Panorama Gardens Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Panorama City, California.
- Location
- 9541 Van Nuys Blvd., Panorama City, California 91402
- CMS Provider Number
- 056337
- Inspections on file
- 44
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Panorama Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy and federal crime reporting requirements when an allegation of staff-to-resident sexual abuse was relayed to staff by law enforcement. A resident with intact cognition reported that a male CNA had inappropriately touched a cognitively intact, functionally dependent roommate. Nursing staff and law enforcement interviewed the alleged victim, who denied the allegation and reported no pain or discomfort, and a head-to-toe assessment showed no injuries. Despite being notified by an RN the same evening, the ADM did not report the allegation to CDPH, LLE, or the Ombudsman within the required two-hour timeframe, contrary to facility policy requiring immediate internal reporting and timely external reporting of all abuse allegations.
A resident with cognitive and physical limitations was allowed to self-administer Imodium and probiotic tablets without an interdisciplinary team assessment or documentation, contrary to facility policy. Staff confirmed that no evaluation was performed to determine if self-administration was clinically appropriate, and the medications were stored at the bedside with unsupervised access.
A resident with cognitive decline and physical limitations was permitted to self-administer Imodium and probiotic tablets stored at bedside, per physician order. However, the facility did not develop a care plan addressing this self-administration, despite policy requiring assessment and documentation by the IDT. The DON confirmed the absence of such a care plan during record review.
A resident with a history of aggressive behavior intentionally made physical contact with another cognitively impaired resident, causing a skin injury to the face. The incident occurred despite staff presence and intervention attempts, and was acknowledged by facility leadership as abuse and a failure to follow abuse prevention policy.
A resident with intact cognition and multiple mental health diagnoses expressed uncertainty about wanting a shower, but a CNA proceeded without consulting the charge nurse, violating the facility's policy on resident rights. The facility's procedure requires confirmation from the charge nurse when a resident's consent is unclear.
A facility failed to notify a physician that a UA was not collected for a resident with multiple diagnoses, including diabetes and sepsis. Despite a stat order, the urine sample was not obtained, and the physician was not informed, contrary to the facility's policy. Interviews revealed that the charge nurse was aware of the issue but did not report it, and the DON confirmed the policy was not followed.
A facility failed to inform a resident's responsible party about dental treatment recommendations, violating the right to make informed decisions. The resident, lacking decision-making capacity, had dental visits with recommendations for extractions, but there was no documentation of communication with the responsible party. Staff confirmed the oversight, which posed a potential risk for delayed care.
A resident with moderate cognitive impairment and physical limitations was unable to reach their call light, preventing them from requesting assistance. The resident, who required substantial assistance with personal care, was observed in a wheelchair without the call light within reach. Both a Licensed Vocational Nurse and the Director of Nursing confirmed the importance of call light accessibility, as outlined in the facility's policy.
A resident with diabetes and end-stage renal disease experienced a significant hyperglycemia episode, but the facility failed to update the care plan accordingly. Despite the facility's policy requiring care plan revisions with significant changes in condition, the care plan was not reviewed or revised, potentially leading to inadequate care and supervision.
The facility failed to provide communication devices in the languages understood by two residents, leading to a deficiency. One resident, primarily Armenian-speaking with severe cognitive impairment, had no communication board at her bedside. Another resident, primarily Shanghainese-speaking, also lacked a communication board, despite facility policy requiring such tools to be accessible. The DON confirmed the absence of these devices, which were kept at the nursing station instead.
A facility failed to accurately assess a resident with an indwelling catheter upon admission and readmission, leading to potential inadequate care. The resident's initial assessments incorrectly indicated the absence of a catheter, despite physician's orders and care plans requiring it. Interviews with the TN and DON confirmed the errors, highlighting the importance of thorough assessments as per facility policy.
The facility failed to complete social services assessments for two residents within the required timeframe, leading to potential delays in care. One resident, with multiple diagnoses including dementia, was observed without hearing aids, affecting communication. Another resident, with major depressive disorder and dementia, lacked an initial assessment in their record. The facility's policy required assessments within seven days, which was not followed.
The facility did not post the actual hours worked by nursing staff, only the projected hours, due to the Payroll staff arriving late. This failure was observed during a survey, and interviews confirmed the oversight. The facility's policy mandates daily posting of staffing numbers to ensure adequate staffing and transparency.
A resident in an LTC facility did not receive their prescribed medications, Gabapentin and Buspirone, within the required one-hour window of the scheduled time. The medications were administered by an LVN at 3:44 p.m., instead of the scheduled 1:00 p.m., violating the facility's policy. Interviews with the LVN and DON confirmed the breach of protocol.
A medication error occurred when a student nurse, unsupervised by an instructor, administered medications intended for one resident to another. The resident who received the wrong medications had a history of metabolic encephalopathy, COPD, and CHF, while the medications were meant for a resident with parkinsonism and hypertension. The error was discovered when the student nurse reported it, highlighting a failure to follow proper identification procedures.
Failure to Timely Report Allegation of Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime under Section 1150B of the Act by not reporting an allegation of staff-to-resident sexual abuse within the required two-hour timeframe to CDPH, local law enforcement, or the Ombudsman. Law enforcement officers arrived at the facility and informed nursing staff that a resident had reported an incident in which a male CNA allegedly entered the shared room and inappropriately touched the roommate two days earlier. The roommate, identified as Resident 2, had intact cognition per a recent MDS and was dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility. A head-to-toe assessment of Resident 2 by nursing staff revealed no injuries, bruising, redness, or other abnormal findings, and Resident 2 denied the allegation and any pain, discomfort, or concerns. Resident 1, who made the report to law enforcement, also had intact cognition and was similarly dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility, according to their MDS and admission records. After law enforcement notified facility staff of Resident 1’s report of sexual abuse toward Resident 2, the RN notified the Administrator by phone the same evening. The Administrator acknowledged that the allegation of sexual abuse was not reported to CDPH, law enforcement, or the Ombudsman because Resident 2 denied the allegation and reported no injury or discomfort, and because the LVN caring for both residents over the following three days had not received any related concerns. This inaction conflicted with the facility’s abuse prevention policy, which requires all allegations of abuse, neglect, misappropriation of resident property, or exploitation to be reported immediately to the Administrator and to appropriate state or federal agencies within applicable regulatory timeframes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in determining whether self-administration of medications was clinically appropriate for a resident. Specifically, a resident with diagnoses including a right foot fracture, age-related cognitive decline, and constipation was not assessed for self-administration of Imodium and probiotic oral tablets, which were stored at the resident's bedside. The resident's Minimum Data Set indicated some cognitive and physical limitations, including the need for assistance with eating, hygiene, and transfers. Despite this, physician orders allowed for unsupervised self-administration of these medications, and documentation in the Medication Administration Record (MAR) reflected this practice. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that no assessment was completed to determine the resident's suitability for self-administration, and no documentation of such an assessment could be found in the resident's records. The facility's policy required the IDT to assess and periodically re-evaluate residents for self-administration, considering cognitive, communication, visual, and physical abilities, and to document the assessment in the chart. This process was not followed for the resident in question, resulting in a deficiency related to medication management and resident safety.
Failure to Develop Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who was self-administering Imodium and probiotic oral tablets, both of which were stored at the resident's bedside. The resident had been admitted with diagnoses including a right foot fracture, age-related cognitive decline, and constipation. According to the Minimum Data Set, the resident was able to make herself understood, required assistance with eating and hygiene, and was dependent on staff for transfers. Physician orders specified that the resident could self-administer these medications, with the family providing the Imodium and both medications being kept at the bedside. During a review of the resident's records, including the Medication Administration Record and care plans, the Director of Nursing confirmed that there was no care plan addressing the resident's self-administration of medications. The facility's own policies required the interdisciplinary team to assess and document a resident's ability to self-administer medications and to include this information in the care plan. Despite these requirements, no such care plan was found for the resident, resulting in a failure to meet the facility's policy and regulatory standards for comprehensive care planning.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident deliberately made physical contact with another resident, resulting in a skin injury. On the date of the incident, one resident, who had intact cognition and a history of behavioral symptoms including physical and verbal aggression, approached another resident seated outside a room and began shouting and behaving aggressively. The second resident, who had impaired cognition and lacked decision-making capacity due to dementia and epilepsy, responded verbally, after which the first resident used his right hand to graze the second resident's left cheek. The incident was witnessed by the Director of Staff Development, who was present and attempted to intervene by standing between the two residents with her arms extended. Despite this, the aggressive resident was able to make physical contact with the other resident's face with the intent to cause injury. Documentation and interviews confirmed that the contact was intentional and met the facility's definition of abuse, as it was a purposeful act intended to inflict harm. The facility's policy clearly states that each resident has the right to be free from abuse, and both the Director of Nursing and the Administrator acknowledged that the incident constituted abuse and was not unavoidable. The facility did not follow its own policy and procedure for the prevention of abuse, resulting in a failure to protect the resident from harm while under the facility's care.
Failure to Confirm Resident's Consent for Shower
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by not confirming if the resident wanted to have a shower on a specific date. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, had the capacity to understand and make decisions, as indicated by their History and Physical and Minimum Data Set assessments. Despite this, the resident expressed uncertainty about wanting a shower, but the Certified Nursing Assistant (CNA) proceeded with the shower without consulting the charge nurse, as required by the facility's procedure. Interviews with the CNA, Director of Staff Development, and Director of Nursing revealed that the CNA did not follow the correct process when the resident was unsure about having a shower. The facility's policy requires that if a CNA is unable to confirm a resident's desire for a shower, the charge nurse should be notified to confirm with the resident. The CNA admitted to not consulting the charge nurse, which was a deviation from the facility's policy and procedure on resident rights, which emphasizes treating residents with consideration, respect, and recognition of their dignity and individuality.
Failure to Notify Physician of Uncollected Urinalysis
Penalty
Summary
The facility failed to adhere to its policy and procedure for Change of Condition Reporting by not notifying the physician that a urinalysis (UA) was not obtained for a resident as ordered. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus, sepsis, Parkinson's disease, and major depressive disorder, had a physician order for a UA to be done immediately. However, the nursing staff did not collect the urine sample, and the physician was not informed of this failure, which was against the facility's policy. Interviews with the nursing staff revealed that the charge nurse was aware of the uncollected UA but did not notify the physician, as required by the facility's policy. The Director of Nursing confirmed that the physician should have been notified within 24 hours if the urine could not be collected, and a change of condition report should have been completed. The facility's policy mandates timely communication of any change in a resident's condition to the physician, which was not followed in this instance.
Failure to Inform Responsible Party of Dental Treatment Recommendations
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident was informed about dental treatment recommendations, which violated the resident's and RP's right to make informed decisions regarding dental care. Resident 85, who was admitted with multiple diagnoses including Type II diabetes mellitus, major depressive disorder, and schizophrenia, was determined to lack the capacity to make decisions. Despite this, there was no documentation indicating that RP 1, the designated responsible party, was informed about the dental treatment recommendations made during visits on two separate occasions. Interviews with facility staff, including the Social Worker, Social Service Director, and Director of Nursing, confirmed the absence of documentation and communication with RP 1 regarding the resident's dental care. The facility's policy required that medically related social service needs, including informing residents and their designated representatives about health status and healthcare choices, be documented. The failure to inform RP 1 about the dental treatment recommendations posed a potential risk for delay in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for Resident 87, which resulted in the resident being unable to call for assistance when needed. Resident 87, who was admitted with diagnoses including Type II diabetes mellitus, required assistance with personal care, and had a contracture of an unspecified joint, was observed in a wheelchair without the call light within reach. The resident expressed a desire for more coffee but was unable to call staff due to the inaccessible call light. During an observation and interview, a Licensed Vocational Nurse confirmed that the call light was not within reach and acknowledged the importance of having it accessible to prevent potential injuries. The Director of Nursing also emphasized the necessity of having the call light within reach to allow residents to communicate their needs. The facility's policy, revised in January 2024, mandates that the call device be placed within the resident's reach before leaving the room, which was not adhered to in this instance.
Failure to Update Care Plan After Resident's Hyperglycemia Episode
Penalty
Summary
The facility failed to review and update the care plan for a resident after a significant change in condition, specifically an episode of hyperglycemia. The resident, who was admitted with diagnoses including diabetes mellitus Type II and end-stage renal disease, experienced an elevated blood sugar level of 446 mg/dl, which was documented on an SBAR Communication Form. Despite this change in condition, the resident's care plan, which was last revised several months prior, was not updated to reflect the new health status. Interviews with the facility's RN and DON confirmed that the care plan was not reviewed or revised following the hyperglycemia episode. The facility's policy requires care plans to be updated quarterly and with any significant change in condition, but this was not adhered to in this case. The failure to update the care plan could potentially result in inadequate care and supervision for the resident, as the effectiveness of the care plan interventions could not be evaluated.
Failure to Provide Communication Devices in Residents' Languages
Penalty
Summary
The facility failed to provide communication devices in the language that residents could understand, affecting two residents. Resident 105, who was primarily Armenian-speaking, had severe cognitive impairment and was receiving hospice care. Despite the resident's need for an interpreter being documented in social service assessments, there was no communication board or device available at her bedside. The Director of Nursing (DON) acknowledged that a communication board with pictures could have been beneficial for Resident 105 to communicate her needs to the staff. Resident 107, who was admitted with a need for assistance with personal care and difficulty walking, primarily spoke Shanghainese. The resident's Minimum Data Set (MDS) indicated intact cognitive skills, but the History and Physical (H&P) noted that she could not make her own decisions and was Korean-speaking. The social service assessment confirmed the need for an interpreter, and the care plan included providing a translator as necessary. However, during an observation, it was noted that there was no communication board at Resident 107's bedside, and the DON confirmed that communication boards were not accessible to the resident. The facility's policy on communication for non-English and aphasic residents required that communication boards be supplied and kept at the resident's bedside, with an additional copy attached to the resident's wheelchair if needed. Despite this policy, the communication boards were kept at the nursing station and not provided to or accessible by Residents 105 and 107, leading to a deficiency in ensuring effective communication for these residents.
Inaccurate Assessment of Resident with Indwelling Catheter
Penalty
Summary
The facility failed to accurately assess a resident with an indwelling catheter upon both admission and readmission, leading to potential inadequate care. The resident, who was admitted with diagnoses including bladder calculus and obstructive and reflux uropathy, was documented incorrectly in the Licensed Nurse-Initial Admission Record as not having urinary retention or an indwelling catheter. This discrepancy was noted on two separate occasions, with the initial assessments on both admission and readmission failing to reflect the presence of the catheter, despite physician's orders and care plans indicating its necessity. Interviews with the Treatment Nurse and Director of Nursing confirmed that the assessments were completed incorrectly, which could result in providing wrong information about the resident's status. The facility's policy required a thorough nursing assessment within 24 hours of admission to gather vital information for maintaining the resident's well-being. However, the failure to document the indwelling catheter in the initial assessments compromised the ability to provide appropriate care and services to the resident.
Failure to Complete Social Services Assessments
Penalty
Summary
The facility failed to ensure that the Social Services department completed their admission assessments for two residents, leading to potential delays in care and services. Resident 301 was admitted with multiple diagnoses, including metabolic encephalopathy, COVID-19, pneumonia, and dementia, and had moderate cognitive impairment. Despite having hearing difficulties and requiring hearing aids, the social services initial assessment was not documented within the required timeframe, and the resident was observed without hearing aids, unable to communicate effectively. The Licensed Vocational Nurse confirmed that the resident came with hearing aids, and the Social Worker acknowledged the lack of documentation and the importance of timely assessments to address potential issues. Resident 29 was admitted with diagnoses such as difficulty in walking, dysphagia, major depressive disorder, and unspecified dementia. The resident required substantial assistance with personal care and had fluctuating capacity to understand and make decisions. The social services assessment was not completed within the required seven days, and the resident's electronic health record lacked the initial assessment documentation. The Social Worker and Social Services Director confirmed the absence of the assessment and the necessity of completing it to understand the resident's needs and discharge plan. The facility's policy required social service assessments to be completed within seven days of admission, but this was not adhered to for both residents. The Director of Nursing confirmed the policy and emphasized the importance of completing the assessments to avoid delayed care and unknown resident needs. The failure to complete these assessments as per the facility's policy resulted in a deficiency in providing medically-related social services to help residents achieve the highest possible quality of life.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that staffing information, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily. On the date in question, the posted document at the nurses' stations and next to the staff time clock only included projected hours for each shift, leaving the actual hours worked blank. This oversight was observed during a survey, and it was confirmed that the actual hours had not been calculated or posted due to the Payroll (PR) staff arriving late to work. Interviews with the PR and the Director of Nursing (DON) revealed that the Director of Staff Development (DSD) or the Scheduler is responsible for posting projected hours, while the PR is tasked with verifying and calculating the actual hours worked. The PR admitted to being unable to complete this task on the day of the survey due to her late arrival. The facility's policy requires daily posting of staffing numbers to ensure transparency and adequate staffing based on the facility's census, but this was not adhered to on the specified date.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications within the required time frame for a resident, which is a deficiency in pharmaceutical services. The resident, who was admitted with diagnoses including osteoarthritis, major depressive disorder, anxiety, and type 2 diabetes, was prescribed Gabapentin for neuropathy and Buspirone for anxiety. According to the facility's policy, medications should be administered within one hour before or after the scheduled time. However, on a specific date, both medications were administered by an LVN at 3:44 p.m., which was beyond the one-hour window for the scheduled 1:00 p.m. administration time. Interviews with the LVN and the DON confirmed the deviation from the facility's medication administration policy. The LVN acknowledged administering the medications late, and the DON reiterated the facility's policy of adhering to the one-hour window for medication administration. The facility's policy on medication administration emphasizes that medications should be given as prescribed and within the specified time frame, which was not followed in this instance.
Medication Error Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a student nurse administered medications intended for another resident. On the specified date, the student nurse, under the supervision of an instructor, prepared medications for one resident but mistakenly administered them to another resident. This error was not immediately corrected because the supervising instructor did not accompany the student nurse during the medication administration, which was against the facility's policy. The resident who received the wrong medications had a medical history that included metabolic encephalopathy, chronic obstructive pulmonary disease, and congestive heart failure. The resident was cognitively intact and required moderate assistance with daily activities. The medications administered in error were intended for another resident with a diagnosis of parkinsonism and hypertension, and included Carbidopa-Levodopa, Pramipexole, and Sodium Chloride. The error was discovered when the student nurse reported the mistake to the instructor, who then informed the Director of Nursing. The facility's policy required that residents be properly identified before medication administration, using methods such as checking identification bands and photographs. The failure to follow these procedures led to the medication error, which posed a risk of adverse reactions for the resident who received the incorrect medications.
Removal Plan
- Resident 1 was assessed by the DON for any adverse effects from the significant medication error.
- Resident 1's Physician (MD 1) was notified of the significant medication error and ordered STAT laboratory tests of Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) for Resident 1.
- Resident 1 was placed on 72 hours Change of Condition (COC) monitoring and supervision. Resident 1 was monitored for medication adverse effects which may include nausea, dizziness, headache, hallucinations, and orthostatic hypotension.
- The Administrator (ADM) cancelled the contract with the affiliated nursing school.
- The ADM and designee interviewed all residents and or resident representative to identify any concern with medication administration.
- The DON and designee ensured that identification of residents based on facility policy, such as wristband and resident photo in the electronic medical records are in place.
- The facility's Pharmacy Consultant provided an in-service training to licensed nurses regarding the policy and procedure (P&P) for Medication Administration.
- The facility's Pharmacy Consultant conducted skills and competency check to licensed nurses and verified through return demonstration and discussion.
- The Interdisciplinary Team (IDT) will conduct room rounds to ensure each resident will have wristbands in place four to five times a week.
- The Director of Staff Development (DSD) or designee will perform random medication pass observation twice a week to ensure compliance with the facility's P&P on Medication Administration.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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