Palm Terrace Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laguna Hills, California.
- Location
- 24962 Calle Aragon, Laguna Hills, California 92637
- CMS Provider Number
- 555257
- Inspections on file
- 37
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Palm Terrace Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an accurate medical record when progress notes were entered for a resident after the resident had already been transferred to the hospital. Policy required concise and accurate clinical documentation, yet an LVN documented a head-to-toe skilled assessment and another note describing agitation, law enforcement involvement, and transfer, all time-stamped after the resident’s departure. Staff interviews confirmed that the notes were written post-discharge, that the LVN documenting was not assigned to the resident and was unaware of the transfer, and that verification with other nurses and CNAs was not done before charting.
Surveyors found that multiple nurses lacked essential competencies in several critical areas. In one case, an LVN caring for a resident with severe respiratory disease and dementia did not call 911 despite marked desaturation, hypothermia, and hypertension, citing the resident’s DNR status, and did not document a reassessment after suctioning or after a bronchodilator treatment. An RN later found the resident hypotensive, hypoxic, and disoriented and arranged transfer. Separately, an LVN and an RN were unable to correctly demonstrate glucometer calibration and were using test strips and control solutions without regard to 90‑day post‑opening expiration, even though their competency records indicated proficiency. Another resident reported being repeatedly given the wrong medication, and an RN confirmed that an LVN had administered calcium with vitamin D instead of ordered calcium alone. In addition, an LVN administering GT medications did not flush the tube before, between, or after medications and failed to use appropriate PPE for a resident on EBP, despite documented sign‑off on GT and infection control skills.
Surveyors found that the facility did not revise pain care plans to include physician-ordered non-pharmacological interventions for three residents experiencing acute or chronic pain related to conditions such as fractures, UTI, stroke, seizures, recent surgery, pressure injuries, and impaired mobility. Although facility policy required person-centered care plans that reflect both pharmacological and non-pharmacological pain interventions, the reviewed care plans only addressed administration of pain medications and omitted ordered measures such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage. During interviews and record reviews, an LVN and the DON confirmed that the residents’ current pain plans of care should have included these non-pharmacological interventions but did not.
The facility failed to follow its pain management policy by not implementing and documenting ordered non-pharmacological pain interventions before administering PRN and scheduled analgesics for three residents. One resident with cognitive impairment received multiple doses of tramadol and acetaminophen without any recorded use of repositioning, relaxation, or other ordered non-drug measures beforehand. Another resident, who reported intermittent abdominal and low back pain and could express needs, received repeated doses of acetaminophen and hydrocodone-acetaminophen with no documentation that non-pharmacological strategies were attempted first. A third resident with fluctuating capacity received frequent Percocet doses for severe pain, again without evidence that ordered non-pharmacological interventions were provided prior to medication administration. An LVN confirmed that such interventions were not used before giving pain medications to two of the residents, and the DON acknowledged the absence of documentation for all three.
Surveyors found multiple failures in medication management, including an LVN administering several crushed meds via GT to a resident without the ordered 50 ml pre- and post-flushes or flushes between meds, and a controlled oxycodone dose for another resident not being recorded on the narcotic log despite administration documented on the MAR. A resident who is independent in decision-making reported repeatedly receiving wrong meds, and an RN confirmed that calcium with vitamin D was given instead of ordered calcium alone. In addition, two residents did not receive ordered topical pain treatments (voltaren gel and a lidoderm patch) because the meds were not available when due, despite policies requiring timely refills.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Staff did not consistently follow the required process of pouring, passing, and immediately signing the EMAR for medication administration. The DON confirmed that advance documentation in the EHR is not acceptable and acknowledged that missed medications could have significant health impacts for a resident. The Administrator and DON were made aware of these findings.
Two residents experienced medication administration errors due to improper documentation and labeling of IV medications. One resident received Vancomycin without the medication bag being dated or signed, while another had a PIV line that was not dated or labeled, hindering compliance with physician orders. These issues were confirmed by RN 1 and acknowledged by the facility's administration.
The facility failed to provide necessary respiratory care by not adhering to physician orders for oxygen administration and not properly labeling oxygen and nebulizer tubing for several residents. A resident received oxygen at a higher rate than prescribed, and multiple residents had undated or incorrectly dated tubing, contrary to facility policy.
A facility failed to ensure a resident was free from significant medication errors when an LVN did not initially check the resident's pulse rate before administering hydralazine, as required by the physician's order. The LVN later checked the pulse rate, which was within the safe range, and administered the medication. The oversight was acknowledged by the LVN and reported to the facility's administration.
The facility did not adhere to pureed food recipes and menu specifications for eight residents on pureed diets. Cold milk and vegetable broth were used instead of warm milk for pureed potatoes, and the incorrect scoop size was used for serving pureed wheat rolls. These discrepancies were confirmed by dietary staff and acknowledged by facility leadership.
The facility failed to ensure food safety and sanitation in the kitchen, with issues such as poorly maintained utensils, unlabeled food items, and lack of hair restraints among staff. These deficiencies were confirmed by the CDM and other staff, posing a risk of foodborne illnesses to residents.
The facility failed to develop baseline care plans for two residents regarding oxygen administration, potentially leading to unmet care needs. One resident received oxygen at a higher rate than ordered, while another's care plan lacked documentation of oxygen use. These issues were confirmed through observations and staff interviews.
The facility failed to properly account for controlled medications, as evidenced by missing signatures on the Narcotic Count Sheet for Medication Cart B. This posed a risk for narcotic diversion, as confirmed by interviews with an LVN and the Interim DON, who acknowledged the missing signatures and the associated risks.
The facility failed to ensure proper medication storage, with open wound care supplies found in a medication cart and orally administered medications stored with externally used medications. An LVN and the Interim DON acknowledged these deficiencies, which were observed during inspections of Medication Cart A and Medication Room A.
The facility failed to maintain accurate medical records for two residents. One resident's records showed vital signs and urinary output documented after discharge, while another resident's records inaccurately documented blood pressure readings from a restricted arm. These errors were confirmed by facility staff and had the potential to impact care.
A resident received the wrong medication when an LVN failed to properly identify the resident before administering levothyroxine 25 mcg, contrary to the facility's policy requiring two identifiers. The resident, who did not have hypothyroidism, informed the LVN of the mistake, but the medication was administered regardless. The DON confirmed the error and policy breach.
The facility failed to administer medications on time for two residents, as required by their P&P. Medications scheduled for 0800 hours were given late due to staffing issues, with one nurse covering for an absent colleague and another attending to a resident with a change in condition. The DON acknowledged that medication administration should not be interrupted, indicating a lapse in task delegation.
The facility failed to serve meals at the desired temperatures, as observed during a test tray inspection and resident interviews. Two residents reported dissatisfaction with the temperature of their meals, noting that the food was often cold. A test tray inspection confirmed that the egg omelet, bacon, and oatmeal were served at temperatures below the desired level, and a taste test verified that these items were cold.
Inaccurate Post-Discharge Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medical record for one of eight sampled residents. Facility policy on Nursing Clinical Documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. The resident in question had an H&P indicating no capacity to understand and make decisions. The resident was admitted to the facility and later discharged to the hospital via EMS at 1800 hours on 2/8/26 after becoming very agitated, yelling, and cussing at staff, which led to the sheriff being called and two officers responding. Progress notes for this resident were documented after the resident had already left the facility. One note, timed at 2149 hours on 2/8/26, described the resident’s agitation, involvement of law enforcement, and transfer to the hospital at 1800 hours. Another note, timed at 2303 hours on 2/8/26, documented a head-to-toe assessment under a skilled evaluation by an LVN. During interviews, an LVN verified that these notes were entered after the resident’s discharge and stated that she would not chart on a resident who was no longer in the facility. The MDS Coordinator acknowledged that the 2303 hours progress note should not have been documented after the resident left. The LVN who entered the 2303 hours note stated she was not assigned to the resident, was only helping with documentation, had seen the resident at the start of her shift, and was unaware of the transfer, adding that staff should have checked with nurses and CNAs before writing the notes.
Widespread Nursing Competency Failures in Emergency Response, Glucometer Use, Med Pass, and GT Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and demonstrated the competencies required to provide safe and effective care, as evidenced by multiple incidents involving five nurses. For one resident with aspiration pneumonia, respiratory failure, COPD, CHF, chronic atelectasis, and dementia, the care plan required monitoring for respiratory distress and reporting changes to the physician. On the night in question, this resident’s vital signs changed significantly: blood pressure rose to 174/102, respiratory rate increased to 22, oxygen saturation dropped to 83–85% on 2 L O2 via nasal cannula, and temperature fell to 95°F. LVN 8 documented thick white phlegm in the resident’s mouth, performed oral suctioning with 200 ml of phlegm obtained, notified the physician and DON, and left messages for emergency contacts, but did not call 911. LVN 8 stated they believed that because the resident was DNR, 911 should not be contacted and that they were waiting for direction from the MD, RN, and family, despite acknowledging the resident was in distress and still breathing with a heartbeat. Further review of the same resident’s record showed that earlier vital signs that night were within normal limits, and that after the change in condition and suctioning, there was no documented reassessment of vital signs. The MAR showed the resident received levothyroxine and ipratropium bromide inhalation, but there was no documentation of vital sign reassessment after the inhalation treatment. Later that morning, RN 1 assessed the resident and found blood pressure 78/58, respiratory rate 12, oxygen saturation 73%, and disorientation with inability to follow commands. Oxygen was escalated to a non-rebreather at 15 L/min and another nurse was instructed to call 911, and the resident was transferred to the hospital. The DON later stated that LVN 8 focused primarily on breathing and failed to address the abnormal vital signs, and that LVN 8 had not attended the facility’s in-service on LVN scope for respiratory devices. Additional deficiencies in competency were identified in glucometer calibration, medication administration, and GT medication technique. When asked to calibrate a glucometer, LVN 2 stated she had only been shown once, believed NOC shift nurses did it, and was unsure when calibration was needed, stating she would ask an RN supervisor. The glucometer quality control record showed mismatched lot numbers and missing open dates on strips, and control solutions labeled with open dates, while RN 1 performed a control test without entering control mode and stated she relied on box expiration dates rather than the 90-day post-opening limit. Both LVN 2 and RN 1 had competency documents indicating they met glucometer calibration skills. Another resident reported that an LVN repeatedly gave her the wrong medications; on one occasion, RN 2 verified that the resident had been given calcium with vitamin D instead of the ordered calcium alone, and RN 2 told the LVN to follow the physician’s order. In a separate observation, LVN 5 administered medications via GT without flushing the tube with 50 ml water before and after, did not flush between medications, and did not wear appropriate PPE for a resident on EBP, despite documentation that GT and infection control competencies had been signed off. These findings collectively showed that multiple nurses lacked the specific competencies and standard-of-practice skills required for safe care.
Failure to Incorporate Ordered Non-Pharmacological Pain Interventions Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to include ordered non-pharmacological pain interventions for three residents. Facility policies on Pain Recognition and Management and Comprehensive Person-Centered Care Planning require that pain management be consistent with professional standards, include both pharmacological and non-pharmacological interventions, and that the interdisciplinary care plan be reviewed and revised after each assessment. For Resident 4, who had a left femoral fracture, a physician’s order dated 11/26/25 specified non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage as needed. However, the pain care plan initiated on 11/28/25 only included administering medication as ordered and did not incorporate these non-pharmacological interventions. During interviews and concurrent record reviews, LVN 7 and the DON acknowledged that the current plan of care for pain should have reflected these interventions. For Resident 19, who had acute/chronic pain related to UTI, stroke, and seizures, a physician’s order dated 1/21/26 also included the same set of non-pharmacological pain interventions. The care plan for acute/chronic pain initiated on the same date listed interventions such as administering medication as ordered but did not include the ordered non-pharmacological measures. Similarly, Resident 27, who reported on-and-off abdominal and lower back pain and had acute pain related to recent surgery, pressure injuries, medical condition, and impaired mobility, had a physician’s order dated 12/17/25 for the same non-pharmacological pain interventions. The pain care plan initiated on 12/18/25 again only reflected medication administration and omitted the non-pharmacological interventions. LVN 7 and the DON confirmed during interviews and record reviews that the residents’ current pain care plans should have included these non-pharmacological interventions, but they were not incorporated.
Failure to Implement and Document Non-Pharmacological Pain Interventions Prior to Analgesic Use
Penalty
Summary
The deficiency involves the facility’s failure to provide and document non-pharmacological pain interventions prior to administering PRN and scheduled pain medications for three residents. Facility policy titled “Pain Recognition and Management” (revised 4/2025) required staff to manage or prevent pain consistent with the comprehensive assessment and care plan, including both pharmacological and non-pharmacological interventions based on resident needs, preferences, and goals. For each of the three residents, physician orders included specific non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage to be used as needed. For one resident with moderate cognitive impairment, physician orders included scheduled and PRN tramadol for pain, as well as PRN acetaminophen for mild and moderate pain, along with ordered non-pharmacological interventions. Medication administration records for November, December, and January showed multiple administrations of tramadol and acetaminophen; however, the medical record contained no documented evidence that any of the ordered non-pharmacological interventions were provided prior to giving these pain medications. The DON later verified these findings during record review. For a second resident who could make her own medical needs known and reported intermittent abdominal and lower back pain, physician orders included PRN acetaminophen for mild and moderate pain, PRN hydrocodone-acetaminophen for severe pain, and the same set of non-pharmacological interventions. MARs for December, January, and February showed repeated administrations of acetaminophen and hydrocodone-acetaminophen, but the medical record lacked documentation that non-pharmacological interventions were implemented before medication administration. A third resident, with fluctuating capacity but able to make needs known, had multiple sequential PRN Percocet orders for severe pain and corresponding non-pharmacological pain orders. MARs for January and February documented frequent Percocet administration, yet there was no documented evidence that non-pharmacological interventions were provided prior to these doses. LVN 7 stated that non-pharmacological interventions should be used before pain medications and confirmed that such interventions were not provided before administering pain medications to two of the residents, and the DON acknowledged the lack of documentation for all three residents.
Multiple Failures in Medication Administration, Documentation, and Availability
Penalty
Summary
The deficiency involves multiple failures in pharmaceutical services, including improper administration of medications via gastrostomy tube (GT), incomplete controlled substance documentation, wrong medication administration, and lack of medication availability. For one resident with GT orders, a nurse crushed several medications (apixaban, Florastor, sennosides, and docusate sodium), mixed each with a small amount of water, and administered them sequentially through the GT without flushing between medications. The nurse also flushed the GT with only 10 ml of water before starting and did not flush with the ordered 50 ml of water before and after medication administration, contrary to the physician’s order specifying 50 ml pre- and post-medication flushes. The nurse later verified she had not followed the ordered flush volumes or flushed between medications, and the DON confirmed awareness of these findings. Another deficiency was identified in the handling and documentation of a controlled medication for a different resident. When the oxycodone 10 mg bubble pack was counted with a nurse, there were 25 tablets remaining, while the Narcotic and Hypnotic Record indicated 26 tablets should be left. The record showed one tablet removed at a specific time, and the MAR showed the resident received oxycodone twice that day at two documented times. The nurse confirmed that the nurse who removed and administered one of the oxycodone doses did not document the removal on the Narcotic and Hypnotic Record, and the DON verified these findings. Additional deficiencies included wrong-medication administration and failure to ensure availability of ordered pain medications. One resident, documented as capable and independent in decision-making, reported that a nurse repeatedly gave her the wrong medications; on one occasion she brought a pill to an RN, who identified it as calcium with vitamin D, while the resident’s order was for calcium only. The RN stated she informed the nurse involved that she must follow the physician’s order and not substitute what was available. In separate observations, two residents with orders for routine topical pain medications (voltaren gel for one resident’s right shoulder three times daily, and a daily lidoderm patch for another resident’s right shoulder) did not receive these medications because they were not available at the time of administration. Nurses stated the medications were out and that refills were being or had just been ordered, despite facility policy and DON expectations that routine medications be reordered several days before the supply is exhausted.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 1 no longer resides at facility as of 08/11/25. On 08/13/25, 08/14/25, and 08/15/25, all licensed nurses were in-serviced by DON on medication rights of administration and provided with a copy of the medication administration P&P which states correct administration and documentation -- pour, pass, sign. Licensed nurses were also educated on the one-hour medication pass parameter time. 2. Resident 2 no longer resides at facility as of 08/26/25. On 08/13/25, Resident 2 was assessed by DON for adverse reactions related to missed medication. Resident denied any adverse reactions. MD was notified of missed medications by DON immediately, and no new orders were given. On 08/13/25, DON provided 1:1 training to LVN 1 regarding the rights of medication administration. LVN 1 was provided with facility's P&P on medication administration. DON also provided LVN 1 with 1:1 in-service on proper procedure for medication clarification, documentation, and monitoring. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/14/25, 08/15/25, 08/18/25, 08/20/25, and 08/22/25, DON, DSD, and RN conducted a medication observation for 20 residents to validate pour, pass, sign, timely medication administration, and correct documentation. All 20 residents received their medication on time, and licensed nurses followed pour, pass, sign procedures and accurately documented administration. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 08/13/25, 08/14/25, and 08/15/25, DON provided in-services to all licensed nurses regarding rights of medication administration and facility's P&P on medication administration, specifically "pour, pass, sign." Additionally, DON and/or designee will provide in-services monthly for 4 months and as needed to ensure compliance and competency with P&P. Starting 08/14/25, DON and/or designee will perform a random medication observation of 4 residents per week for 12 weeks and as needed to ensure timely medication administration and accurate documentation. Any deficient findings will be reported to the DON and/or designee for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON and/or designee will report to the QA&A Committee monthly for review and recommendations for 3 months until substantial compliance is achieved. Completion Date: 08/27/25
Failure to Ensure Immediate and Accurate Medication Documentation
Penalty
Summary
Staff were required to follow the administration process of pouring, passing, and immediately signing the EMAR for safe and accurate documentation of medication administration. When questioned about the acceptability of advance documentation in the EHR for care and services, including medication administration, the DON confirmed that such practice was not acceptable. The DON also acknowledged that any missed medication could significantly impact a resident's health, depending on the medication's indication. During an interview, both the Administrator and DON were informed of and acknowledged these findings.
IV Medication Administration Errors
Penalty
Summary
The facility failed to ensure the proper administration and documentation of IV medications for two residents, leading to medication errors. Resident 38 was observed receiving an IV antibiotic, Vancomycin, without the medication bag being dated, timed, or signed by the administering nurse. This lack of documentation was confirmed by RN 1 during an observation and interview. The resident's medical records indicated a physician's order for Vancomycin to be administered every 12 hours for an abdominal abscess, but the absence of proper labeling posed a risk for medication errors. Similarly, Resident 587 had a PIV line that was not dated or labeled, as observed during a room visit. The physician's order required the PIV site to be changed every 72 hours or as needed, but the lack of labeling made it difficult to track the duration of the PIV line. RN 1 confirmed the oversight, acknowledging that the PIV sites should be dated and labeled to comply with the physician's orders. Both the Administrator and Interim DON were informed of these findings and acknowledged the deficiencies.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, as evidenced by multiple deficiencies in the administration and management of oxygen therapy. For Resident 686, the facility did not adhere to the physician's order for oxygen administration, providing oxygen at a higher rate than prescribed. Observations revealed that the resident was receiving oxygen at 5 liters per minute instead of the ordered 3 liters per minute. This discrepancy was not documented, and there was no evidence that the physician was notified of the change or the resident's subsequent difficulty in breathing and decreased oxygen saturation. Additionally, the facility did not ensure proper labeling and dating of oxygen tubing for Residents 28 and 438. Resident 28's nasal cannula tubing was dated incorrectly, and Resident 438's tubing was undated, contrary to the facility's policy that requires tubing to be changed weekly and dated. These lapses in protocol were confirmed through interviews with staff, who acknowledged the oversight in labeling the tubing. Furthermore, Resident 436's nebulizer tubing was also found to be undated, which is a deviation from the facility's policy. The lack of proper documentation and adherence to procedures for respiratory equipment management could potentially impact the residents' medical conditions. These findings highlight the facility's failure to maintain consistent and accurate respiratory care practices for its residents.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication administration observation. The facility's policy requires that medications be administered as prescribed by the attending physician, including checking specific parameters before administration. On the specified date, a Licensed Vocational Nurse (LVN) prepared hydralazine for a resident, which is used to treat high blood pressure. The medication's instructions required the nurse to hold the medication if the resident's systolic blood pressure (SBP) was less than 110 mmHg or if the pulse rate was less than 60 beats per minute. Although the LVN checked the resident's blood pressure, they did not initially check the pulse rate before preparing to administer the medication. Upon being reminded of the requirement, the LVN checked the resident's pulse rate, which was 69 beats per minute, and then administered the medication. The resident's medical records confirmed the physician's order to hold the medication under the specified conditions. The LVN acknowledged the oversight during an interview, and the facility's Administrator and Interim Director of Nursing were informed of the findings. This oversight in following the medication administration protocol had the potential to negatively impact the resident's health outcomes.
Failure to Follow Pureed Food Recipes and Menu
Penalty
Summary
The facility failed to ensure that the pureed food recipes and menu were followed for eight residents receiving pureed diets. Specifically, the pureed recipe for potatoes was not adhered to, as cold milk and vegetable broth were used instead of warm milk, contrary to the facility's documented recipe. This deviation was confirmed during an observation and interview with a dietary staff member, who acknowledged the discrepancy in the preparation of pureed red potatoes. Additionally, the facility did not follow the prescribed serving size for pureed wheat rolls. The menu specified the use of Scoop #16, equivalent to 1/4 cup, but instead, Scoop #12, equivalent to 1/3 cup, was used. This was observed during a tray line observation and confirmed by the Dietary Supervisor Assistant. The facility's Administrator, DON, and CDM acknowledged these findings, indicating a failure to adhere to the established dietary guidelines and menu specifications.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. Several deficiencies were noted, including the poor condition of food preparation utensils and equipment. A large pot was heavily marred with black discoloration, and cutting boards were observed with significant wear and discoloration. A can opener had brown discoloration, and other kitchen tools such as a measuring cup, spatula strainer, and ice cream scoopers were found with residues and chipped handles. These conditions were verified by the Certified Dietary Manager (CDM) and other kitchen staff, who acknowledged the risk of food contamination. Additionally, the facility did not adhere to its policy on labeling and dating food items. Unlabeled and undated food items were found in the freezer and refrigerator, including containers of solid food substances and various beverages. The CDM confirmed these findings and admitted to not knowing why certain food items were not stored properly. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with the Dietary Supervisor Assistant, which was acknowledged as a requirement by the Dietary Resource. These failures had the potential to cause foodborne illnesses to the residents consuming food prepared in the kitchen.
Failure to Develop Baseline Care Plans for Oxygen Administration
Penalty
Summary
The facility failed to develop baseline care plans to address the administration of oxygen for two residents, which had the potential for their care needs not being met. Resident 686, who was admitted with a history of acute respiratory failure secondary to congestive heart failure, had a physician's order for oxygen administration at 3 liters per minute via nasal cannula. However, during an observation, it was noted that the resident was receiving oxygen at 4 liters per minute, and there was no baseline care plan in place to address this discrepancy. This was confirmed by both an LVN and an RN during interviews and medical record reviews. Similarly, Resident 438 had a physician's order for continuous oxygen at 3 liters per minute via nasal cannula, but the resident's plan of care did not document the administration of supplemental oxygen. An observation confirmed that the resident was receiving oxygen as ordered, but the lack of documentation in the care plan was verified by the IP during an interview and medical record review. These oversights in care planning could potentially lead to unmet care needs for the residents involved.
Failure to Properly Account for Controlled Medications
Penalty
Summary
The facility failed to ensure the proper accounting and safeguarding of controlled medications, specifically narcotics, which posed a risk for loss or diversion. The deficiency was identified through a review of the facility's policies and procedures, which require a physical inventory of all controlled medications to be conducted by two licensed nurses at each shift change. This inventory is to be documented on an audit record or accountability record. However, the Narcotic Count Sheet for Medication Cart B showed multiple instances of missing signatures from incoming and outgoing licensed nurses on specific dates, indicating that the required inventory checks were not properly documented. Interviews with facility staff, including an LVN and the Interim DON, confirmed the missing signatures on the Narcotic Count Sheet. The LVN explained that the purpose of the Narcotic Count Sheet log is to ensure that narcotic medication counts are reconciled and accounted for at the end of each shift. The Interim DON acknowledged the missing signatures and stated that failing to account for controlled medications poses a risk for narcotic diversion. This lack of proper documentation and accountability for controlled substances represents a significant deficiency in the facility's pharmaceutical services.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper medication storage, as observed during an inspection of Medication Cart A. Open packages of wound care supplies, including Skin Closure Strips and calcium alginate dressing, were found in the medication cart. These items were not stored in a manner that maintained their sterility, as they were open and partially used. The Licensed Vocational Nurse (LVN) acknowledged these findings and confirmed that all wound care supplies should be single-use to ensure sterility. Additionally, the facility did not adhere to its policy of storing orally administered medications separately from externally used medications. During an inspection of Medication Room A, it was observed that Latanoprost eye drops and nitroglycerin tablets were stored together in the same tray inside the refrigerator. Furthermore, various over-the-counter and house supply medications, including earwax softener drops, nasal spray, calamine lotion, artificial tears, nicotine patches, and pain reliever patches, were stored side by side without separation. The Interim Director of Nursing (DON) acknowledged these findings and confirmed that internal and external medications should be stored separately.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their care. For Resident 85, the medical records inaccurately documented vital signs and urinary output after the resident had been discharged and transferred to an acute hospital. This discrepancy was confirmed during an interview with the Interim Director of Nursing (DON), who acknowledged that such documentation should not have occurred once the resident was no longer at the facility. For Resident 44, the facility did not accurately document the blood pressure access site in the resident's medical record. Despite a care plan and physician's order specifying that no blood pressure readings should be taken from the left arm due to an AV shunt, the records showed multiple instances where blood pressure was measured from the left arm. This was verified by the MDS Coordinator and acknowledged by the Administrator and Interim DON. These documentation errors had the potential to impact the residents' care needs due to the inaccuracies in their medical information.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A licensed nurse, identified as LVN 6, did not properly check and identify the resident before administering medication. The facility's policy and procedure for medication administration, dated January 2019, required the use of at least two identifiers to confirm resident identity before medication administration. However, LVN 6 administered levothyroxine 25 mcg to a resident who did not have a history of hypothyroidism, without verifying the resident's identity using the required methods. The incident occurred in the early morning when LVN 6 administered the medication to the resident, who was able to make self-understood and understand others, as indicated by a BIMS summary score of 14. The resident informed LVN 6 that she did not take medications in the early morning, but LVN 6 proceeded to administer the medication and later returned to acknowledge the error. The Director of Nursing confirmed the medication error and verified that the facility's policy was not followed, resulting in the resident receiving the wrong medication.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to provide necessary pharmacy services to two residents, resulting in medications not being administered within the prescribed time. The facility's policy and procedure (P&P) for medication administration requires medications to be given within 60 minutes of the scheduled time, except for those ordered before or after meals. However, observations and interviews revealed that medications scheduled for 0800 hours were administered late to both residents. For Resident 1, an interview and observation on 9/3/24 showed that medications due at 0800 hours were administered late because the nurse assigned to administer them did not show up. LVN 2, who was observed administering the medications, confirmed the delay and stated that he had to cover for the absent nurse, resulting in late administration for other residents as well. Similarly, LVN 3 confirmed that she finished administering the 0800 hours medications at 0954 hours, indicating a consistent delay in medication administration. Resident 2's medical records showed multiple medications scheduled for 0800 hours, including atenolol-chlorthalidone, fish oil, gabapentin, and Prozac. On 9/3/24, LVN 4 administered these medications late due to attending to a resident with a change in condition. The Director of Nursing (DON) stated that medication administration should not be interrupted and expected other staff to handle residents with changes in condition, highlighting a failure in staffing and task delegation that led to the deficiency.
Deficiency in Meal Temperature
Penalty
Summary
The facility failed to ensure that meals were served at the desired temperatures, which could potentially lead to decreased oral intake and undesirable weight loss for residents. During interviews, two residents expressed dissatisfaction with the temperature of their meals. One resident stated that the hot food items on their meal tray were not hot enough and expressed a preference for warm food. Another resident mentioned that the food could be improved and noted that it was often cold. A test tray inspection was conducted to assess the temperature of the food being served. The inspection revealed that the egg omelet, bacon, and oatmeal were served at temperatures significantly below the desired level, with readings of 105.6, 86.1, and 108.6 degrees Fahrenheit, respectively. Additionally, the milk was found to be at 51.2 degrees Fahrenheit. A taste test confirmed that the egg omelet, oatmeal, and bacon were cold, and the Dietary Services Supervisor (DSS) verified the temperature drop, acknowledging that the food items were indeed cold.
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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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