Paramount Convalescent Hosp.
Inspection history, citations, penalties and survey trends for this long-term care facility in Paramount, California.
- Location
- 8558 East Rosecrans Avenue, Paramount, California 90723
- CMS Provider Number
- 056446
- Inspections on file
- 25
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Paramount Convalescent Hosp. during CMS and state inspections, most recent first.
A resident with a history of stroke, hemiplegia, and hypertension experienced multiple episodes of elevated blood pressure over several months without timely assessment or physician notification by nursing staff, despite care plan and physician orders requiring such actions. The resident was eventually transferred to the hospital with hypertensive urgency after further increases in blood pressure and the onset of a headache. Staff interviews confirmed that required monitoring and notification procedures were not followed.
A resident with an indwelling urinary catheter was observed without a privacy bag covering the drainage bag, compromising their dignity and privacy. Despite facility policies requiring privacy bags, staff failed to apply one, leading to potential embarrassment for the resident. Staff interviews confirmed awareness of the requirement to maintain resident dignity by covering drainage bags.
The facility failed to provide adequate care for residents with limited ROM and mobility, specifically for three residents. For one resident, baseline ROM measurements were not obtained, and the resident's orthosis was not assessed for fit and wear tolerance, leading to ROM limitations and a contracture. Another resident did not receive baseline ROM measurements, and ROM changes were not monitored over ten months, placing the resident at risk for further limitations. Additionally, a resident's hips were not positioned at midline while lying in bed, potentially contributing to further ROM limitations.
The facility failed to follow infection control protocols, including not changing tube feeding bags every 24 hours, improper hand hygiene during wound care, and inadequate handling of soiled linens. Additionally, shared care equipment was not disinfected between uses, and the facility lacked a Legionella water management program.
The facility failed to maintain proper nail hygiene for two residents, leading to deficiencies in personal care. One resident with arthritis had unclean and long nails, despite care plans requiring regular maintenance. Another resident with dementia and diabetes was observed with dirty nails while eating, with no documentation of care refusal. Staff interviews revealed a lack of communication and adherence to nail care policies.
Two residents in an LTC facility experienced inadequate pressure ulcer care. One resident developed a Stage 1 pressure injury on the nose due to improper monitoring of a nasal cannula, while another with a Stage 4 ulcer was not repositioned effectively, leading to potential worsening of the condition. Staff interviews revealed communication lapses and failure to adhere to skin assessment protocols.
The facility failed to provide effective pain management for two residents. One resident with hypertension and headaches was not assessed or treated for pain in a timely manner, and another resident with cognitive impairments was not assessed for pain appropriately. The facility's policy on pain management, requiring the use of appropriate assessment tools based on cognitive status, was not followed, leading to deficiencies in care.
The facility failed to conduct annual competency evaluations for RNAs, affecting 13 residents receiving RNA services. In one case, a resident with limited ROM and mobility did not receive proper PROM exercises, and assistance was needed to apply an orthosis. Additionally, a RNS and LVN were not competent in taking a resident's blood pressure before administering Nitroglycerin, using an incorrect cuff size, which could lead to inaccurate readings and adverse reactions.
A LTC facility failed to maintain a medication error rate below five percent, with errors observed in two residents due to late administration of medications. A resident with complex medical conditions received multiple medications significantly later than prescribed, while another resident also experienced delays. The LVN responsible did not inform physicians of the delays, potentially affecting medication effectiveness. The DON confirmed the need for timely administration and physician notification.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled food items and improper hand hygiene observed. A cook did not wash hands or change gloves between tasks and failed to wear a beard net, risking cross-contamination. These actions violated the facility's policies on food safety and hygiene.
A resident with hemiplegia and hemiparesis did not receive prescribed PT, SLP, and OT services despite having physician-signed care plans. The resident required assistance for ADLs and had impairments in mobility and communication. Evaluations recommended specific therapies, but these were not implemented due to a verbal agreement among therapists to use restorative nursing aide services instead, contrary to the physician's certification.
The facility failed to ensure accurate documentation for two residents with mobility concerns, leading to false records of care provided. Additionally, a medication administration record inaccurately reflected medication given to a resident, as an LVN documented under another's name, violating facility policy.
A resident with cognitive impairments and multiple diagnoses was found with bilateral 1/2 siderails on their bed without a physician's order, contrary to the facility's restraint-free policy. Staff confirmed the siderails were used as restraints, posing risks of entrapment and injury, and no proper assessment or monitoring was conducted.
An LVN failed to maintain a resident's head of the bed at the required 30-degree angle during g-tube medication administration, contrary to facility policy. The resident, with a history of dementia and other health issues, was positioned incorrectly, risking aspiration. Interviews confirmed the policy and the LVN's acknowledgment of the error.
Two residents in an LTC facility experienced deficiencies in pain management due to the facility's failure to implement comprehensive care plans. One resident's pain monitoring was delayed despite a care plan, while another resident with a Stage 4 pressure ulcer had no pain management plan, leading to observable distress. Staff interviews confirmed these oversights, highlighting a failure to adhere to facility policies on care planning and pain management.
A resident with limited mobility and cognitive impairment was transferred using a mechanical lift by a single CNA, contrary to the care plan and facility policy requiring two staff members. This action increased the risk of accidents, as observed by the DON, who intervened to stop the transfer.
A resident with multiple mental health diagnoses was prescribed Alprazolam for anxiety without documented non-pharmacological interventions being attempted first. Facility staff, including an LVN and the RN Supervisor, confirmed that interventions like providing a calm environment or assessing for pain were not used before administering the medication. The facility's policy required such interventions to be attempted to avoid unnecessary psychotropic medication use.
A resident with end-stage renal disease and diabetes did not receive meals that accommodated her food preferences, despite dietary interventions in her care plan. The resident reported receiving unsuitable foods, and staff confirmed that her dislikes were communicated but not addressed. The facility's policy to obtain and note food preferences was not followed, risking decreased meal intake and weight loss.
A resident with legal blindness and intact cognitive function signed an arbitration agreement without proper explanation or assistance. Interviews revealed that the facility did not follow protocol, as the resident was not fully informed of the agreement's implications, and no witness was present during the signing.
The QAA Committee failed to implement corrective actions for RNA services, leading to repeated deficiencies in providing ROM and mobility services. A resident with hemiplegia received fewer AROM exercises than required, another did not consistently receive a palm guard or daily exercises, and a third resident with end-stage renal disease received PROM less frequently than needed. The DON confirmed the lack of evidence that these issues were addressed in QAA meetings.
A facility failed to maintain the wall in a resident's room, where a hole was observed in the drywall behind the bed. The Maintenance Supervisor confirmed the hole was not reported in the Maintenance Log, despite daily room rounds. The resident, with multiple health conditions, required assistance for daily activities. The facility's Preventative Maintenance Program policy was not followed, leading to the deficiency.
Failure to Assess and Notify Physician for Elevated Blood Pressure
Penalty
Summary
The facility failed to assess a resident during multiple episodes of elevated blood pressure and did not notify the physician in a timely manner, as required by the resident's care plan and physician orders. The resident, who had a history of hemiplegia, cerebral infarction, atherosclerotic heart disease, and hypertension, was cognitively impaired and required varying levels of assistance with daily activities. Physician orders and care plans directed staff to monitor blood pressure regularly and notify the physician of significant abnormalities or changes in condition. Despite these directives, the resident experienced several documented episodes of systolic blood pressure above 150 mmHg over a period of months, with no evidence that staff assessed the change in condition or notified the physician as required. On the day of transfer to an acute care hospital, the resident had multiple high blood pressure readings and reported a headache, but staff did not notify the physician until after the condition had escalated. Upon arrival at the hospital, the resident was diagnosed with hypertensive urgency. Interviews with nursing staff and the DON confirmed that staff did not follow the care plan or facility policy regarding monitoring and physician notification for elevated blood pressure. Facility policies and job descriptions required staff to observe for changes in resident status, notify the physician and family, and document accordingly, but these procedures were not followed in this case.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag, compromising the resident's dignity and privacy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and urinary retention, had moderate cognitive impairment and required substantial assistance for toileting and showering. During an observation, it was noted that the resident's catheter drainage bag was not covered, which was confirmed by multiple staff members, including a CNA, LVN, and RNS, who acknowledged the importance of maintaining resident dignity by covering drainage bags. The facility's policy and procedure on catheter care, dated December 19, 2022, indicated that privacy bags should be available and used to cover catheter drainage bags at all times. Despite this policy, the staff failed to apply a privacy bag to the resident's drainage bag, leading to the potential for the resident to feel embarrassed and have low self-esteem. Interviews with the staff revealed that they were aware of the requirement to cover drainage bags to maintain resident dignity, yet the deficiency occurred, indicating a lapse in adherence to the facility's established procedures.
Failure to Provide Adequate ROM Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents with limited range of motion (ROM) and mobility, specifically for three residents. For Resident 43, the facility did not obtain baseline ROM measurements upon admission and during occupational therapy evaluation. The resident's left wrist hand orthosis was not assessed for fit and wear tolerance upon discharge from occupational therapy services. Additionally, the facility did not provide restorative nursing assistant services for passive range of motion exercises and the application of the orthosis for extended periods, leading to the development of ROM limitations and a contracture in the left hand. Resident 5 also did not receive baseline ROM measurements upon admission and during physical and occupational therapy evaluations. The facility failed to monitor ROM changes over a ten-month period, placing the resident at risk for further ROM limitations. The resident's care plan included interventions for passive range of motion exercises and the application of a palm guard, but these were not consistently implemented, as observed during interviews and record reviews. For Resident 18, the facility did not position the resident's hips at midline while lying in bed, which could contribute to further ROM limitations. The facility's failure to adhere to its policies and procedures for joint mobility screening and assessment, as well as the lack of consistent monitoring and implementation of recommended interventions, resulted in deficiencies in the care provided to these residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control measures, resulting in several deficiencies. For instance, the facility did not ensure that tube feeding and water bags for two residents were changed every 24 hours, as confirmed by multiple staff members, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing. This oversight was acknowledged by the staff, who stated that the bags should be changed daily to prevent infection. In another instance, a Treatment Nurse failed to perform hand hygiene during wound care treatment for a resident with a Stage 4 pressure injury. The nurse changed gloves without washing hands between handling soiled dressings and applying medication, which was against the facility's policy. This was confirmed by the Infection Prevention Nurse and the Director of Nursing, who emphasized the importance of hand hygiene to prevent cross-contamination. Additionally, the facility did not handle dirty linens properly after providing personal care to a resident with ESBL, a resistant bacterial infection. A Certified Nursing Assistant was observed carrying soiled linens without placing them in a plastic bag, contrary to the facility's policy. The Infection Prevention Nurse confirmed that this practice could lead to cross-contamination. Furthermore, the facility lacked a Legionella water management program, which was acknowledged by the Maintenance Supervisor and the Administrator, indicating a potential risk for Legionella growth.
Deficiency in Nail Care for Residents
Penalty
Summary
The facility failed to ensure proper nail care for two residents, leading to deficiencies in personal hygiene and potential health risks. Resident 17, who suffers from Psoriatic Arthritis Mutilans and atrial fibrillation, was observed with unclean and long fingernails. Despite being unable to cut his own nails due to arthritis, the care plan for Resident 17 included interventions to maintain clean and short nails to prevent skin injuries and infection. However, observations and interviews revealed that the resident's nails were not properly maintained, and there was a lack of documentation indicating the need for nail trimming. Similarly, Resident 45, diagnosed with diabetes mellitus, unspecified dementia, and osteoporosis, was observed with long and dirty fingernails. The care plan for Resident 45 included regular nail care as part of daily living activities, but observations showed the resident eating with unclean nails, posing a risk of ingesting bacteria. Interviews with staff indicated a lack of communication and documentation regarding the resident's refusal of nail care, and there was no care plan addressing noncompliance or refusal of care. The facility's policy and procedure on nail care emphasized routine cleaning and inspection during daily living activities, yet these were not adequately followed for the two residents. The failure to maintain proper nail hygiene for Residents 17 and 45 was confirmed through observations, interviews, and record reviews, highlighting a deficiency in the facility's care practices.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident 39, who was admitted with conditions including aphasia, Alzheimer's disease, and a respiratory disorder, developed a Stage 1 pressure injury on the nose due to improper monitoring of the nasal cannula. Despite being dependent on staff for personal care and having a high risk for pressure injuries as indicated by a Braden Scale score of 11, the redness on the nasal septum was not reported or addressed in a timely manner. The CNA noticed the redness and applied ointment but did not effectively communicate this to the LVN, who failed to conduct the necessary skin checks. Resident 18, who had a Stage 4 pressure ulcer on the sacrococcyx area and contractures in both knees, was not repositioned adequately to offload pressure from the affected area. Despite having a care plan that included interventions to prevent further skin breakdown, the resident was often found lying on his back, which could exacerbate the pressure injury. The staff struggled to reposition the resident due to his contractures and frequent movements, and the use of pillows for repositioning was ineffective as the resident often removed them. Interviews with staff revealed a lack of communication and adherence to protocols for monitoring and reporting skin conditions. The facility's policy required regular skin assessments and immediate reporting of any concerns, but these were not consistently followed. The DON acknowledged that improper repositioning and ineffective interventions could lead to worsening pressure injuries, highlighting the need for better monitoring and assessment practices.
Inadequate Pain Management for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide effective pain management for two residents, leading to deficiencies in care. Resident 11, who was admitted with hypertension and headaches, was not assessed or treated for pain in a timely manner. Despite having a care plan that required pain monitoring every four hours, this was not initiated until a day after the plan was updated. On one occasion, Resident 11 reported having a headache since the morning and had not received his scheduled medication. The LVN responsible for administering the medication admitted to not doing so because Resident 11 was sometimes difficult, and he forgot to ask another nurse to assist. This oversight was acknowledged by the RN Supervisor and the DON, who emphasized the importance of pain assessment, especially given Resident 11's hypertension, which could lead to serious complications like a stroke. Resident 18, who had multiple diagnoses including a stage 4 pressure ulcer and cognitive impairments, was also not assessed for pain appropriately. The resident's cognitive impairments made it difficult for them to communicate pain levels effectively using a numerical pain rating scale. Despite this, the LVN used this method to assess pain, which was not suitable given the resident's condition. During a wound dressing change, Resident 18 exhibited nonverbal signs of pain such as moaning and grimacing, which were not adequately considered in the pain assessment. Both the RN Supervisor and the DON acknowledged that nonverbal signs should have been used to assess pain due to the resident's cognitive limitations. The facility's policy on pain management, which requires the use of appropriate pain assessment tools based on a resident's cognitive status, was not followed. This resulted in inadequate pain management for Resident 18, as the staff did not use nonverbal indicators to assess pain. The failure to adhere to the policy and properly assess pain in residents with cognitive impairments led to deficiencies in the care provided to both Resident 11 and Resident 18.
Deficiencies in Staff Competency Evaluations and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that five Restorative Nursing Assistants (RNAs) had their annual competency evaluations for providing range of motion (ROM) exercises, application of orthotics, and ambulation to 13 residents receiving RNA services. This deficiency was observed during an interview with the Director of Rehabilitation, who confirmed that the purpose of the RNA program was to maintain residents' function and prevent decline in mobility. The competency evaluations for the RNAs were last completed in May 2023, and should have been completed again in May 2024, but were not. This lapse in competency evaluations had the potential to affect the quality of care provided to residents, including Resident 43, who had limited ROM and mobility due to conditions such as end-stage renal disease and hemiplegia. In a specific incident, Resident 43 was observed receiving RNA services, where RNA 1 and RNA 2 performed exercises on the resident's limbs. However, RNA 2 was unable to fully extend the resident's left-hand fingers and required assistance to apply a left wrist-hand orthosis. RNA 2 also forgot to perform PROM exercises on the resident's left elbow. This incident highlighted the lack of competency in performing necessary tasks, which could lead to a decline in the resident's ROM and mobility. Additionally, the facility failed to ensure that a Registered Nurse Supervisor (RNS) and a Licensed Vocational Nurse (LVN) were competent in taking a resident's blood pressure before administering Nitroglycerin. Resident 27, who had conditions such as morbid obesity and congestive heart failure, complained of chest pain, and the RNS used an incorrect blood pressure cuff on the forearm instead of the upper arm. This could have resulted in an inaccurate blood pressure reading, potentially leading to adverse reactions with the medication. The facility's policy indicated that staff should have the appropriate competencies to ensure resident safety, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by eleven medication errors out of thirty-three opportunities, resulting in a 33.33 percent error rate. This deficiency was observed in two of the four sampled residents, specifically Residents 28 and 37. The errors were primarily due to the late administration of medications, which were not given within the facility's protocol time frame of one hour before or after the scheduled time. Resident 28, who has a complex medical history including acute and chronic respiratory failure, pulmonary hypertension, hypertensive heart disease, epilepsy, diabetes mellitus type 2, diabetic neuropathy, and dementia, received multiple medications significantly later than the prescribed time. Medications such as Amiodarone, Apixaban, Budesonide, Levetiracetam, Pregabalin, and Sildenafil were administered well past the scheduled 9:00 a.m. time, with some given as late as 2:16 p.m. Similarly, Resident 37, with diagnoses including hypertensive heart disease, cerebral infarction, and depression, also received medications like Finasteride, Gabapentin, and Hydralazine later than scheduled. The Licensed Vocational Nurse (LVN) responsible for administering these medications acknowledged the delay and stated that the facility protocol allows for a two-hour window for medication administration. However, the LVN did not inform the residents' physicians of the delays, which could potentially affect the therapeutic effectiveness of the medications. The Director of Nursing confirmed that the medications should have been administered within the specified time frame and that the physicians should have been notified of any delays to ensure proper treatment outcomes.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Several food items, including an open bag of peanut butter dough, frozen fries, and bottles of salsa, were found without proper labeling and dating, which is essential to prevent foodborne illnesses. Interviews with kitchen staff confirmed that these items should have been labeled with the date they were opened and a use-by date, as per the facility's policy. This oversight was acknowledged by the staff, who recognized the importance of labeling to ensure food safety. Additionally, a cook was observed not practicing proper hand hygiene during food preparation and distribution. The cook did not wash hands or change gloves between tasks, such as cooking, checking food temperatures, and plating meals, which is a critical step in preventing cross-contamination. Furthermore, the cook did not wear a beard net while handling food, despite having facial hair, which could lead to contamination. These practices were contrary to the facility's policies on handwashing, glove use, and personal hygiene, which are designed to maintain a safe and sanitary environment.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to provide necessary therapy services to a resident with significant mobility and communication concerns, as outlined in the resident's physician-signed care plans. The resident, who had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was admitted with functional range of motion limitations and required various levels of assistance for activities of daily living. Despite having care plans for physical therapy (PT), speech therapy (SLP), and occupational therapy (OT) that were signed and certified by the resident's physician, these services were not implemented. The PT evaluation indicated that the resident had impaired range of motion in both ankles and required therapeutic exercises, neuromuscular reeducation, and other interventions three times per week for four weeks. Similarly, the SLP evaluation identified mild to moderate oral dysphagia, necessitating treatment twice a week for four weeks. The OT evaluation noted impairments in the right shoulder, wrist, and hand, with a contracture in the right hand, and recommended therapy three times per week for one week. Despite these evaluations and plans, the therapies were not provided, and the resident did not receive any interventions to improve communication, mobility, or activities of daily living. Interviews with the Director of Rehabilitation and the Director of Nursing revealed that the resident's therapy plans were not implemented because the resident was considered totally dependent for mobility and ADLs. Instead, there was a verbal agreement among the therapists that the resident would benefit more from restorative nursing aide services rather than therapy. This decision was made despite the physician's certification of the need for therapy services, and the facility's policy aimed at restoring residents to their highest level of function.
Inaccurate Documentation and Medication Administration Errors
Penalty
Summary
The facility failed to ensure accurate documentation for two residents with limited range of motion and mobility concerns. For one resident, the documentation inaccurately recorded that a Restorative Nursing Assistant (RNA) provided passive range of motion (PROM) exercises and applied a wrist-hand orthosis (WHO) on a day when the RNA was on vacation and not present at the facility. Observations and interviews revealed that the resident did not receive the prescribed exercises and orthosis application as documented, indicating false and inaccurate record-keeping. Another resident's documentation inaccurately reflected that an RNA provided active range of motion (AROM) exercises to both legs on specific dates. However, interviews revealed that the RNA did not perform these exercises due to a past conflict with the resident, and the documentation was completed by the RNA without providing the services. This led to inaccuracies in the resident's clinical records, as the actual services provided were not documented by the RNAs who performed them. Additionally, the facility failed to ensure that a medication administration record (MAR) accurately reflected the administration of medication to a resident. A Licensed Vocational Nurse (LVN) documented under another LVN's name, leading to potential liability issues and inaccuracies in the resident's medical records. The facility's policy requires that the individual who administers medication records the administration directly after the medication is given, which was not followed in this instance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of bilateral 1/2 siderails on the resident's bed without a physician's order or assessment. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, schizoaffective disorder, and contracture of both knees, was observed with siderails that were not ordered by a physician. The resident's cognitive skills were moderately impaired, requiring substantial assistance with daily activities, and the use of these siderails was not in compliance with the physician's order for 1/4 assist devices. Observations revealed that the resident was lying in bed with both 1/2 siderails up, which was confirmed by the RN Supervisor as being against the physician's order. Interviews with staff, including a CNA, LVN, and the DON, indicated that the use of these siderails was considered a form of restraint, as they restricted the resident's movement and could lead to potential risks such as skin tears, fractures, or entrapment. The facility's policy on a restraint-free environment was not adhered to, as there was no monitoring or assessment for the use of these siderails. The facility's policy and procedure emphasized the prohibition of restraints for discipline or convenience, and required behavioral interventions to be exhausted before applying physical restraints. However, the use of bilateral 1/2 siderails without proper authorization and assessment demonstrated a failure to comply with these guidelines, placing the resident at risk for unnecessary restraint and associated complications.
Improper Positioning During G-Tube Medication Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 4 failed to maintain the head of the bed for Resident 38 at a minimum of 30 degrees during the administration of medications through a gastrostomy tube (g-tube), as per the facility's policy and procedure. This failure was observed during an incident where LVN 4 checked the g-tube for placement and residual while Resident 38 was lying on her right side at a 20-degree angle. LVN 4 then began administering medications without re-checking the g-tube placement or residual after repositioning Resident 38 to a 75-degree angle on her back. Resident 38 had a medical history that included a gastrostomy tube for feeding, hypertensive heart disease, depression, diabetes mellitus type 2, and dementia. The resident was noted to have impaired cognitive skills and was unable to make decisions for herself. The facility's policy required the head of the bed to be elevated at a minimum of 30 degrees during feeding or medication administration to prevent aspiration and pneumonia. Interviews with LVN 4, the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed the facility's policy and the importance of proper positioning to prevent aspiration pneumonia. LVN 4 admitted to positioning Resident 38 incorrectly to save time, acknowledging the risk of aspiration and potential fatality. The facility's policy and procedure documents reiterated the need for proper positioning during enteral feeding and medication administration.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to deficiencies in pain management. Resident 11 was admitted with diagnoses including hypertension and headaches. A care plan was initiated on October 2, 2024, focusing on managing Resident 11's constant pain with an intervention to monitor pain every four hours. However, documentation showed that pain monitoring did not begin until October 3, 2024, at 4:00 p.m., indicating a delay in implementing the care plan. Interviews with staff confirmed that the care plan was not followed as required, placing Resident 11 at risk for delayed care and treatment. Resident 18, who was readmitted with multiple diagnoses including a Stage 4 pressure ulcer, major depressive disorder, and cognitive impairments, did not have a care plan addressing pain despite observable signs of distress during wound dressing changes. The resident was observed moaning and grimacing, yet no care plan was in place to manage the pain associated with the pressure ulcer. Interviews with nursing staff revealed that a care plan for pain was only initiated after the surveyor began investigating the issue, highlighting a significant oversight in addressing the resident's pain management needs. The facility's policies and procedures require the development of a comprehensive care plan within seven days of completing the Minimum Data Set assessment, including measurable objectives and timeframes to meet residents' needs. Additionally, the facility's pain management policy emphasizes the importance of managing pain in accordance with the comprehensive assessment and plan of care. The failure to adhere to these policies resulted in inadequate pain management for both residents, as evidenced by the lack of timely interventions and documentation.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to safety protocols during the transfer of a resident with limited range of motion and mobility. Resident 18, who has diagnoses including parkinsonism, autistic disorder, and contractures of both knees, was observed being transferred by a single Certified Nursing Assistant (CNA) using a mechanical lift, despite the care plan and facility policy requiring two staff members for such transfers. This action was observed during a transfer from the bed to the shower bed, placing the resident at increased risk for accidents, including potential falls and physical injury. The deficiency was identified during an observation where CNA 10 was seen operating the mechanical lift alone, contrary to the facility's policy and the resident's care plan, which both mandate two-person assistance for mechanical lift transfers. The Director of Nursing (DON) intervened during the observation, instructing CNA 10 to halt the transfer and wait for additional assistance. CNA 10 later acknowledged the requirement for two-person assistance but cited the unavailability of other staff as the reason for proceeding alone. The facility's policy on Safe Resident Handling/Transfers, revised earlier in the year, clearly states the necessity of two staff members for mechanical lift transfers to ensure resident safety and minimize injury risk.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 18, was free from unnecessary medication by not implementing non-pharmacological interventions before administering psychotropic medication. Resident 18, who was diagnosed with major depressive disorder, bipolar disorder, schizoaffective disorder, and autistic disorder, was prescribed Alprazolam for anxiety manifested by an inability to relax. However, there was no documentation of non-pharmacological interventions being attempted prior to the administration of Alprazolam, which could lead to unnecessary use of psychotropic medication. Interviews with facility staff, including an LVN and the RN Supervisor, revealed that non-pharmacological interventions such as offering food, repositioning, providing a calm environment, listening to music, and assessing for pain were not utilized before administering Alprazolam. The RN Supervisor and the Director of Nursing acknowledged that the behavior described as 'inability to relax' was too general and not specific enough to warrant the use of Alprazolam. The facility's policy required that non-pharmacological interventions be attempted to facilitate the reduction or discontinuation of psychotropic drugs, and that PRN orders for such medications should only be used when necessary for a diagnosed specific condition with documented rationale.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of a resident with end-stage renal disease, diabetes mellitus, and dependence on renal dialysis. The resident, who had fluctuating capacity to understand and make decisions, was dependent on staff for various activities of daily living. The care plan for the resident included dietary interventions to regulate protein and potassium intake and to follow up with the resident's food preferences. However, the meal tray card for the resident did not indicate any food preferences or dislikes, and the resident reported receiving foods like potatoes, yams, and cheese, which were not suitable for her kidney condition. Interviews with staff revealed that the resident's dislike for certain foods, such as cheese on scrambled eggs, was communicated to the dietary manager, but no action was taken to address these preferences. The dietary manager confirmed that nutritional assessments are conducted upon admission and as needed, but was unaware of the resident's dislike for cheese. The facility's policy required obtaining food preferences and noting them in the dietary records, but this was not followed, leading to the potential for decreased meal intake and weight loss for the resident.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident was fully informed and aware of the implications of signing a binding arbitration agreement. The resident, who was legally blind and had a diagnosis of Diabetes Mellitus, was admitted to the facility and signed the arbitration agreement. However, during an interview, the resident stated that she could not recall signing the agreement or having it explained to her. She also mentioned that she would not have signed such an agreement if she had understood its nature. The resident's cognitive function was assessed as intact, but her visual impairment required assistance for signing documents, which was not adequately provided. Interviews with the Admissions Coordinator and the Director of Nursing revealed that the proper protocol was not followed when the resident signed the arbitration agreement. The Admissions Coordinator, who was not employed at the facility at the time, stated that a witness should have been present due to the resident's blindness. The Director of Nursing confirmed that the resident should not have been asked to sign the agreement without a family member or representative present, as it compromised her rights. The facility's policy required that residents or their representatives acknowledge understanding the agreement, which was not ensured in this case.
Failure to Implement Corrective Actions for RNA Services
Penalty
Summary
The Quality Assessment Assurance (QAA) Committee at the facility failed to implement corrective actions from a previous re-certification survey concerning the Restorative Nursing Aide (RNA) services. This failure resulted in repeated deficiencies related to the provision of range of motion (ROM) and mobility services. Specifically, the facility did not ensure that passive range of motion (PROM) exercises and splint applications were consistently provided to residents as per their care plans. For instance, Resident 32, who was admitted with hemiplegia and hemiparesis, was supposed to receive active range of motion (AROM) exercises five times a week but reported receiving them only twice a week. Similarly, Resident 5, with similar diagnoses, was not consistently provided with a palm guard or daily exercises as required by their care plan. Resident 43, who had end-stage renal disease and hemiplegia, was supposed to receive PROM and have a wrist hand orthosis applied five times a week but reported receiving exercises only once a week. The Director of Nursing (DON) confirmed the lack of evidence that these deficiencies were addressed in QAA meetings, indicating a systemic issue in addressing and correcting the RNA service deficiencies.
Facility Failed to Maintain Wall Integrity in Resident's Room
Penalty
Summary
The facility failed to maintain the wall in one of its rooms, specifically Room A, where a hole was observed in the drywall behind a resident's bed. This deficiency was identified during observations and interviews conducted over several days. The Maintenance Supervisor confirmed that the hole was not reported in the facility's Maintenance Log, despite daily room rounds being performed by the maintenance staff. The presence of the hole posed potential hazards, including the risk of water, fire, and pest intrusion into the resident's room. The resident involved, identified as Resident 27, was admitted with multiple health conditions, including morbid obesity, hypertensive heart disease, congestive heart failure, type 2 diabetes mellitus, and reduced mobility. The resident required varying levels of assistance for daily activities and was found lying awake in bed during the observation. The facility's Preventative Maintenance Program policy indicated that the Maintenance Director was responsible for ensuring the safety and operability of the building, but the hole in the drywall was not addressed, leading to the deficiency.
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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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