Palms Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chowchilla, California.
- Location
- 1010 Ventura Avenue, Chowchilla, California 93610
- CMS Provider Number
- 055047
- Inspections on file
- 21
- Latest survey
- April 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Palms Care Center during CMS and state inspections, most recent first.
The facility did not post daily nurse staffing information with the required breakdown of RN, LVN/LPN, and CNA hours, instead combining all hours into a single figure. The staffing information was also posted in a staff-only area, making it inaccessible to residents and visitors without assistance. Facility leadership confirmed the lack of separated data and accessible posting, and there was no policy in place to ensure compliance.
Three residents did not receive individualized, person-centered care plans to address their specific needs, including one resident's preference for ileostomy care, another's ongoing medication refusal, and a third's self-harm behaviors and fall risk. Staff were aware of these issues but did not create or implement appropriate care plans, resulting in unmet needs and increased risks.
Staff failed to follow infection prevention protocols, including not performing hand hygiene between residents during medication administration and after room entry and exit, and improper storage of oxygen tubing. These actions were observed among multiple staff and residents, with staff acknowledging the importance of hand hygiene and facility policies requiring it.
Two residents did not receive care according to professional standards: one developed open, unhealing wounds from persistent skin picking without physician notification or proper documentation by LVNs and CNAs, and another received oxygen therapy at a higher rate than ordered, with staff unable to explain the deviation or duration. Facility policies and job descriptions required adherence to physician orders and reporting of changes, but these were not followed.
A resident with no cognitive impairment and a stated preference for drawing, coloring, and writing was not provided with activities matching these interests. The care plan did not reflect the resident's preferences, and staff interviews confirmed that activity documentation and scheduling did not address the resident's requests, despite repeated mentions in resident council meetings and facility policies requiring individualized activity planning.
A facility failed to ensure that a qualified RD provided consistent consultation and oversight for food and nutrition services, resulting in a resident with complex medical needs and severe cognitive impairment not receiving timely follow-up or individualized care planning for significant weight changes. The RD worked irregular hours, did not attend IDT meetings, and did not consistently document or update care plans, leading to gaps in nutritional recommendations and monitoring.
A resident's POLST form was found to be incomplete, lacking both the date prepared and the required signature of the resident or their legally recognized decisionmaker. The form was scanned into the medical record without these critical elements, despite the responsibilities outlined for the Medical Records Clerk and Social Services Director. The resident had multiple medical conditions and moderate cognitive impairment at the time of the deficiency.
Two residents were found without accessible call lights, with one resident's call light on the floor and another's out of reach, leading to one resident hitting the wall to get staff attention. Staff and the DON confirmed that call lights are required to be within reach, and facility policy supports this expectation.
A resident with a history of aggression was left unsupervised in the dining room, leading to an altercation where the resident struck another resident, causing a skin tear and bleeding. Despite a care plan requiring one-on-one supervision, staff failed to assign a CNA during the incident, resulting in a lack of monitoring. The facility's policy to prevent abuse and ensure safety was not followed, as confirmed by the DON.
The facility failed to hire a qualified Dietary Manager (DM) to oversee food and nutrition services for 56 of 61 residents. The DM was still in school and not yet certified, which was confirmed by the Registered Dietitian (RD). The job description and FDA Food Code require certification, which the DM did not have, potentially affecting residents' nutrition and health.
The facility failed to maintain kitchen sanitation standards, affecting 56 of 61 residents. Issues included a dirty dishwasher, cracked and peeling pans, a large icicle in the walk-in freezer, and torn oven mitts, all of which posed risks of contamination and injury.
The facility failed to meet professional standards when an LPN did not follow proper inhalation technique for two residents' inhalers, and LNs signed off on a resident's splint/orthotic device without ensuring it was applied. The DON confirmed these practices were against protocol.
The facility failed to obtain informed consent for the administration of psychotropic medications to a resident with dementia. The resident was given quetiapine fumarate and risperidone without being fully informed of the risks and benefits, as confirmed by interviews with the LVN, MDSC, and DON. Facility policies require informed consent for such medications, but this was not obtained prior to administration.
A resident was placed on a low air loss mattress without being informed or allowed to decline the plan of care. The resident's request for fitted sheets was ignored, leading to feelings of frustration and physical discomfort. Staff admitted that the resident was not educated about the mattress and its contraindications, and the resident was not involved in the decision-making process.
The facility failed to provide a clean and homelike environment for a resident with malnutrition and anxiety disorder. The resident's bathroom had chipped and peeling paint, and sand in the toilet bowl, leading her to use her briefs instead. Staff confirmed the poor condition of the bathroom, acknowledging it did not meet the standard for a homelike environment.
The facility failed to ensure the MDS assessment accurately reflected a resident's health and functional status. A resident with right-sided weakness due to a cerebral infarction was inaccurately coded in the MDS assessment, which was confirmed by both an LVN and the MDSC. The DON acknowledged the responsibility for ensuring accurate MDS assessments.
A facility failed to develop and implement a comprehensive care plan for a resident on apixaban for atrial fibrillation. Despite the medication being prescribed, no care plan was initiated to monitor its side effects. This oversight was confirmed by the LVN, MDSC, and DON, who acknowledged the necessity of such a care plan. The resident, admitted with multiple diagnoses, expressed a need for assistance due to limited mobility.
An LVN left a medication cart unlocked and unattended while administering medication to a resident with asthma, quadriplegia, and heart failure. This was against the facility's policy, which requires medication carts to be locked when not under direct observation.
A facility failed to maintain an infection control program when an LVN did not sanitize a blood pressure cuff and stethoscope after use and did not wash her hands before preparing medications for a resident with hypertensive heart disease and atherosclerotic heart disease. The DON confirmed these actions violated infection control protocols.
Failure to Post Complete and Accessible Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted with all required details and in a location that was readily accessible to residents and visitors. Specifically, the posted staffing documents did not separate or specify the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational/Practical Nurses (LVNs/LPNs), and Certified Nursing Assistants (CNAs). Instead, the information was combined into a single 'Total Hands on PPD' figure, omitting the breakdown required by regulations. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator confirmed that they could not locate or provide the separated staffing data on the posted documents for multiple reviewed dates. Additionally, the daily nurse staffing information was posted behind the nursing station, an area marked as restricted to staff only, making it inaccessible to residents and visitors without staff assistance. The DSD, DON, and Administrator all acknowledged that the information was not easily accessible and that there was no facility policy or procedure in place for posting daily nurse staffing information as required. This failure affected all 60 residents in the facility, as neither they nor their visitors could independently view the required nurse staffing information.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs and increased risks. For one resident with an ileostomy, the care plan did not address her preference to maintain the stoma uncovered and self-manage care using personal washcloths, despite her cognitive intactness and repeated communication of her preferences to staff. Observations and interviews confirmed that staff were aware of her choices and the challenges with the ileostomy bag, but no individualized care plan was created to guide staff in honoring her preferences or managing associated risks. Another resident, who was cognitively intact and had a history of epilepsy, atrial fibrillation, and hypertension, repeatedly refused critical medications for seizure control and blood pressure management. The care plan did not address this ongoing medication refusal, and there was no documentation of person-centered interventions, education provided, or consistent notification of the responsible party and physician as required by facility policy. Staff interviews confirmed the absence of a care plan for medication refusal, and the responsible party reported not being informed of changes in the resident's condition. A third resident, with moderate cognitive impairment and a history of diabetes, depression, and gait abnormalities, exhibited self-harm behaviors by picking at wounds, leading to unhealed and bleeding injuries. No individualized care plan was developed to address this behavior or provide interventions for wound care. Additionally, the resident, identified as high risk for falls, did not receive consistent implementation of a toileting schedule or adequate supervision, resulting in an unwitnessed fall. Staff interviews and record reviews confirmed the lack of care planning and monitoring for both self-harm and fall prevention, despite documented high fall risk and previous incidents.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for several residents, as evidenced by multiple staff not adhering to hand hygiene protocols and improper handling of medical equipment. During medication administration, two LVNs were observed not performing hand hygiene between residents, despite facility policy and their own acknowledgment of its importance. This occurred with multiple residents, some of whom had varying levels of cognitive impairment, and was confirmed through both observation and staff interviews. The facility's policies required hand hygiene before administering medication and between resident care, but these were not followed. Additionally, a resident's oxygen nasal cannula tubing was found resting on top of the oxygen concentrator and in direct contact with the wall, rather than being stored in a protective bag as required by facility policy. Staff interviews confirmed that this was not in accordance with procedures and could lead to cross contamination. The resident in question had a history of chronic obstructive pulmonary disease and acute respiratory failure, and was actively receiving oxygen therapy per physician orders. Further, a CNA was observed failing to perform hand hygiene after leaving one resident's room and before entering and exiting another resident's room, even after providing assistance. Both the CNA and other staff acknowledged the importance of hand hygiene to prevent cross contamination, and the facility's policy required hand hygiene upon entering and exiting resident rooms. These lapses were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Follow Professional Standards in Wound Care and Oxygen Administration
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. In the first case, a resident with a history of diabetes, depression, muscle weakness, and abnormal gait was observed to have open, bleeding, and unhealing wounds on her arms and shoulder due to persistent itching and picking at her skin. Licensed Vocational Nurses (LVNs) did not notify the physician about the resident's continued skin picking and resulting wounds, despite documentation in progress notes and observations by staff. Certified Nursing Assistants (CNAs) also failed to report the resident's behavior and skin condition to the charge nurse, and there was no documentation of skin checks during bathing or showering. The facility's policies and job descriptions required staff to report and document such changes, but these procedures were not followed. In the second case, another resident with chronic respiratory failure, hypoxia, heart failure, and pneumonia was not administered oxygen therapy according to the physician's order. The resident was ordered to receive oxygen at 2 liters per minute (LPM) via nasal cannula, but was observed receiving 5 LPM. The LVN and Respiratory Therapist (RT) could not determine how long the resident had been receiving the incorrect dosage or who had made the adjustment. Both staff members acknowledged that oxygen is considered a medication and must be administered as prescribed. The facility's policies, as well as job descriptions for LVNs and RTs, required adherence to physician orders for medication administration, including oxygen therapy. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the observed practices did not align with professional standards or facility policies. The DON stated that all physician orders and medications must be administered as prescribed, and only authorized personnel should adjust oxygen concentrators. The failures in both cases were corroborated by record reviews, staff interviews, and direct observations, demonstrating a lack of compliance with established protocols for wound care and medication administration.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to provide activities that met the preferences and interests of one resident, who expressed a desire to participate in drawing, coloring, and writing activities. Despite documentation in the resident's initial activity review indicating a preference for writing, and multiple verbal requests for more drawing, coloring, and writing opportunities, these interests were not reflected in the resident's care plan. The care plan only noted that the resident enjoyed watching television independently, omitting any mention of his stated interests in creative activities. Interviews with facility staff, including an LVN and the Activities Director, confirmed that the resident's care plan was not updated to reflect his preferences, and there were no progress notes documenting participation in or refusal of independent activities such as drawing or coloring. The Activities Director acknowledged responsibility for ensuring that activities matched resident interests and for updating care plans and activity notes accordingly. Additionally, the Activities Director did not add painting or coloring activities to the activity calendar in response to resident council requests, instead opting for a general "Residents Choice" day, which required residents to specifically request materials for their preferred activities. Facility documentation, including resident council minutes and activity calendars, showed repeated requests for more painting and coloring activities, but these were not consistently incorporated into the monthly activity schedules. Facility policies and job descriptions emphasized the importance of providing resident-specific activities based on comprehensive assessments and care plans, as well as supporting resident self-determination and participation. However, these policies were not followed in the case of this resident, resulting in a lack of meaningful activity options aligned with his interests.
Failure to Provide Adequate Dietitian Oversight and Nutritional Care
Penalty
Summary
The facility failed to ensure that the Registered Dietitian (RD) provided adequate consultation and support for food and nutrition services, specifically in the assessment and development of individualized care plans for a resident who experienced significant weight changes. The RD was not consistently present at the facility, working irregular hours and often after completing work at another job. The RD did not participate in staff training, interdisciplinary team (IDT) meetings, or regular follow-up on residents' nutritional needs, including those triggered for weight changes. The Certified Dietary Manager (CDM) and Director of Nursing (DON) both indicated that the RD's involvement was limited, and the RD did not create or update care plans for residents, nor did he provide timely recommendations for residents with ongoing weight fluctuations. A review of records showed that the RD had only written one note in the affected resident's chart since January, despite the resident being flagged for significant weight changes in both February and March. The DON was unsure if the RD was aware of the resident's weight loss and confirmed that the RD was not involved in weekly IDT meetings where such issues were discussed. The RD's job description required him to assess and monitor residents' nutritional status, provide recommendations, develop and update care plans, and participate in audits and staff guidance, but these duties were not consistently fulfilled due to the RD's limited and inconsistent presence at the facility. The resident involved had a complex medical history, including hemiplegia, gastrostomy, and a history of stroke, and was assessed as having severe cognitive impairment. Despite being at high risk for nutritional issues, the resident did not receive adequate follow-up or individualized care planning from the RD. The facility's documentation and interviews confirmed gaps in the RD's recommendations and lack of ongoing monitoring, which was inconsistent with both facility policy and regulatory requirements for dietetic services.
Incomplete POLST Form in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident when the Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete. During interviews and record reviews, it was observed that the POLST for the resident was missing critical information, including the date the form was prepared and the signature of the resident or their legally recognized decisionmaker. Both the LVN and the Director of Nursing confirmed that the POLST was not properly completed, as the required signatures and dates were absent. The resident had a documented history of type 2 diabetes mellitus, depression, muscle weakness, and gait abnormalities, and was assessed as moderately cognitively impaired. The facility's own job descriptions indicated that the Medical Records Clerk was responsible for ensuring records were complete before filing, and the Social Services Director was responsible for overseeing advance care planning and ensuring staff were aware of residents' end-of-life wishes. Despite these responsibilities, the incomplete POLST was scanned into the resident's chart without the necessary signatures. The facility's policy and procedure for medical records accuracy was requested but not provided during the survey.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in the call lights being found on the floor and tucked in bedside drawers, out of the residents' reach. One resident, who had no cognitive impairment and diagnoses including congestive heart failure, diabetes mellitus, and adult failure to thrive, was observed lying in bed without access to a call light, which was on the floor. The resident stated he could not get a hold of staff when the call light was not accessible. Another resident, with severe cognitive impairment, dementia, bipolar disorder, and muscle weakness, was observed hitting the wall to get staff attention because her call light was out of reach. She stated it was difficult to get staff's attention without the call light. Staff interviews confirmed that call lights are expected to be within residents' reach and that failure to do so could prevent residents from calling for help. The Director of Nursing also stated that staff are expected to ensure call lights are accessible and acknowledged the risk to residents if they are unable to reach their call lights. Review of facility policy confirmed the requirement for staff to keep call lights within reach of residents while in bed.
Failure to Supervise Aggressive Resident Leads to Injury
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a history of aggressive behavior, resulting in an incident where the resident struck another resident. The aggressive resident, who had a care plan intervention for one-on-one supervision due to his aggressive tendencies, was left unattended in the dining room. This lapse in supervision led to the resident hitting another resident on the left hand, causing a skin tear and bleeding that required treatment. The aggressive resident was admitted with diagnoses including dementia and type 2 diabetes mellitus, and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. Despite the care plan specifying constant one-on-one supervision, there was a documented failure to assign a Certified Nurse Assistant (CNA) to supervise the resident during the time of the incident. Interviews with staff, including CNAs and Licensed Vocational Nurses (LVNs), confirmed that the resident was not being monitored as required, which placed other residents at risk. The Director of Nursing (DON) acknowledged that the facility's policy and procedure for preventing abuse and ensuring resident safety were not followed. The facility's policy emphasized the importance of protecting residents from physical harm and abuse, yet the lack of supervision allowed the aggressive resident to harm another resident. The incident was witnessed by another resident, but no staff member was present to intervene or witness the altercation, highlighting the failure in implementing the required supervision for the aggressive resident.
Unqualified Dietary Manager Hired
Penalty
Summary
The facility failed to hire a qualified Dietary Manager (DM) to oversee the food and nutrition services for 56 of 61 residents. During an interview, the DM admitted that she was still in school to become a certified dietary manager and had not yet completed her training or obtained certification. The Registered Dietitian (RD) confirmed that the DM was not certified and emphasized the importance of having a certified dietary manager to comply with state regulations and ensure proper food safety and nutrition standards in the kitchen. A review of the Dietary Manager job description indicated that the minimum requirements for the role included certification as a dietary manager, certification as a food service manager, or similar national certification for food service management and safety. Additionally, the Food Code from the U.S. Food and Drug Administration requires the person in charge to demonstrate knowledge of foodborne disease prevention and food safety by being a certified food protection manager. The facility's failure to meet these requirements had the potential to affect the nutrition status and health of the residents receiving food from the kitchen.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to ensure safe preparation, distribution, and storage practices in the kitchen, affecting 56 of 61 residents. Observations revealed that the top of the dishwasher was covered with dirt, crumbs, and white residue, which could have contaminated the dishes. Both the Dietary Supervisor and Cook acknowledged that the dishwasher should have been cleaned daily, and the Registered Dietitian confirmed that the residue could lead to improper cleaning of the dishes. The facility's policy and procedure on sanitation, as well as the US Food Code, were not followed in this instance. Additionally, three of seven pans in the kitchen had cracked and peeling cooking surfaces. The Registered Dietitian and Dietary Supervisor both stated that the pans should have been replaced to prevent the coating from contaminating the food. The facility's policy on sanitation and the US Food Code require that equipment and utensils be clean and intact to prevent cross-contamination. The walk-in freezer had a large icicle hanging inside, which was acknowledged by the Cook, Registered Dietitian, and Dietary Supervisor as a potential hazard and an indication of a malfunctioning freezer. Torn oven mitts with exposed interior fabric were also observed, posing a risk of burns and contamination. The facility's policy on sanitation and the US Food Code emphasize the importance of maintaining equipment in good condition to ensure food safety.
Failure to Follow Proper Inhaler Technique and Treatment Orders
Penalty
Summary
The facility failed to meet professional standards of practice for three residents. Licensed Vocational Nurse (LVN) 2 did not follow the facility's procedure for proper inhalation technique for metered dose inhalers (MDI) when administering medication to two residents. Specifically, LVN 2 did not wash or wipe the mouthpiece of the inhalers before and after use, which is against the facility's infection control protocol. This was confirmed through observations and interviews with LVN 2 and the Director of Nursing (DON), who acknowledged the importance of cleaning the inhalers to prevent bacterial growth and potential respiratory infections. Additionally, the facility failed to properly follow treatment orders for a resident requiring a splint/orthotic device. Licensed Nurses (LNs) were signing the Electronic Treatment Administration Record (eTAR) without ensuring that the splint/orthotic device was applied as ordered. LVN 2 admitted to signing the eTAR without verifying the application of the device, and another LVN also confirmed this practice. The DON stated that this was not acceptable and that nurses should verify the application before signing the eTAR. The residents involved had significant medical histories, including COPD, asthma, heart failure, hypertension, and muscle weakness. One resident was cognitively intact, while another was severely impaired in decision-making. The failure to follow proper procedures for inhaler use and the application of the splint/orthotic device could have serious implications for their health and well-being.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a physician Informed Consent was obtained for the use of psychotropic medication for one of six sampled residents (Resident 26). Resident 26 was administered quetiapine fumarate and risperidone from 3/26/24 to 4/8/24 without being fully informed of the risks and benefits, and without having the knowledge to make an informed decision. This failure was observed during an interview and record review with Licensed Vocational Nurse (LVN) 3, who confirmed that the medications were administered without a signed informed consent. The Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) also confirmed that informed consent should have been obtained prior to the administration of psychotropic medications. Resident 26 was admitted with a diagnosis of dementia with unspecified severity and psychotic disturbance. The resident's Medication Administration Record (MAR) indicated that quetiapine fumarate and risperidone were administered daily during the specified period. The facility's policy and procedure documents, dated 7/2022 and 2/2022, respectively, state that residents and/or their representatives should be informed of the risks, benefits, and potential adverse consequences of antipsychotic and psychotropic medications, and that informed consent should be obtained. Despite these policies, the facility did not obtain the necessary informed consent before administering the medications to Resident 26.
Failure to Honor Resident's Rights in Care Plan Participation
Penalty
Summary
The facility failed to honor a resident's rights by not informing or allowing the resident to decline a plan of care. Resident 12, who was cognitively intact with a BIMS score of 15, was placed on a low air loss (LAL) mattress without being educated on its function or the reason for its use. The resident's request for fitted sheets, which were contraindicated for the LAL mattress, was ignored, leading to feelings of frustration, being ignored, and physical discomfort. During observations and interviews, it was noted that Resident 12 repeatedly requested fitted sheets for her mattress, which were not provided. The resident expressed feeling unsanitary and disrespected due to lying on a bare mattress. Licensed Vocational Nurse (LVN) 1 admitted that the resident was not educated about the LAL mattress and its contraindications for fitted sheets. The Director of Nursing (DON) confirmed that the resident should have been informed about the mattress and given the option to decline its use. Further interviews revealed that the resident was placed on the LAL mattress as a preventative measure for a red area on her buttock. However, the resident was not involved in the decision-making process and was not informed of alternative options for wound prevention. The facility's policy on resident rights emphasized the importance of involving residents in their care plans, which was not adhered to in this case.
Failure to Provide a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for Resident 45, who was admitted with diagnoses of malnutrition and anxiety disorder. During an interview, Resident 45 reported that the bathroom in her room was dirty, with chipped and peeling paint around the sink and sand in the bottom of the toilet bowl. She expressed that the bathroom took a long time to be cleaned, leading her to use her briefs instead of the bathroom. Observations by staff, including an LVN, the Director of Nursing, and the Director of Maintenance, confirmed the poor condition of the bathroom, acknowledging that it did not provide a homelike environment. The facility's policy and procedure on Resident Rights, dated October 2022, states that residents have the right to a safe, clean, comfortable, and homelike environment. However, the observations and interviews indicated that the facility did not meet this standard for Resident 45. The chipped and missing paint, along with the unclean bathroom, were validated by multiple staff members, including the LVN, DON, and DM, who all agreed that the condition of the bathroom was not acceptable for a homelike environment.
Inaccurate MDS Assessment for Resident with Right-Sided Weakness
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status. Specifically, for one resident with right-sided weakness due to a cerebral infarction, the MDS assessment inaccurately coded the resident's functional limitation in range of motion. This discrepancy was identified during an observation and interview where the resident was unable to move his right arm and leg without assistance, which was confirmed by both the Licensed Vocational Nurse (LVN) and the Minimum Data Set Coordinator (MDSC). The MDSC admitted to coding the section incorrectly and acknowledged the responsibility for ensuring the accuracy of the MDS assessment. The Director of Nursing (DON) also confirmed that it was the responsibility of the staff completing the MDS assessments to ensure their accuracy. The facility's policy and procedure on conducting accurate resident assessments emphasized that qualified staff knowledgeable about the resident should conduct accurate assessments addressing each resident's status, needs, strengths, and areas of decline. Despite this policy, the MDS assessment for the resident in question was not completed accurately, potentially leading to unmet care needs for the resident.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident (Resident 57) who was administered apixaban, an anticoagulant medication, for atrial fibrillation. Despite the medication being prescribed on 1/30/24, no care plan was initiated to monitor the side effects of the anticoagulant. This oversight was confirmed during interviews and record reviews with the Licensed Vocational Nurse (LVN), the Minimum Data Set Coordinator (MDSC), and the Director of Nursing (DON). Each acknowledged that a care plan should have been developed to address the resident's anticoagulant use and its potential side effects, such as bleeding. Resident 57, who was admitted to the facility on 1/30/24, had multiple diagnoses including cerebral infarction, atrial fibrillation, and hypertension. During an observation and interview, Resident 57 expressed his need for assistance with care due to his inability to move the right side of his body. The facility's policy required a baseline care plan within 24 hours of admission and a comprehensive care plan within seven days, but this was not followed. The failure to create a care plan for the anticoagulant medication placed Resident 57 at potential risk for unmet anticoagulant needs.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. During a medication pass observation, an LVN was seen preparing medications for a resident and then leaving the medication cart unlocked and unattended while administering the medication inside the resident's room. This action was against the facility's policy, which mandates that medication carts must be locked when not under direct observation. The incident involved a resident with multiple diagnoses, including asthma, quadriplegia, and heart failure. The Director of Nursing confirmed that the facility's practice requires medication carts to be locked when unattended to prevent unauthorized access. The facility's policy and procedure on medication storage also stipulate that all drugs and biologicals must be stored in locked compartments and only accessible to authorized personnel.
Infection Control Deficiency Due to Improper Equipment Sanitization and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection control program, resulting in a deficiency when a Licensed Vocational Nurse (LVN) did not sanitize the blood pressure cuff and stethoscope after using them on a resident. The LVN also did not wash her hands before preparing medications for the same resident. This incident was observed in the east wing hallway by the resident's room, where the LVN was passing medications. The LVN admitted to not sanitizing the equipment and not washing her hands, acknowledging that these actions were against infection control protocols and could lead to cross-contamination and the spread of infection among residents. The resident involved had been admitted to the facility with diagnoses including hypertensive heart disease with heart failure and atherosclerotic heart disease. The Director of Nursing (DON) confirmed that the LVN should have followed proper infection control procedures, including sanitizing equipment and washing hands before medication preparation. The facility's policies and procedures also mandated these actions to prevent contamination and infection. The failure to adhere to these protocols was identified as an infection control issue by the DON.
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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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