherence to the schedule and maintain infection control standards. Interviews with staff, including a registered nurse who was the Sub-acute Coordinator, confirmed that the night shift RTs were responsible for changing and dating the equipment. The facility's undated policy and procedure documents also indicated that disposable equipment should be labeled with the patient's name and date and changed as scheduled. However, the lack of adherence to these procedures led to the observed deficiencies in infection control practices.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required three-month timeframe for six residents. This deficiency was identified during an interview and record review conducted on December 11, 2024, with the MDS nurse. The MDS nurse confirmed that Resident 57's quarterly assessment was overdue by more than three months. Further review revealed that the quarterly assessments for Residents 14, 38, 28, 30, and 35 were also not completed within the required timeframe, as their last assessments were conducted on August 4, 2024, and should have been completed by November 4, 2024. The Director of Nursing (DON) confirmed the oversight, acknowledging that the quarterly MDS assessments for the six residents were not completed within the 92-day requirement from the last assessment. The facility's policy, revised in October 2023, mandates that nursing homes submit OBRA-required MDS records for all residents in Medicare- or Medicaid-certified beds every quarter unless the resident is no longer in the facility. This failure had the potential to negatively impact the residents' quality of care and the staff's ability to be aware of and address the residents' care needs appropriately.
Controlled Medication Accountability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications and the appropriate use of pain medications for several residents. The Controlled Drug Records (CDR) for five residents did not reconcile with the Medication Administration Records (MAR), leading to discrepancies in medication administration documentation. For instance, Resident 7 had discrepancies in the administration of oxycodone, with doses signed out but not documented on the MAR. Similar issues were observed with Residents 54, 53, 70, and 68, where doses of controlled medications were signed out but not recorded on the MAR, indicating a lack of proper documentation and potential for medication errors. Additionally, the facility failed to administer medication as ordered by the prescriber for one resident. Resident 70 received a dose of Norco for pain that was not indicated in the physician's order. The order specified the medication for right hand/wrist pain, but the resident was given the medication for back, neck, and hip pain, which was not covered by the existing order. This discrepancy was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), highlighting a failure to adhere to the prescribed medication orders. The facility's policies and procedures were not followed, as evidenced by the lack of documentation on the MAR and the administration of medication without the appropriate indication. The Consultant Pharmacist and the DON both confirmed the necessity for accurate documentation and adherence to physician orders to ensure resident safety and proper pain management. The facility's failure to document medication administration accurately and to administer medications as ordered by the physician resulted in deficiencies in pharmaceutical services provided to the residents.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Specifically, a half-gallon carton of Mocha Mix in the number two reach-in refrigerator was found without a use-by-date label, despite being opened on November 29, 2024. Similarly, a Ziploc bag containing shredded carrots in the number three reach-in refrigerator was dated December 7, 2024, but lacked a use-by-date label. The Food Service Assistant (FSA) acknowledged that both items should have had use-by-date labels, as per the facility's policy. Additionally, the walk-in freezer was found to have a four-ounce orange sherbet container on the floor, along with black residue on the floor and lower part of the wall behind the freezer racks. The FSA admitted that the sherbet should not have been on the floor and that the area should have been cleaned, as she was responsible for cleaning the walk-in freezer twice a month. The Food Service Director confirmed that the Mocha Mix and shredded carrots should have been labeled with the name of the food item, the date prepared/stored, and the use-by-date, and emphasized the importance of daily visual checks for cleanliness in the walk-in freezer.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure timely identification and implementation of trauma-informed practices and care planning for a resident with post-traumatic stress disorder (PTSD). The resident, who had a history of trauma including abuse and substance dependence, was observed expressing feelings of sadness and a desire to discuss his PTSD. Despite being cognitively intact and having the capacity to make healthcare decisions, there was no documented evidence that the resident's psychosocial history and psychologist's evaluation were discussed by the Interdisciplinary Team (IDT). Furthermore, a trauma-informed care plan was not developed for the resident following the psychologist's evaluation. The Social Service Director acknowledged that the resident did not initially verbalize his traumatic history upon admission and admitted to not discussing the psychologist's findings with the IDT. The facility's policy on trauma-informed care emphasizes culturally sensitive and person-centered care, yet this was not adhered to, resulting in the resident's mental and psychosocial needs not being met.
Failure to Document Pain Assessments for Pain Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications due to inadequate documentation of pain assessments associated with the administration of pain medication. Specifically, a resident had a physician's order for hydrocodone with acetaminophen (Norco) to be administered as needed for moderate to severe pain. However, the Medication Administration Record (MAR) for December 2024 showed that the resident received Norco on several occasions without any documented pain assessment before or after the medication was given. This lack of documentation included the absence of a pain rating scale and pain assessment, which are crucial for evaluating the necessity and effectiveness of the medication. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the requirement for pain assessments to be documented in the MAR. The DON emphasized the importance of documenting pain assessments to determine the effectiveness of the medication and to understand whether the resident's pain was managed, improved, or worsened. A review of the facility's pain management policy further supported the need for documentation of pain assessments and responses to pain management interventions. The failure to document these assessments potentially led to unnecessary or ineffective pain management for the resident.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations and interviews. A Certified Nursing Assistant (CNA) did not wear personal protective equipment (PPE) while caring for a resident on Enhanced Barrier Precautions (EBP), despite a sign indicating the requirement for PPE. The CNA acknowledged forgetting to wear PPE and recognized the importance of doing so to prevent the spread of germs. Interviews with other staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the expectation that PPE should be worn to protect both residents and staff from infections. Additionally, the facility did not place two residents on EBP who had indwelling medical devices. One resident with a urinary catheter and another with a gastrostomy tube were not on EBP, and there were no signs or isolation carts with PPE outside their rooms. Interviews with CNAs and LVNs revealed a lack of awareness and implementation of EBP for these residents, despite the facility's policy indicating that residents with indwelling medical devices should be on EBP. The Infection Prevention (IP) nurse confirmed that residents with devices such as IVs, gastrostomy tubes, and urinary catheters should be on EBP, with appropriate signage and PPE available. The facility's policy on EBP was reviewed, indicating the need for gown and glove use during high-contact care activities to prevent the transmission of multidrug-resistant organisms. However, these practices were not consistently followed, leading to potential risks of infection spread.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to accommodate the needs of a resident when the call light button was not within reach. During an observation and interview, the call light was found hanging on the wall behind the resident's bed, and the resident was unaware of its location. This was confirmed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), both of whom acknowledged that the call light should be within the resident's reach to ensure they can call for assistance when needed. The resident involved had been admitted with a fracture of the pelvis and age-related osteoporosis, conditions that necessitate easy access to assistance to prevent falls and injuries. The facility's policy requires that call lights be placed within the resident's reach, but this was not adhered to, increasing the risk of harm to the resident.
Failure to Assess and Notify After Resident Fall
Penalty
Summary
The facility failed to ensure timely assessment and notification following an unwitnessed fall involving a resident. On August 15, 2024, a resident experienced an unwitnessed fall, which was discovered by two CNAs who found the resident partially on the floor. Despite the CNAs informing the LVN Charge Nurse about the incident, there was no immediate assessment conducted, and the physician was not notified as required by the facility's policy. Interviews with facility staff revealed that the CNAs reported the incident to the LVN Charge Nurse, who denied being informed of any changes or incidents involving the resident. The CNAs and the Respiratory Therapist who assisted in the situation expected the nurse to assess the resident, but this did not occur. The Registered Nurse and the facility Administrator confirmed that the expectation was for the LVN Charge Nurse to assess the resident and notify the Nursing Supervisor and the physician immediately. The facility's Medical Director confirmed that he did not receive any notification of the fall. A review of the resident's medical record showed no documentation of the incident or notification to the physician. The facility's policy on changes in resident condition mandates that the resident, attending physician, and resident representative be notified of such events, and that changes be documented in the medical record, which was not adhered to in this case.
Failure to Provide Meal Consistent with Resident's Food Allergies
Penalty
Summary
The facility failed to provide a resident with an alternative meal consistent with the resident's identified food allergies. During an unannounced visit, it was found that a resident with allergies to peanuts and tomatoes was given a tuna sandwich containing tomatoes. The resident informed the nursing staff about the allergy, and the sandwich was replaced. However, this incident indicates a lapse in the facility's process for checking and accommodating food allergies. Interviews with the staff, including a CNA, cook, registered dietician, and dietary supervisor, revealed that the established procedure involves checking the resident's diet card for allergies before providing alternative meals. Despite these procedures, the resident still received a meal containing an allergen. The facility's policy and procedure on diet cards emphasize the importance of ensuring that food items served are consistent with the tray card information, which was not followed in this instance.
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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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