Palomar Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Escondido, California.
- Location
- 1260 E Ohio Avenue, Escondido, California 92027
- CMS Provider Number
- 555764
- Inspections on file
- 33
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Palomar Heights Post Acute during CMS and state inspections, most recent first.
A resident with a G-tube and seizure history was found lying in bed with eyes closed while a clear plastic cup containing crushed medications mixed in liquid was left unattended on the bedside table. Physician orders required morning administration of ascorbic acid, furosemide with blood pressure parameters, and a multivitamin via G-tube, and the MAR showed these medications as given. An LN reported leaving the medications at the bedside to dissolve further and acknowledged they should not have been left there, while the DON stated medications must not be left unattended in resident rooms. The facility’s medication storage policy required locked compartments for biologicals when not in use and specified that items shall not be left unattended, which conflicted with the observed practice.
A resident with a G-tube and seizure diagnosis was found lying in bed with a cup of crushed medications mixed in liquid left unattended on the bedside table, while the MAR showed the morning doses of ascorbic acid, furosemide, and a multivitamin as already administered via G-tube. An LN reported leaving the medications to further dissolve after giving water and had documented them as given, and the DON confirmed medications should not be left unattended and that documentation must reflect when drugs are withheld or given at unscheduled times. This resulted in inaccurate medical record documentation contrary to facility policy and prescriber orders.
Multiple deficiencies were identified in medication administration and documentation, including late administration of aspirin for a resident, improper technique for nasal spray administration, failure to verify G-tube placement and use gravity for medication delivery, and unaccounted controlled medications for two residents due to incomplete documentation and lack of reconciliation between records.
Surveyors found that expired insulin was stored in a medication cart, ipratropium/albuterol inhalation vials were left exposed to light in an open box, and a box of ampicillin vials was kept unlabeled in a medication room drawer. Nurses and nursing leadership confirmed these practices did not meet facility policy or manufacturer guidelines for medication storage and labeling.
Multiple residents reported that meals were often served cold, lacked taste, and were unattractive, with some avoiding facility food altogether. Surveyors confirmed these concerns through interviews and a test tray evaluation, finding that while food temperature was acceptable, the main entrée was tasteless, and the Dietary Services Supervisor agreed with this assessment.
The QAA Committee did not identify or include trends related to resident nail care, grooming, and annual staff performance evaluations in the QAPI plan, despite these deficiencies being found by surveyors. The DON confirmed that the QAPI team was only monitoring call lights, falls, and UTIs, and had not addressed the additional areas as required by facility policy.
A resident with swallowing difficulties was fed by a CNA who stood over the bed instead of sitting at eye level, contrary to facility policy and staff training. Staff interviews confirmed the expectation to sit while feeding to maintain dignity, but the CNA did not comply due to lack of a chair in the room.
Two residents, one with COPD and dementia and another with a corneal ulcer and vision impairment, were not properly assisted with or offered Advance Directives (AD) upon admission. Facility staff failed to document whether ADs were requested, accepted, or declined, despite policy requirements and resident reports that assistance was not provided. This resulted in a deficiency related to honoring residents' rights regarding healthcare preferences.
Several residents experienced deficiencies in their living environment, including unaddressed maintenance issues such as a leaking toilet, missing caulking, a hole in the wall, and cobwebs in vents, as well as the failure to replace or reimburse lost clothing. Staff interviews confirmed that these concerns were not properly documented or addressed, resulting in an environment that was not clean, well-maintained, or homelike.
A resident with a history of pulmonary fibrosis showed improvement in ADLs, but the IDT did not timely review or determine the need for a Significant Change of Status Assessment (SCSA), and the care plan was not updated to reflect these changes. The MDS nurse confirmed the SCSA was not discussed or completed on time, and the physician was not notified of the improvement.
A resident with a history of pulmonary fibrosis did not have their MDS and CAA assessments completed and transmitted within the federally required 14-day timeframe. The MDS nurse and DON confirmed the delay, which could have led to delays in care planning and unmet care needs.
A resident with a history of major depressive disorder and moderate cognitive deficits did not have their care plan updated to reflect their preferred social activities or participation frequency. The Activities Director was unaware of the need to revise activity care plans after reassessments, and the care plan had not been updated in nearly a year, despite the resident's expressed interests and needs for assistance.
A resident with a history of pulmonary fibrosis was re-admitted and experienced improvement, but the care plan was not updated after a Significant Change of Status Assessment (SCSA). The MDS nurse did not complete required assessments on time, and the DON confirmed that care plans should be updated promptly to reflect current conditions, as outlined in facility policy.
Three residents who were unable to perform personal hygiene tasks independently were observed with long, dirty fingernails, and in some cases, requested assistance with nail care that was not provided. Staff interviews confirmed that nail care was not performed as needed, and facility policy requiring daily cleaning and regular trimming was not followed.
A resident with moderate cognitive deficits and a history of major depressive disorder did not consistently receive meaningful activities aligned with her preferences, such as social gatherings and assistance with mobility, due to lapses in activity planning and care plan updates. The AD did not update the activity care plan after reassessments, and activities were not provided as frequently as documented in the resident's plan, resulting in unmet psychosocial needs.
A resident with muscle weakness and chronic venous hypertension experienced pain when a CNA used a Hoyer lift to weigh the resident without a second staff member present, resulting in the lift striking the resident's left knee. Staff interviews and facility policy confirmed that two staff are required for safe use of the mechanical lift, but this protocol was not followed.
A resident with PTSD and a history of traumatic brain injury, seizures, and repeated falls did not receive trauma-informed care as required. Direct care staff, including a CNA and charge nurse, were unaware of the resident's PTSD diagnosis and specific triggers, and there was no scheduled staff training on PTSD. Although the Social Service Director maintained a PTSD care plan binder, several staff members did not know about it or the expectation to review it, resulting in a failure to minimize the resident's exposure to trauma triggers.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by record review and staff interviews. Despite facility policy mandating annual evaluations after the probationary period, these evaluations were missing for multiple years for both CNAs.
A licensed nurse did not consistently verify meal tray contents against tray cards before distribution, only checking trays for therapeutic diets and not for regular diets or allergies. This resulted in a failure to ensure residents received the correct diets as ordered.
A licensed nurse did not document an incident where a resident with cognitive impairment was found sitting on the floor after reportedly losing balance and being assisted by staff. The DON confirmed that such incidents should be documented as falls, but no record was made in the clinical file.
A resident with end-stage stroke was admitted with orders for hospice care, but the facility failed to ensure timely communication and awareness of the resident's hospice certification status. The Social Service Director, responsible for coordinating hospice care, was unaware that the physician's certification had expired, and staff interviews confirmed that re-certification is necessary for continued hospice services. This lapse indicated a breakdown in the process for coordinating and documenting hospice care.
Staff did not discard an unlabeled IV hydration bag and uncapped IV tubing left hanging at a resident's bedside, despite the resident not having an active IV line. The equipment remained in the room for several days, and the resident had a history of HIV and moderate cognitive deficits. The ICPN and DON confirmed the items should have been labeled and removed, but the facility's infection control policy lacked guidance on IV equipment disposal.
The facility failed to develop and implement adequate policies for influenza and pneumococcal immunizations, neglecting to provide necessary education to residents or their representatives and failing to document immunization status in medical records. This oversight includes not offering influenza immunizations during the required period and not ensuring pneumococcal immunizations were administered unless contraindicated.
A resident with a below-the-knee amputation fell while transferring from bed to a wheelchair with nonfunctioning brakes. Despite the resident's report, the issue was not logged or addressed by the facility's maintenance team. Observations confirmed the brakes were faulty, and the facility's policies on equipment maintenance were not followed, contributing to the fall.
A resident with a below-the-knee amputation fell while transferring from bed to a wheelchair due to malfunctioning brakes. Despite the resident's report, the wheelchair brakes remained unfixed. Staff confirmed the brake issue, and the maintenance log showed no prior reports, indicating a lapse in equipment maintenance and reporting.
A resident with congestive heart failure and ischemic cardiomyopathy was found unresponsive and later pronounced deceased after the facility failed to assess a change in condition and notify the physician. The resident had refused a shower, appeared pale and sweaty, but the licensed nurse did not follow up on vital signs or assess the condition due to being busy. The facility's policy required prompt notification and assessment, which was not adhered to.
Unattended Medications Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to medication storage and administration when a resident’s crushed medications mixed in a tea-colored liquid were observed in a clear plastic cup left unattended on the bedside table. During an unannounced complaint visit, the resident was observed lying in bed with eyes closed while the medication cup remained at the bedside. The resident’s admission record showed diagnoses including attention to gastrostomy and seizures, and the MDS assessment had a blank BIMS cognition section. Physician orders indicated the resident was to receive ascorbic acid 500 mg, furosemide 40 mg with parameters to hold for systolic blood pressure less than 100, and a multivitamin with minerals, all to be administered via G-tube in the morning. The MAR for the same date showed these medications as administered and signed off by a licensed nurse. In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water and acknowledged she should not have left them in a clear cup at the bedside because some residents or someone might pick them up and swallow them. The DON stated that medications should not be left anywhere in resident rooms unattended and emphasized this was important for resident safety. Review of the facility’s “Storage of Medications” policy stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, that compartments containing biologicals shall be locked when not in use, and that items shall not be left unattended. The observed practice of leaving medications unattended at the bedside was inconsistent with this policy.
Inaccurate MAR Documentation and Unattended Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation when a resident’s medications were documented as administered despite being left unattended at the bedside. During an unannounced complaint visit, a resident with a gastrostomy tube and seizure diagnosis was observed lying in bed with eyes closed, while a clear plastic cup containing crushed medications mixed in a tea-colored liquid was found on the bedside table. The resident’s MDS showed the BIMS cognition section was blank. Physician orders directed that several medications, including ascorbic acid, furosemide (with a hold parameter for SBP <100), and a multivitamin with minerals, be given via G-tube in the morning. The MAR for that morning indicated these medications were administered and signed off by a licensed nurse as given. In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water she had administered earlier and had already documented the medications as given on the MAR. The DON stated that medications should not be left unattended in any resident rooms and confirmed that the nurse had documented the medications as administered via G-tube. The facility’s “Administering Medications” policy stated that only appropriately licensed personnel may prepare, administer, and document medications, that medications are to be administered in accordance with prescribers’ orders, and that if a drug is withheld, refused, or given at a time other than scheduled, the individual administering the medication must document this. The observed practice and documentation for this resident were inconsistent with these requirements, resulting in inaccurate medical record documentation.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for several residents. For one resident, aspirin prescribed as a stroke prophylaxis was administered outside the one-hour window specified by the physician's order, with documentation showing the medication was given over two hours late. Both the licensed nurse and the Director of Nursing acknowledged the importance of timely administration and adherence to physician orders, as outlined in facility policy. Another resident received Fluticasone nasal spray for allergies, but the administration did not follow the manufacturer's instructions. The nurse instructed the resident to tilt her head back instead of forward, contrary to the packaging insert. Both the nurse and the Director of Nursing confirmed that following manufacturer guidelines is necessary for medication effectiveness, and the nurse admitted to not following the correct procedure during administration. A third resident with a G-tube did not have proper placement verification before medication administration, as the nurse used water instead of air for auscultation and administered medication using a syringe/plunger rather than by gravity, which is against facility policy. Additionally, for two other residents, controlled medications could not be accounted for due to discrepancies between the controlled drug record and the electronic medication administration record. The nurses and Assistant Director of Nursing confirmed that documentation was incomplete and that required audits and reconciliations were not performed, as required by facility policy.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were stored and labeled according to accepted standards of practice. During inspection of two medication carts and one medication room, expired insulin was found stored in a medication cart, and a nurse acknowledged it should have been discarded after 28 days due to potential loss of potency. Additionally, ipratropium/albuterol inhalation vials were stored in an open box, exposing them to light, contrary to manufacturer instructions to keep them protected from light. The nurse responsible for the cart confirmed the box should have been closed to prevent light exposure. In the medication room, a box of ampicillin vials was found inside a drawer without a medication label, stored alongside unrelated items such as a plastic bag and a pen. The nurse present was unaware of the reason for the unlabeled storage. The Assistant Director of Nursing stated that the ampicillin should have been labeled with the resident's name and other required information, and the Director of Nursing confirmed that expired insulin and improperly stored medications should have been discarded. Facility policy and manufacturer guidelines reviewed by surveyors supported these requirements for medication labeling and storage.
Deficiency in Food Palatability and Temperature
Penalty
Summary
Surveyors identified a deficiency related to the preparation and serving of food, based on both resident interviews and direct observation. Multiple residents reported that the food was often served cold, lacked taste, and was unattractive in appearance. Specific complaints included food being cold at breakfast, unappetizing combinations, insufficient variety, and poor presentation. Some residents stated they avoided eating the facility's food, with one resident relying on family to bring in meals. These concerns were echoed during a confidential group interview, where residents noted that food quality was particularly poor on weekends when the supervisor was not present. To verify these complaints, surveyors conducted a test tray evaluation during a lunch service. The test tray was assessed for temperature and taste by both the surveyor and the Dietary Services Supervisor (DSS). While the temperature of the food was found to be palatable, the roast turkey was described as tasteless, a finding with which the DSS agreed. The report documents that the facility failed to cook food in a way that preserved its palatability, leading to resident dissatisfaction and the potential for decreased food intake.
QAA Committee Failed to Identify and Address Deficient Trends in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and include certain quality deficiencies in the Quality Assurance Performance Improvement (QAPI) plan. Specifically, during a recertification and relicensing survey, surveyors identified trends related to resident nail care, grooming, and annual staff performance evaluations that were not being monitored or addressed by the QAA Committee. The Director of Nursing (DON) confirmed that the QAPI team was primarily focused on call lights, falls, and urinary tract infections, and had not recognized or prioritized the additional deficient trends found by surveyors. Facility policy requires the QAPI program to address all systems and practices affecting residents, including clinical care, quality of life, and staff performance, and to prioritize high-risk or problem-prone areas. However, the QAA Committee did not identify or include the surveyor-identified trends in their QAPI plan, contrary to policy expectations. This omission was acknowledged by the DON during interviews and was supported by a review of the facility's QAPI documentation.
Failure to Promote Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a resident with dysphagia and oropharyngeal swallowing difficulties was not provided care in a manner that promoted dignity and respect during mealtime. During an observation, two CNAs assisted the resident with breakfast while the resident was in bed. One CNA fed the resident while standing next to the bed, rather than sitting at the resident's eye level. The CNA acknowledged that she was taught to sit while feeding residents to promote dignity but did not do so because there was no chair available in the room. Interviews with staff, including another CNA, the Director of Staff Development, and the Director of Nursing, confirmed that the facility's expectation and policy require staff to sit at the resident's eye level when providing feeding assistance. The facility's policy on meal assistance specifically states that residents should be fed with attention to safety, comfort, and dignity, and not while standing over them. The failure to follow this policy resulted in care that did not honor the resident's right to dignity.
Failure to Assist with or Document Advance Directives for Two Residents
Penalty
Summary
The facility failed to assist with or obtain Advance Directives (AD) for two residents, resulting in a deficiency related to honoring residents' rights to specify their healthcare preferences. For one resident with a history of COPD and dementia, the Social Service Director acknowledged that while a Physician Orders for Life Sustaining Treatment (POLST) was present in the clinical record, there was no AD on file. The Admissions Coordinator was unable to find documentation that an AD was requested, refused, discontinued, or offered, and only a consent to treat form was signed by the resident's responsible party. The Director of Nursing confirmed that it was expected for ADs to be part of the clinical chart and emphasized the importance of knowing who would be responsible for healthcare decisions. For another resident admitted with a corneal ulcer and blindness in one eye, the Director of Nursing and Admissions Director both confirmed that there was no documentation of an AD being offered, accepted, or declined. The resident reported that the admission agreement was read quickly and that he was not offered assistance with creating an AD, despite the facility's policy stating that staff would offer such assistance and document the resident's decision. The lack of documentation and failure to offer or assist with ADs for these residents constituted the identified deficiency.
Failure to Maintain Safe and Homelike Environment and Replace Lost Belongings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents. One resident reported missing three shirts, which were not replaced or reimbursed by the facility despite being reported to staff. The Social Services Director stated the shirts were not replaced because they were not listed on the belongings sheet, although the resident's belongings sheet did indicate shirts were present. The Administrator later acknowledged that the shirts should have been replaced. As a result, the resident did not have enough shirts for daily use. Additionally, three other residents experienced issues with the cleanliness and maintenance of their living environment. One resident and his roommate reported a leaking toilet, missing caulking, a missing baseboard, and cobwebs in the bathroom vent. Another resident reported a hole in the wall behind his door that had been present since admission. Observations confirmed these deficiencies, and staff interviews revealed that maintenance issues were not documented in the maintenance binder as required. The Maintenance Supervisor admitted to not having time to address these issues and not conducting regular room checks. The Director of Nursing confirmed that the environment should be visually appealing and that the reported issues should have been addressed.
Failure to Timely Assess and Update Care Plan After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to properly assess and document a significant change in condition for a resident who was re-admitted with a history of pulmonary fibrosis. Despite evidence of improvement in activities of daily living (ADLs) such as eating, oral hygiene, and toileting, the Interdisciplinary Team (IDT) did not review or determine the need for a Significant Change of Status Assessment (SCSA) during the comprehensive skilled review. The Minimum Data Set (MDS) nurse confirmed that the SCSA was not discussed or initiated in a timely manner, and the care plan was not updated to reflect the resident's improvement as required by the Resident Assessment Instrument (RAI) manual. Additionally, the care plan for the resident's ADLs, last revised prior to the improvement, did not include updated information from the SCSA. The MDS nurse also stated that the resident's physician was not notified of the improvement, and the IDT did not solidify whether an SCSA was appropriate during their review. The Director of Nursing indicated that the expectation was for the IDT and MDS nurse to know and apply the criteria for SCSA and to discuss significant changes in status for all residents, but this did not occur in this instance.
Late Completion of MDS and CAA Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) and Care Area Assessment (CAA) within the required timeframe for one resident. Specifically, the MDS and CAA for a resident who was re-admitted with a history of pulmonary fibrosis were not completed and transmitted to the state within 14 days of the assessment reference date, as mandated by federal regulations. Record review showed that the assessment completion and care plan updates were late, with the MDS nurse confirming that the required assessments had not been completed on time. Interviews with the MDS nurse and the Director of Nursing confirmed that the assessments and care plan updates were delayed, which could have resulted in delays in care planning and unmet care needs for the resident. The MDS nurse acknowledged that the late completion of the MDS could have delayed necessary care updates and may have impacted the resident's ability to maintain or improve their independence in activities of daily living.
Failure to Update Person-Centered Care Plan for Resident Activities
Penalty
Summary
The facility failed to develop a person-centered care plan that addressed all of a resident's needs, specifically neglecting to include the resident's preferred activities. The resident, who had a history of major depressive disorder and moderate cognitive deficits, expressed a desire to participate in social activities such as bingo and coffee gatherings but required assistance to get out of bed and to change into her own clothing. Despite these expressed preferences and needs, the care plan had not been updated since the previous year and did not reflect the resident's current activity interests or participation frequency as indicated in her activity participation review. Interviews with the Activities Director (AD) revealed a lack of awareness regarding the need to update activity care plans following quarterly and comprehensive reassessments. The AD acknowledged the importance of updating care plans to support residents' mental and physical well-being but had not done so for this resident. The Director of Nursing (DON) confirmed that activity preferences should be established through resident interviews and incorporated into individualized care plans, and that the AD should contribute to these updates as part of the interdisciplinary team. The facility's policy also required resident participation in care planning, including determining the type, amount, frequency, and duration of care.
Failure to Update Care Plan After Significant Change Assessment
Penalty
Summary
The facility failed to update the care plan for one resident following a Significant Change of Status Assessment (SCSA), as required by federal guidelines. The resident, who had a history of pulmonary fibrosis and was re-admitted to the facility, experienced an improvement in their condition that was not reflected in the revised care plan dated 1/25/25. A review of the clinical chart showed that the care plan for activities of daily living (ADL) did not include updated information from the SCSA regarding the resident's improvement. Interviews with facility staff revealed that the MDS nurse acknowledged the required assessments, including the MDS and CAA, were not completed on time, and the care plan was not updated to reflect the resident's improved self-care abilities. The DON confirmed the importance of timely completion of these assessments and care plan updates to ensure they reflect the resident's current condition. The facility's policy also requires the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition.
Failure to Provide Adequate Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically nail care and shaving, for three residents who were unable to perform these tasks independently. Observations and interviews revealed that one resident with hemiplegia and hemiparesis had long fingernails with debris underneath and expressed a desire to have her nails trimmed. A CNA confirmed that nail care was scheduled weekly and acknowledged the risk of fungus and bacteria from long nails. Another resident, dependent on staff for personal hygiene due to muscle weakness and lymphedema, had long fingernails with black debris and requested staff assistance to clean under his nails. A licensed nurse also confirmed the need for nail cleaning for hygiene purposes. A third resident with Parkinsonism, requiring substantial assistance with personal hygiene, was observed with long fingernails and black debris under the nails. Both the resident and a treatment nurse confirmed the need for nail trimming and cleaning for infection control. The Director of Nursing stated that residents' fingernails should be kept short and clean to prevent skin tears and infections. Review of the facility's policy indicated that nail care should include daily cleaning and regular trimming, which was not consistently provided to these residents.
Failure to Provide Resident-Centered Activities Based on Assessment and Preferences
Penalty
Summary
The facility failed to provide meaningful activities that matched the preferences and needs of a resident with a history of major depressive disorder and moderate cognitive deficits. The resident, who required assistance to get out of bed and preferred social activities such as bingo and coffee gatherings, reported uncertainty about participating in activities due to inconsistent assistance with mobility and personal care, such as not being helped to change into her own clothing. Interviews and record reviews revealed that the Activities Director (AD) did not consistently offer or document activities according to the resident's stated preferences and care plan, particularly during March and April. The AD acknowledged that activities were not provided as preferred and that the resident's care plan interventions had not been updated since the previous year, despite quarterly and comprehensive assessments being conducted. Further, the AD was unaware of the need to update activity care plans following reassessments, and the facility's policy required activities to be based on comprehensive, resident-centered assessments and preferences. The Director of Nursing (DON) confirmed that activities should be tailored to each resident's preferences and that the AD should update care plans as part of the interdisciplinary team. The lack of updated care plans and failure to provide activities as preferred resulted in the resident not receiving adequate social and meaningful engagement as outlined in her care plan and facility policy.
Failure to Provide Adequate Supervision During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, chronic venous hypertension, and arthritis in the left knee experienced pain during a transfer using a Hoyer lift. The incident happened when a Certified Nurse Assistant (CNA) weighed the resident using the lift without a second staff member present, contrary to facility policy and staff training, which require two people for safe operation of the mechanical lift. The resident reported that the sling was not applied correctly and the metal part of the lift struck his left knee, causing pain. Interviews with staff, including the Restorative Nurse Assistants (RNAs), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the expectation and policy is for two staff members to be present when using a Hoyer lift. The CNA involved in the incident proceeded alone because other CNAs were on break, despite being aware of the two-person requirement. Review of the facility's policy further supported that at least two nursing assistants are needed to safely move a resident with a mechanical lift.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident diagnosed with Post Traumatic Stress Disorder (PTSD) among a sample of 24 residents. The resident had a history of traumatic brain injury, repeated falls, seizures, and PTSD, with documented triggers including feeling belittled due to a history of abusive relationships and anxiety related to car rides following multiple car accidents. The care plan identified these triggers and the need to minimize exposure to them. However, interviews with staff revealed that direct care staff, including a CNA and a charge nurse, were unaware of the resident's PTSD diagnosis, her specific triggers, or the location of the PTSD care plan binder. The medication nurse was aware of the PTSD diagnosis but did not know the resident's specific triggers. The Social Service Director confirmed knowledge of the resident's PTSD and triggers and stated that this information was available in a PTSD binder on the unit, which staff were expected to review. Despite this, the Director of Staff Development acknowledged that there were no scheduled in-services on PTSD for the year, and several staff members were unaware of the PTSD binder or the expectation to review it. The Director of Nursing stated that staff should be familiar with residents' PTSD history and triggers and that this information should be care planned and accessible. Facility policy required assessment and care planning to minimize exposure to trauma triggers, but staff interviews and record review demonstrated that this was not consistently implemented.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two out of five Certified Nurse Assistants (CNAs) whose records were reviewed. Specifically, one CNA hired in April 2023 did not have performance evaluations for 2024 and 2025, and another CNA hired in January 2022 did not have evaluations for 2023 and 2025. This was confirmed during a record review and interviews with the Director of Staff Development and the Director of Nursing, both of whom acknowledged the importance of annual evaluations for assessing employee attendance, skills, goals, and training needs. The facility's policy requires performance evaluations at the end of a 90-day probationary period and at least annually thereafter, but this policy was not followed for the CNAs in question.
Failure to Verify Meal Tray Diets by Licensed Nurse
Penalty
Summary
The facility failed to ensure that meal tray diets were properly verified by a licensed nurse prior to distribution to residents. On 5/28/25, lunch trays were delivered to the floor, and a licensed nurse was observed checking only a few trays by lifting their lids and comparing the contents to the tray cards. The nurse did not open every tray to confirm the food matched the tray card for each resident. During an interview, the nurse stated that she only checked trays for therapeutic diets that could prevent choking and did not verify the contents of regular trays or check for allergies or specific resident requests. As a result, there was a failure to confirm that each resident received the correct diet as ordered, including consideration for allergies and special dietary needs, as required by facility policy.
Failure to Document Resident Fall Incident
Penalty
Summary
A licensed nurse failed to document an incident involving a resident who was found sitting on the floor in her room. The resident, who had a history of stroke, vascular dementia, and mild cognitive impairment, reported to her responsible party that she had fallen and hit her head the previous night, and that two staff members assisted her to get up. The responsible party relayed this information to the Assistant Director of Nursing, who stated there was no report of a fall. When interviewed, the resident confirmed she had lost her balance, fallen, and was helped by staff, but denied any injury. The nurse who found the resident on the floor stated that the resident claimed she had chosen to sit on the floor because she did not have a chair, and the nurse assisted her to a chair without documenting the incident in the clinical record. Another nurse indicated she would have assessed and documented if she had found the resident on the floor. The Director of Nursing stated that any incident of a resident being found on the floor should be documented as a fall, regardless of the resident's explanation. A review of the facility's fall policy did not provide guidance on documentation for such incidents.
Failure to Ensure Timely Hospice Certification and Communication
Penalty
Summary
The facility failed to ensure there was a process for communicating hospice services for one of two residents reviewed for hospice services. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction was admitted with physician orders to receive hospice care for end-stage stroke. During review, it was found that the physician's certification for hospice had expired, and the Social Service Director (SSD), who was responsible for coordinating hospice care, was not aware of the expired certification. Despite the expiration, the SSD believed the resident was still under hospice care. Interviews with facility staff, including a licensed nurse and the Director of Nursing (DON), revealed that hospice re-certification is necessary to determine continued eligibility for hospice services. The facility's policy indicated that obtaining physician certification and recertification is required for each resident under hospice care. However, the lack of awareness and communication regarding the expired certification demonstrated a breakdown in the process for ensuring proper coordination and documentation of hospice services for the resident.
Failure to Discard Unlabeled IV Equipment and Maintain Infection Control
Penalty
Summary
Facility staff failed to follow proper infection control practices by not discarding an unlabeled intravenous (IV) hydration bag and uncapped IV tubing that was left hanging in a resident's room. Over several days, observations confirmed that the IV bag, which was undated and unlabeled, remained attached to an IV pole at the resident's bedside, despite the resident not having an active IV line. The IV tubing was also uncapped and unlabeled. The resident, who had a history of HIV and moderate cognitive deficits, shared the room with two other residents. Multiple observations and interviews with the resident, staff, and the Infection Control Prevention Nurse (ICPN) confirmed the presence of the IV equipment and the lack of labeling or proper disposal. The ICPN and Director of Nursing (DON) acknowledged that the IV hydration and tubing should have been labeled and discarded immediately, and that the IV pole should have been cleaned and stored properly. The facility's infection control policy did not provide guidance on the proper storage and disposal of IV devices and equipment. The failure to remove and properly dispose of the IV equipment was identified through direct observation, interviews, and record review, and was recognized by facility staff as an infection control issue.
Deficiency in Immunization Policies and Procedures
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to develop and implement adequate policies and procedures for influenza and pneumococcal immunizations. Specifically, the facility did not ensure that each resident or their representative received education regarding the benefits and potential side effects of these immunizations before they were offered. Additionally, the facility failed to document in the residents' medical records whether the education was provided, whether the immunizations were administered, or if they were refused due to medical contraindications or personal choice. The report highlights that the facility did not offer influenza immunizations to residents between October 1 and March 31 annually, as required, nor did it ensure that pneumococcal immunizations were offered unless contraindicated or previously administered. This lack of compliance with regulatory requirements indicates a significant oversight in the facility's immunization practices, potentially impacting the health and safety of the residents.
Failure to Maintain Wheelchair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to prevent a fall incident involving a resident who was transferring from bed to a wheelchair with nonfunctioning brakes. The resident, who had a below-the-knee amputation and was hard of hearing, attempted to transfer independently but fell when the wheelchair moved despite the brakes being locked. The resident reported the incident and noted that the wheelchair brakes were still not fixed at the time of the survey. Observations and interviews with staff confirmed that the wheelchair's brakes were not functioning properly, allowing the wheels to move even when the brakes were engaged. The process for reporting broken equipment was not followed, as the issue with the wheelchair brakes was not logged in the maintenance book, and the Director of Maintenance was not notified. The facility's maintenance log showed no record of the wheelchair brakes being reported as broken prior to the survey. The facility's policies on fall risk management and maintenance of assistive devices were not adhered to, as there was no regular maintenance or inspection of the resident's wheelchair brakes. The interdisciplinary team did not address the malfunctioning brakes in their notes following the fall, and the care plan did not include interventions to ensure the wheelchair brakes were functioning properly. This oversight contributed to the resident's fall and the potential for further injury.
Failure to Maintain Wheelchair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a wheelchair in proper working condition, leading to a fall incident involving a resident. The resident, who had a below-the-knee amputation and was hard of hearing, attempted to transfer from bed to the wheelchair. Despite the brakes being locked, the wheelchair moved, causing the resident to fall. The resident reported the incident and stated that the wheelchair brakes were still not functioning properly. Multiple staff members, including CNAs, the Director of Maintenance (DOM), and the Director of Nursing (DON), confirmed that the wheelchair's brakes were not functioning as expected. The DOM acknowledged that the facility provided the wheelchair and that he would check the brakes if a problem was reported, but there was no regular maintenance schedule for wheelchair brakes. The maintenance log did not contain any prior reports of the wheelchair's brake issues, indicating a lapse in the reporting and maintenance process. The facility's policies on fall risk management and assistive devices emphasize the importance of maintaining equipment to prevent accidents. However, the maintenance log and wheelchair cleaning schedule showed no documentation of the wheelchair needing or receiving repairs. The interdisciplinary team note following the resident's fall did not address the inspection or repair of the wheelchair, highlighting a gap in the facility's response to the incident.
Failure to Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for a resident with congestive heart failure and ischemic cardiomyopathy. The resident was admitted with these diagnoses and was found unresponsive during a night shift. The certified nurse assistant (CNA) reported the unresponsiveness to the charge nurse, who initiated cardiopulmonary resuscitation (CPR) and called 911. Paramedics arrived shortly after and pronounced the resident deceased. Prior to this incident, the resident had refused a shower during the afternoon shift, citing not feeling well, and appeared pale and sweaty. The CNA reported this to the licensed nurse (LN) on duty, who instructed the CNA to take the resident's vital signs (VS). However, the LN did not follow up on the VS or assess the resident's condition due to being busy. The resident's symptoms of sweating and paleness, which were signs of ischemia, were not communicated to the physician. The facility's policy required prompt notification of the physician and detailed assessment of any change in a resident's condition. However, the LN did not perform an assessment or notify the physician, leading to a lack of awareness of the resident's deteriorating condition. The director of nurses confirmed that the LN should have taken the VS and assessed the resident before notifying the physician. The director of staff development had conducted training on change of condition documentation, but the LN involved did not attend the in-service.
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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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