Palo Alto Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Palo Alto, California.
- Location
- 911 Bryant Street, Palo Alto, California 94301
- CMS Provider Number
- 055646
- Inspections on file
- 21
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Palo Alto Post-acute during CMS and state inspections, most recent first.
During meal service, pureed fish and bread were found to be bland, and several hot food items, including regular and pureed options, were served below the required 135°F. The DM and RD confirmed these issues, which were identified through direct observation and staff interviews.
Surveyors found unsanitary cooking pans with discoloration and rust in the kitchen, and observed a dietary aide failing to follow proper hand hygiene and glove use during meal tray preparation. Both issues were acknowledged by dietary staff and had the potential to impact all residents receiving food from the kitchen.
Surveyors observed multiple infection control lapses, including dusty oxygen concentrator filters for two residents and repeated failures by CNAs and an LVN to perform hand hygiene before and after glove use, between resident contacts, and before handling medications or food. These actions did not follow facility policy or standard infection prevention protocols.
Facility staff did not monitor or document side effects for several residents receiving antibiotics, despite physician orders and facility protocols requiring such monitoring. Nursing staff and the DON confirmed that documentation was missing from the MAR and progress notes, and this was found during interviews and record reviews. The facility's antibiotic stewardship policy required monitoring and documentation, but these were not followed for the affected residents.
A CNA was observed standing while feeding a resident, contrary to facility policy requiring staff to be seated when feeding, and acknowledged she could have adjusted the bed or resident's position to comply. This failure did not honor the resident's right to dignity during mealtime.
An infection preventionist left her laptop open and unattended in a hallway with a resident's face sheet, containing personal and medical information, visible on the screen. She walked away to speak with staff in other areas, leaving the information exposed and unprotected.
Two residents received psychotropic medications without proper informed consent or monitoring. One was given a sedative hypnotic for insomnia without documented consent, monitoring, or a care plan addressing the medication. Another had an antipsychotic dose increased without updated consent. Facility policy requiring informed consent and ongoing evaluation was not followed.
Two residents prescribed antipsychotic medications did not have comprehensive, person-centered care plans specific to their medications, as required by facility policy. For one resident, there was no care plan for Aripiprazole and no baseline AIMS assessment was completed. For another, there was no care plan for Perphenazine, despite care plans for other psychotropic medications. These deficiencies were confirmed by the DON during interviews and record reviews.
A resident admitted with a pacemaker did not have required device information—such as implant date, device and lead details, and follow-up schedule—documented in the clinical record, despite facility policy mandating this documentation. The DON confirmed the absence of this information during record review.
Licensed nurses administered Norco, prescribed for severe pain, to a resident on multiple occasions when her pain level was below the physician-ordered threshold. The DON confirmed that pain medication was not given according to the specified pain level, as documented in the MAR.
Two residents using bed rails for mobility assistance did not have their side rail assessments updated as required by facility policy. Despite physician orders and ongoing use of side rails, the assessments were overdue, and the DON confirmed they were not completed on schedule.
A resident received Ferosul and Calcium Citrate at the same time, despite orders and pharmacy policy requiring assessment for drug interactions. The concurrent administration of these medications, which should be separated to avoid decreased iron absorption, was confirmed by the pharmacist consultant and supported by drug reference materials.
A pharmacist consultant's recommendation to include specific administration instructions for alendronate in a resident's medication record was not followed. The resident, who had osteoporosis, did not have the recommended instructions documented in her administration record, and the DON confirmed this omission during a record review.
A resident receiving dabigatran, an anticoagulant, was not monitored for side effects and did not have the medication use addressed in their care plan, contrary to facility policy. The DON confirmed the lack of monitoring and care planning for this medication.
Surveyors observed a 12% medication error rate when three residents did not receive medications as ordered: one did not receive a prescribed calcium/vitamin D tablet, another was given Diroximel Fumarate without food, and a third did not receive a scheduled inhalation treatment. In each instance, medications were not administered per physician orders or manufacturer instructions, as confirmed by the DON.
Surveyors found that medications and biologicals were not stored properly, including a medication refrigerator with ice buildup and a yellowish-brown substance, as well as expired over-the-counter medications and an opened bottle of medication for a discharged resident in the Central Supply Room. The DON confirmed these issues, which were not in line with facility policy requiring proper sanitation and timely removal of outdated medications.
Seventeen bedrooms were found to have less than the required 80 square feet per resident, with measurements showing square footage per resident ranging from 71.37 to 75. Interviews with residents and staff revealed no reported concerns about space or privacy.
Failure to Ensure Palatable and Properly Heated Food Service
Penalty
Summary
The facility failed to ensure that food served to residents was both palatable and maintained at a safe, appetizing temperature. During a test tray observation and tasting, pureed fish and pureed bread were found to be bland and lacking in taste. The dietary manager acknowledged the issue after tasting the foods, and the registered dietitian confirmed that foods should be palatable and not bland. Facility policies require that resident food preferences be satisfied and that food acceptability be routinely monitored by both food service and nursing staff. Additionally, the temperatures of several hot food items, including regular fish, regular vegetables, pureed fish, pureed orzo, and pureed bread, were measured and found to be below the required 135 degrees Fahrenheit at the time of service. Both the dietary manager and the registered dietitian confirmed that hot foods should be served at or above this temperature, as outlined in the facility's policies and procedures for safe food temperatures. These deficiencies were identified during direct observation and interviews with facility staff.
Failure to Maintain Kitchen Sanitation and Hand Hygiene During Food Preparation
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and food safety standards in the kitchen. During a kitchen tour, five large cooking pans were found with brownish to blackish discolorations and rusty spots. Both the dietary manager and the registered dietitian acknowledged the unsanitary condition of these pans, confirming that such equipment should not be kept or used in the kitchen. Additionally, during tray line preparation, a dietary aide was seen leaving the kitchen while still wearing gloves, then returning and continuing to assist with meal trays without removing the used gloves, washing hands, or donning new gloves. The dietary aide, dietary manager, and registered dietitian all confirmed that proper hand hygiene and glove use were not followed as required by facility policy. These lapses in sanitation and hand hygiene had the potential to affect all 55 residents receiving food from the kitchen.
Infection Control Deficiencies: Hand Hygiene and Equipment Cleaning Lapses
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several instances involving both staff and equipment. During observations, the filters of two residents' oxygen concentrators were found to be dusty, despite facility policy and manufacturer recommendations requiring weekly cleaning and preventive maintenance. The infection preventionist confirmed that the filters should have been cleaned, but this was not done as required. Multiple staff members did not adhere to hand hygiene protocols. One certified nursing assistant (CNA) was observed leaving a resident's room with gloves on, disposing of trash in the hallway, and then returning to the resident's room to continue care without changing gloves or sanitizing hands. The same CNA also failed to sanitize hands after removing gloves before retrieving supplies. Another CNA removed gloves after repositioning a resident but did not sanitize hands before assisting with the resident's meal or before leaving the room, handling food items and utensils with potentially contaminated hands. A licensed vocational nurse (LVN) was observed administering oral medications to two residents consecutively without performing hand hygiene before or after glove use, or between resident contacts. The LVN acknowledged the lapse in hand hygiene, and the Director of Nursing confirmed that hand hygiene is required between residents during medication administration. Facility policies reviewed support the need for hand hygiene before and after glove use, between resident contacts, and before handling medications.
Failure to Monitor and Document Antibiotic Side Effects
Penalty
Summary
Facility staff failed to monitor and document the side effects of antibiotic therapy for seven out of eleven residents who were receiving antibiotics. These residents had various medical conditions, including tuberculosis, respiratory failure, pneumonia, aortic valve stenosis, osteomyelitis, COPD, post-liver transplant care, and urinary tract infections. Physician orders for antibiotics such as Levofloxacin, Ethambutal, Linezolid, Vancomycin, Ciprofloxacin, Ceftriaxone, Cefdinir, and Bactrim were present in the residents' records. Interviews with nursing staff, including RNs and the Infection Preventionist, confirmed that the facility's protocol required monitoring for side effects such as rash, hives, dizziness, allergic reactions, nausea, vomiting, and changes in cognition during antibiotic therapy. Staff stated that this monitoring should be documented in the Medication Administration Record (MAR) or progress notes. However, record reviews and staff interviews revealed that there was no documentation of such monitoring for the affected residents during their antibiotic courses. The Director of Nursing verified that there was no documentation of antibiotic monitoring in the MAR or progress notes for the residents in question. The facility's policy on antibiotic prescribing practices required protocols for monitoring and documentation as part of its Antibiotic Stewardship Program, but random audits found these requirements were not met for the residents identified.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while feeding lunch to a resident in her room, rather than sitting as required by facility policy. During an interview conducted at the time of the observation, the CNA stated she did not feel comfortable sitting to feed the resident because she had to reach, but acknowledged that she could have adjusted the bed level and repositioned the resident to feed her while seated. The facility's policy on promoting and maintaining resident dignity during mealtimes specifies that all staff should be seated, if possible, when feeding residents. This action did not align with the policy and failed to honor the resident's right to dignity during mealtime.
Resident Confidentiality Breach Due to Unattended Laptop
Penalty
Summary
The infection preventionist (IP) failed to protect a resident's right to confidentiality by leaving her laptop open and unattended in the hallway with the resident's face sheet displayed on the screen. The face sheet contained sensitive information, including the resident's name, address, date of birth, emergency contact, medical history, medications, allergies, and insurance details. The IP left the laptop on a stand in the hallway and walked away to the lobby to speak with the maintenance director, then continued to another hallway to talk with other staff, leaving the screen visible and accessible to unauthorized individuals. The IP later confirmed during an interview that she had left the laptop open and unattended, acknowledging that she should have closed it before leaving.
Failure to Obtain Informed Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medication use, as required by policy and regulation. For one resident with depression and schizoaffective disorder, Belsomra was prescribed and administered for insomnia without obtaining informed consent, without monitoring for sleep or side effects, and without a care plan that addressed the medication's use or related interventions. The Director of Nursing confirmed that there was no documentation of informed consent, no monitoring after the medication was started, and the care plan did not include specific interventions related to Belsomra. For another resident with bipolar disorder and schizophrenia, the dose of the antipsychotic medication Perphenazine was increased without obtaining updated informed consent for the new dosage. The DON verified that the consent on file was for a different dose than what was being administered. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing psychotropic medications, and that such information be documented, but this was not followed in these cases.
Failure to Develop and Implement Comprehensive Care Plans for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were prescribed antipsychotic medications. For one resident with diagnoses including anxiety disorder, depression, and unspecified mood disorder, there was no care plan specific to the prescribed antipsychotic medication, Aripiprazole. Additionally, required interventions such as a baseline Abnormal Involuntary Movement Scale (AIMS) assessment were not completed, and the care plan did not address the black box warning associated with the medication. The Director of Nursing (DON) confirmed these omissions during record review and interview, and the facility's policy required ongoing evaluation of psychotropic medication effects in accordance with the resident's care plan. For another resident with bipolar disorder and schizophrenia, the facility did not create a care plan specific to the prescribed antipsychotic medication, Perphenazine. Although this resident had care plans for other psychotropic medications, there was no individualized plan addressing Perphenazine, as verified by the DON. The facility's policy stipulated that all psychotropic medications should be included in the comprehensive care plan, with measurable objectives and timeframes to meet the resident's needs. These deficiencies were identified through interviews and medical record reviews, which revealed that the facility's practices did not align with its own policies and procedures regarding the use of psychotropic medications and the development of comprehensive care plans. The lack of specific care plans and failure to implement required monitoring interventions for antipsychotic medications were directly observed and confirmed by facility staff.
Missing Pacemaker Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident admitted with a pacemaker had complete and necessary information about the device documented in the clinical record. Upon review, the resident's admission record and physician order confirmed the presence of a pacemaker, but the clinical record lacked essential details such as the cardiologist's information, implant date, device model and serial number, lead model and serial number, battery longevity, device settings, and scheduled checkup period. During an interview, the DON was unable to locate any pacemaker information in the resident's record, despite facility policy requiring all pacemaker documentation to be included in the resident's chart and permanent record.
Pain Medication Administered Outside Physician-Ordered Parameters
Penalty
Summary
Licensed nurses administered Norco 5-325 mg, a medication prescribed for severe pain (pain level 7-10), to a resident who had been admitted for aftercare following joint replacement surgery. The physician's order specified that Norco should only be given for severe pain, but the medication was administered on multiple occasions when the resident's pain level was documented as less than 7. These administrations occurred on numerous dates throughout the month, as recorded in the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed upon review of the MAR that Norco was given to the resident when her pain level did not meet the threshold specified in the physician's order. The facility's job description for registered nurses requires compliance with professional standards and physician orders when administering medications. The failure to follow the prescribed pain management protocol resulted in the resident receiving pain medication inappropriately.
Failure to Timely Update Bed Rail Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the proper use and timely reassessment of bed rails for two residents who utilized side rails. For one resident with a history of arthropathic psoriasis, the side rail assessment was last updated several months prior to the observation, despite a physician's order for side rails to assist with bed mobility. The DON confirmed that the assessment had not been updated regularly or quarterly as required. Similarly, another resident with a cervical vertebra fracture had an outdated side rail assessment, with the last update occurring months before the observation, even though there was an active physician's order for side rails for bed mobility. The DON acknowledged that this assessment was also not updated according to the facility's schedule. The facility's policy requires that side rail assessments be completed at least quarterly, upon significant change in status, or when there is a change in the type of bed, mattress, or rail. However, both residents' assessments were not updated in accordance with this policy. These lapses were identified through observation, record review, and interviews with the DON, who verified the assessments were overdue. The failure to update side rail assessments as scheduled constituted a deficiency in the facility's adherence to its own procedures for the safe use of bed rails.
Failure to Separate Administration of Iron and Calcium Resulting in Drug Interaction
Penalty
Summary
The facility failed to ensure the effective use of medications for a resident who was prescribed Ferosul (iron supplement) and Calcium Citrate. According to the resident's clinical record, there were physician orders for Ferosul 325 mg every 48 hours at 9 a.m. for anemia, and Calcium Citrate 250 mg every day at 9 a.m. and 5 p.m. As a result, both medications were administered together at 9 a.m. every 48 hours starting from the date the iron supplement was ordered. During an interview, the pharmacist consultant confirmed that Ferosul and Calcium Citrate should be administered at least two hours apart due to a significant drug-drug interaction that decreases iron absorption. Reference to Lexicomp, a nationally recognized drug information resource, indicated that concurrent administration of calcium and ferrous sulfate can decrease iron absorption by an average of 60%. The facility's policy required the pharmacy to assess medication profiles for potential adverse drug interactions at admission and with each new order, but this was not effectively implemented in this case.
Pharmacist's Medication Administration Recommendation Not Implemented
Penalty
Summary
The facility failed to ensure that a pharmacist consultant's recommendation regarding the administration of alendronate for a resident with osteoporosis was implemented. The pharmacist consultant had recommended that the administration record for alendronate include specific instructions: to administer the intact tablet at least 30 minutes before the first food, beverage, or medication of the day with 6 to 8 ounces of plain water, and to ensure the individual does not lie down for at least 30 minutes and until after the first food of the day. Review of the resident's administration record showed that these instructions were not included as recommended. The director of nursing confirmed during an interview that the recommendation was not acted upon, despite facility policy requiring staff to address all medication regimen review recommendations.
Failure to Monitor and Care Plan Anticoagulant Use
Penalty
Summary
A resident was admitted to the facility and had a physician's order for dabigatran etexilate mesylate, an anticoagulant, to be administered twice daily. Review of the resident's clinical record showed there was no documentation that the resident was monitored for side effects associated with the medication, such as abnormal bleeding or bruising, nor was there evidence that the use of the anticoagulant was addressed in the resident's care plan. The facility's policy on anticoagulant therapy required monitoring for adverse drug effects and inclusion of anticoagulant use and monitoring in the care plan. The DON confirmed during interview that these actions were not completed for this resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Improper Administration
Penalty
Summary
A medication error rate of 12% was identified during a medication pass, with three errors observed out of 25 opportunities involving three residents. One resident did not receive their prescribed Calcium Carbonate with Vitamin D tablet as ordered by the physician because the medication was not available at the time of administration. Another resident received Diroximel Fumarate capsules, a medication for multiple sclerosis, without food, contrary to the physician's order and manufacturer instructions that specify the medication should be administered at least 20 minutes after food intake. The nurse did not verify if the resident had eaten prior to administration. Additionally, a third resident did not receive their prescribed Fluticasone-Salmeterol inhalation for asthma as ordered, as the medication was not available during the scheduled medication pass. In each case, the medications were not administered in accordance with physician orders and manufacturer specifications, as confirmed by concurrent interviews and record reviews with the Director of Nursing. Facility policy requires medications to be administered as ordered by the physician and in accordance with professional standards of practice.
Improper Storage and Expired Medications Found During Inspection
Penalty
Summary
Surveyors observed that medications and biologicals were not stored in accordance with professional standards and the facility's own policies. During an inspection of the medication room, a mini refrigerator was found with significant ice buildup in the freezer compartment, which prevented the freezer door from closing properly and made it difficult to open. Additionally, a yellowish-brown streak was noted on the right shelf bracket inside the refrigerator. The DON confirmed these findings and acknowledged that the refrigerator could be cleaned better. The facility's policy requires medications to be stored in a manner that ensures proper sanitation and environmental control. In a separate inspection of the Central Supply Room, five expired over-the-counter medications and an opened bottle of medication labeled for a discharged resident were found. The DON confirmed the presence of these expired items and the medication belonging to a discharged resident, stating she was unaware of why they were still stored there. Facility policy specifies that discontinued, outdated, or deteriorated medications should be routinely removed and destroyed according to established procedures.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to ensure that 17 out of 27 bedrooms met the required minimum of 80 square feet per resident for multiple occupancy rooms, as determined by room measurements. Specific rooms were identified where the square footage per resident ranged from 71.37 to 75 square feet, which is below the regulatory standard. During the survey, both residents and staff were observed and interviewed, and no concerns or complaints were expressed regarding space or privacy affecting the care provided to residents.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
