Pine Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, California.
- Location
- 1139 Cirby Way, Roseville, California 95661
- CMS Provider Number
- 555801
- Inspections on file
- 30
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pine Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that three residents at risk for falls and requiring varying levels of assistance with ADLs and transfers did not have accessible, functional call light systems as required by their care plans and facility policy. Two residents were observed awake in bed with their call light buttons on the floor under the bed and out of reach, and CNAs confirmed the lights should have been placed within reach. Another resident reported that his call light had been broken for several days, staff interviews indicated the call light frequently malfunctioned, and observation with staff confirmed the system was broken with no alternative call system provided and no documentation in the maintenance log.
Three residents did not receive care and services as ordered, including the application of TED stockings and lymphatic compression devices. One resident with endocarditis and muscle weakness was not provided with TED hose or offered the compression device as ordered, while two other residents with conditions such as congestive heart failure and multiple sclerosis were not provided with TED hose or daily weights as prescribed. Staff and nursing leadership confirmed these orders were not followed, and facility policy required adherence to physician orders.
Two residents who required staff assistance for ADLs were found with untrimmed, dirty fingernails, dry and scaly feet, and old food residue in their beards. Staff confirmed these hygiene deficiencies and acknowledged that the residents should have been properly cleaned and groomed, in accordance with their care plans and facility policy.
The facility did not consistently document the administration of hydrocodone-acetaminophen for three residents with orthopedic and spinal injuries, resulting in discrepancies between the Controlled Drug Record and the Medication Administration Record. The DON acknowledged the importance of accurate documentation for controlled drug accountability, but the facility's policy was not followed.
Surveyors found that medication carts contained a loose, unlabeled tablet and were left unlocked and unattended, contrary to facility policy. Additionally, a discontinued medication for a resident with respiratory conditions remained in the medication refrigerator with active medications days after discharge, instead of being promptly removed and stored for disposal as required.
Staff did not deliver bedside water pitchers for two days, resulting in four residents—each at risk for dehydration due to medical conditions and not on fluid restrictions—being left without consistent access to water. Observations and interviews confirmed the absence of water pitchers, with some residents only receiving water at mealtimes. Both nursing and CNA staff acknowledged that water pitchers should have been provided, and facility policy required monitoring and supporting resident hydration.
Licensed nursing staff documented treatments and medications as provided when they were not administered, including TED hose and IV antibiotics, and failed to accurately complete informed consent for a psychotropic medication. Additionally, meal tickets containing resident-identifiable information were disposed of in regular garbage instead of confidential shredding, breaching confidentiality protocols.
A resident with dysphagia and partial paralysis had a G-tube in place, but there was no current physician order or care plan addressing the device. Multiple staff, including an LPN, NP, and DON, confirmed the absence of required documentation and care planning for the G-tube, despite facility policy requiring comprehensive care plans for all medical devices.
A resident with dysphagia and partial paralysis had a physician order for 1:1 supervision and assistance during meals, including cues to slow eating and pre-cut food. Staff were observed leaving the resident unattended during meals, and there was no documentation of required supervision for the past month. Facility policies required following physician orders and providing meal assistance based on individual needs, but these were not followed.
The facility failed to meet professional standards for food storage and service practices, including unlabeled opened food packages, improperly stored food items, and ineffective sanitizer solution. These deficiencies were acknowledged by the Food and Nutrition staff and were in violation of the facility's policies and the U.S. Food and Drug Administration's Food Code.
The facility failed to follow infection control standards, including improper sanitation of a shower chair, washing machine, and vital signs machine, as well as inadequate hand hygiene and labeling of oxygen tubing, nebulizer equipment, and urinals. These failures decreased the facility's potential to prevent the spread of infection.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their MDS. One resident's MDS inaccurately indicated one-sided impairment despite both knees being contracted, while another resident's MDS incorrectly noted intermittent catheterization without physician orders. These inaccuracies were confirmed by the MDS Coordinator and nursing staff.
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. The residents had various medical devices and needs, including urinary catheters, a PICC line, an abdominal binder, and TED hose, but there were no documented care plans for these items. The Director of Nursing confirmed the omissions, and the facility could not provide a policy for Baseline Care Plans.
The facility failed to update a resident's care plan to include the use of an elopement management bracelet, despite multiple observations of the resident wearing the bracelet. Both the ADON and DON confirmed the care plan was not revised, contrary to facility policy.
The facility failed to implement physician's orders for a resident's use of TED hose and an abdominal binder, and did not properly assess and cover a PICC line. Additionally, an elopement management bracelet was applied to another resident without a physician's order, with no documented communication between staff and the physician.
The facility failed to ensure that a resident with a history of stroke and dysphagia was assisted to an upright position while eating, increasing the risk of aspiration. The resident was observed lying in bed while eating, and staff acknowledged the need for the resident to be sitting up to prevent choking. Interviews with staff confirmed the importance of proper positioning during meals.
The facility failed to ensure all drugs were properly labeled, as an aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in a medication cart. Staff confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The facility's policy requires medications to be labeled with specific information, which was not followed in this instance.
Failure to Maintain Accessible and Functional Call Light Systems for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to functioning call light systems within reach, as required by their care plans and facility policy. For one resident with a neck fracture, dementia, and no capacity to make decisions, the care plan identified risk for falls and directed staff to keep the call light within reach. During observation, this resident was found awake in bed with a neck brace, and the call light button was on the floor under the bed. The resident stated he did not know where his call light was, and a CNA confirmed its location and acknowledged it should have been placed where the resident could reach it. A second resident, with diabetes, polyneuropathy, retinopathy, gait and mobility abnormalities, and muscle weakness, had an MDS showing intact cognition but required varying levels of assistance with ADLs and transfers. The care plan for this resident, which addressed fall risk, included interventions to keep the call light within reach and to educate/remind the resident to call for assistance with all transfers. During observation, this resident was also found awake in bed with the call light button on the floor under the bed and the cord stuck on the bed frame. The resident reported being unable to reach the call light, and a CNA confirmed the situation and stated the call light should always be within the resident’s reach. A third resident, with a history including a left upper arm fracture, diabetes, muscle weakness, and congestive heart failure, had an MDS indicating mostly substantial/maximal assistance needs for ADLs and supervision or assistance for bed mobility and transfers. The care plan for this resident, addressing fall risk, included instructions to educate/remind the resident to call for assistance with all transfers and to keep the call light within reach. Staff interviews revealed that this resident’s call light “usually gets broken” and that staff would try to fix it, but it would break again. The resident reported feeling annoyed and uncomfortable in the room because the call light had been broken for several days and stated that staff were aware but had not fixed it. Observation with a CNA and the Maintenance Supervisor confirmed the call light system was broken, there was no alternative call system in place, and there was no entry in the maintenance logbook documenting the broken call light. The DON stated she expected residents to have working call lights within reach and acknowledged safety concerns when call lights are not working or not within reach.
Failure to Follow Physician Orders for Compression Devices and Stockings
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for three residents by not following physician orders for the application of Thrombo-Embolic Deterrent (TED) stockings and lymphatic compression devices. One resident, admitted with endocarditis and generalized muscle weakness, had physician orders for TED hose to be applied every morning and removed in the evening, as well as for a lymphatic compression device to be offered after meals. During observation and interview, the resident was found wearing regular socks instead of TED stockings and reported that the compression device had not been offered. The assigned nurse confirmed the devices were not applied as ordered and that the compression device was stored out of sight in the resident's room. Another resident, admitted with congestive heart failure and muscle weakness, had an order for compression stockings to be worn during the day and removed at night, as well as an order for daily weights. Observations revealed the resident was not wearing compression stockings, and record review showed daily weights were not completed as ordered. The Director of Staff Development confirmed the omission of daily weights and the absence of compression stockings during review of the resident's records. A third resident, admitted with muscle weakness and multiple sclerosis, had an order for TED hose to be applied in the morning and removed at bedtime. During observation and interview, the resident was not wearing TED hose and stated she had never been fitted for them while at the facility. The physical therapy assistant and licensed nurse confirmed that TED hose were not available among the resident's belongings and had not been applied. The Director of Nursing and Nurse Practitioner both stated their expectation that staff follow physician orders as written. Facility policy also required that prescribed medication and treatment orders be carried out as prescribed.
Failure to Provide Adequate Hygiene and Grooming for Two Dependent Residents
Penalty
Summary
Two residents who required assistance with activities of daily living (ADLs) were observed to have untrimmed, jagged fingernails with black substances underneath, dry and scaly skin on their feet, and traces of colored-liquid and old, dry food residue in their beards. These findings were confirmed during multiple observations and interviews with facility staff, including the Treatment Nurse, Assistant Director of Nursing, and Director of Nursing. Both residents had documented medical conditions—one with osteoarthritis, generalized muscle weakness, and a left below-knee amputation, and the other with Parkinson's disease and dementia—that necessitated staff assistance for ADLs, as reflected in their care plans. Despite these documented needs, the residents were not provided with adequate hygiene and grooming, as evidenced by their physical condition during the survey. Staff interviews confirmed that the residents should have been cleaned and groomed, and that the lack of hygiene could lead to discomfort, skin irritation, and affect their dignity. Facility policy required appropriate care and services for residents unable to perform ADLs independently, but this was not followed for the two residents in question.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled medications for three residents who were prescribed hydrocodone-acetaminophen for pain management following orthopedic and spinal injuries. For one resident, the Controlled Drug Record (CDR) indicated a dose was administered, but this was not reflected in the Medication Administration Record (MAR). For another resident, multiple instances were found where the CDR showed administration of the medication, but the MAR did not document these doses. In a third case, there was a discrepancy between the administration times recorded in the CDR and the MAR for the same dose. Interviews with the Director of Nursing confirmed the importance of correct documentation for controlled drug accountability and acknowledged that incorrect records could be associated with medication misuse and drug diversion. The facility's policy required immediate and accurate documentation of controlled medication administration on both the accountability record and the MAR, including date, time, amount administered, and the nurse's signature, but this procedure was not consistently followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications. During an inspection of a medication cart, a loose, unlabeled white tablet was found at the bottom of a drawer containing blister packs. The nurse present acknowledged that medication carts should not contain loose or unlabeled medications. Additionally, a medication cart was found unlocked and unattended at a nursing station, which was confirmed by both a licensed nurse and the Director of Nursing (DON) as a safety concern and contrary to facility policy. The facility's policy requires all drugs and biologicals to be stored in their original packaging and for medication carts to be locked when not in use. Another deficiency was identified regarding the handling of discontinued medications. A prescription drug belonging to a discharged resident, who had a history of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, was found stored in the medication refrigerator alongside active medications several days after the resident's discharge. The nurse and DON confirmed that discontinued medications should be removed immediately upon discharge and stored separately for disposal. Facility policy also states that discontinued, outdated, or deteriorated drugs must be placed in designated bins for destruction, which was not followed in this instance.
Failure to Provide Bedside Water Pitchers Results in Hydration Deficiency
Penalty
Summary
The facility failed to provide sufficient hydration to four residents when staff did not deliver bedside water pitchers for two consecutive days. Observations and interviews revealed that these residents, all of whom had medical conditions placing them at risk for dehydration, did not have water pitchers at their bedside tables during multiple checks. Instead, some residents only had partially filled cups or received water only at mealtimes, which was inconsistent with their care plans and facility policy. Resident records indicated that none of the affected residents were on fluid restrictions, and their care plans specifically identified them as being at risk for dehydration. For example, one resident with a history of urinary tract infection, type 2 diabetes, and high blood pressure, who was also prescribed a diuretic, had significantly reduced fluid intake on the days in question compared to her average intake for the month. Other residents with moderate cognitive impairment also lacked bedside water pitchers, and staff interviews confirmed that water pitchers should have been provided regardless of fluid restriction status. Staff interviews further clarified that the night shift was responsible for providing fresh water pitchers, and the day shift was expected to replace any missing pitchers. However, both nursing and CNA staff acknowledged that the absence of water pitchers could lead to adverse outcomes, and the facility's own hydration policy required staff to monitor hydration status and provide supportive measures, including supplemental fluids. The deficiency was directly linked to the failure of staff to ensure water pitchers were consistently available at residents' bedsides.
Inaccurate Documentation and Breach of Resident Confidentiality
Penalty
Summary
Licensed nursing staff documented the administration of treatments and medications that were not actually provided to several residents. For example, one resident with orders for TED hose and a lymphatic compression device was not wearing the devices as ordered, and the nurse confirmed she had not applied them despite documenting otherwise. Similarly, two other residents with orders for TED hose were not wearing them, and the responsible nurse admitted to documenting their application on the MAR when she had not performed the task. In another case, a resident's intravenous antibiotics were documented as administered by a nurse not authorized to do so, and the nurse acknowledged the documentation was inaccurate. The facility also failed to safeguard resident-identifiable information. Meal tickets containing residents' names, room numbers, dietary information, and allergies were disposed of in the regular garbage rather than in a confidential shredding bin. This practice was confirmed by both the dietary worker and the dietary manager, who acknowledged that the tickets contained confidential information and should not have been discarded with regular waste. Additionally, the facility did not accurately complete informed consent documentation for the administration of a psychotropic medication. The consent form for a resident receiving brexpiprazole was signed and witnessed by two nurses, but the section indicating the name of the person giving verbal or phone consent was left blank. The assistant director of nursing confirmed that the consent was incomplete and inaccurate, as the responsible party's name was not documented as required.
Failure to Develop and Implement Care Plan for G-Tube
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with diagnoses including dysphagia and partial paralysis to the left side, and who had a G-tube in place. Upon review of the resident's admission record, order summary report, and care plan documentation, it was found that there was no current physician's order or care plan addressing the G-tube, despite its presence. The resident expressed a desire to have the G-tube removed, and during multiple interviews and record reviews with facility staff, it was acknowledged that the necessary documentation and care planning for the G-tube were missing. Further interviews with a licensed nurse, nurse practitioner, and the director of nursing confirmed that there was no current order for the G-tube and no care plan developed, revised, or resolved for its care and treatment. The facility's own policy requires a comprehensive care plan that includes measurable objectives to meet the resident's needs, including medical devices. The lack of a care plan for the G-tube meant the resident's specific needs related to this device were not formally addressed.
Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to meet professional standards for food storage and service practices, as observed during a survey. Opened food packages, such as a bottle of barbecue sauce and various seasonings, were found without labels indicating the date they were opened. This lack of labeling was acknowledged by the Food and Nutrition Assistant (FNA) and the Food and Nutrition Director (FND), who both stated that opened food items should be labeled with the date to determine their shelf life based on storage guidelines. The facility's policy and procedure, as well as posted guidelines, were not followed in these instances. Additionally, several food items, including frozen waffles and bins of sugar and brown rice, were found removed from their original packaging without proper labels identifying the contents. The FNA confirmed that these items should have been labeled to indicate what the product was. This practice is in violation of the facility's policy and the U.S. Food and Drug Administration's Food Code, which requires that food storage containers be identified with the common name of the food to prevent contamination. Furthermore, opened and unsecured packages of meatless meatballs, meatless breaded wings, and oatmeal cookie dough were found in the freezer. The FNA and FND both acknowledged that these bags should be securely closed to prevent cross-contamination and freezer burn. The facility also failed to maintain the proper concentration of quaternary ammonium sanitizer solution, as observed during multiple tests where the solution was found to be below the effective range of 200 to 400 parts per million (ppm). The FND and Dietary Aide (DA) confirmed that the solution needed to be changed more frequently to ensure its effectiveness, as per the facility's policy and procedure.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards of practice in several instances. A shower chair with a brown substance was observed stored in the hallway, and staff did not follow the recommended minimum disinfectant contact time for sanitation of the chair. Additionally, staff did not sanitize the exterior surface of the washing machine, including the door handle, after loading dirty laundry. Staff also failed to perform hand hygiene prior to donning and after doffing personal protective equipment during medication administration. Furthermore, staff did not disinfect the vital signs machine between resident use and after use. Oxygen tubing for three residents was not labeled with a date, and nebulizer equipment for one resident was not labeled with a date or stored in an anti-microbial bag. Lastly, urinals for two residents were not labeled with resident identifiers. These failures decreased the facility's potential to prevent the spread of infection.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, resulting in discrepancies in their Minimum Data Sheets (MDS). Resident 15, who was admitted with multiple diagnoses including hemiplegia and hemiparesis, was observed with both knees contracted and experiencing significant pain. However, the MDS inaccurately indicated impairment on only one side. This inaccuracy was confirmed by the MDS Coordinator, who acknowledged that the assessment should have reflected impairment on both sides, potentially affecting the resident's plan of care. Similarly, Resident 301's MDS inaccurately indicated that the resident was receiving intermittent catheterization, despite no physician orders for such a procedure. This discrepancy was confirmed during a review of the resident's MDS and Order Summary Report (OSR) by the MDS Coordinator and a Licensed Nurse. The Director of Nursing stated that resident assessments are expected to be accurate, as per the facility's policy and procedure on resident assessments.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. Resident 297, admitted with diagnoses including fractures and muscle weakness, had a urinary catheter in place due to urinary retention, but there was no care plan documented for the catheter. Similarly, Resident 301, readmitted with muscle weakness, a fracture, and chronic respiratory failure, also had a urinary catheter without a corresponding care plan documented. These omissions were confirmed during a review of their care plans and physician orders, which indicated the presence of urinary catheters without associated care plans. Resident 307, admitted with lymphoma, benign prostatic hyperplasia, and muscle weakness, had multiple medical devices and needs, including a urinary catheter, a PICC line, an abdominal binder, and TED hose. However, there was no documented care plan for any of these items. During an observation and interview, Resident 307 confirmed the presence of these devices and the lack of use of the abdominal binder and TED hose. The Director of Nursing confirmed the missing care plans for all three residents and acknowledged that the baseline care plans should have included these essential details within the first 24-48 hours of admission. The facility was also unable to provide a policy and procedure for Baseline Care Plans when requested.
Failure to Update Care Plan for Elopement Management Bracelet
Penalty
Summary
The facility failed to revise the care plan for Resident 310 to reflect the placement of an elopement management bracelet. Resident 310, who was admitted with diagnoses including a left hip fracture, dysphagia, and dementia without behavioral disturbance, was observed wearing the bracelet on multiple occasions. However, the care plan dated from 4/4/24 to 4/18/24 did not include this critical update. Certified Nursing Assistant 5 was unaware of the bracelet's purpose, indicating a lack of communication and documentation regarding the resident's care needs. The Assistant Director of Nursing and the Director of Nursing both confirmed that the care plan had not been updated to include the elopement management bracelet, despite the facility's policy requiring care plans to be revised to meet residents' individual needs. This oversight was acknowledged during interviews and record reviews, highlighting a failure to provide consistent nursing interventions for Resident 310.
Failure to Implement Physician's Orders and Unauthorized Use of Elopement Bracelet
Penalty
Summary
The facility failed to ensure services provided met nursing professional standards for two residents. For Resident 307, the physician's orders for the use of thrombo-embolic deterrent hose (TED hose) and an abdominal binder to prevent orthostatic hypotension were not implemented. Additionally, Resident 307's peripherally inserted central catheter (PICC) was not assessed for patency and was not covered with an appropriate dressing. The Assistant Director of Nursing (ADON) confirmed that there were multiple shifts where the orders for TED hose were not documented as executed, and the PICC dressing was observed to be not intact and needed changing. For Resident 310, an elopement management bracelet was applied without a physician's order. The resident's records indicated no risk for elopement, and there was no documented communication between the nursing staff and the physician regarding the application of the bracelet. The Medical Doctor (MD) and Nurse Practitioner (NP) confirmed that there was no documentation or communication about the order for the bracelet in the communication binder, and the MD was unaware of the order. These failures decreased the facility's potential to ensure physician's orders were carried out for residents, as evidenced by the lack of implementation and documentation of prescribed treatments and the application of an elopement management bracelet without proper authorization.
Failure to Assist Resident to Upright Position While Eating
Penalty
Summary
The facility failed to ensure that Resident 28 was assisted to an upright position while eating lunch, which decreased the potential to prevent food aspiration and aspiration pneumonia. Resident 28, who had a history of stroke, dysphagia, and generalized muscle weakness, was observed lying in bed while eating a bowl of soup. When asked, Resident 28 indicated that lying down was not the best position to eat. A Certified Nursing Assistant (CNA) acknowledged that the resident was lying back too much and should be sitting up to eat, and subsequently raised the head of the bed to an upright position. The resident did not express any discomfort with sitting upright. Interviews with the Director of Staff Development (DSD), the Restorative Nursing Assistant Supervisor (RNAS), and the Director of Nursing (DON) confirmed that residents should be sitting up while eating to prevent choking. The facility's policy on Activities of Daily Living (ADLs) indicated that residents who are unable to carry out ADLs independently should receive appropriate support and assistance with dining. A review of a research article highlighted the importance of appropriate posture to prevent aspiration in older adults with dysphagia, emphasizing that the head of the bed should be raised by at least 30 degrees for those who cannot get out of bed.
Failure to Properly Label Medications
Penalty
Summary
The facility failed to ensure all drugs were properly labeled, as observed during a survey at nursing station 1. An aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in medication cart 1. Licensed Nurse 3 confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The Regional Nurse Consultant also confirmed the medication should have been labeled. The Assistant Director of Nursing stated that unlabeled medications should be discarded due to safety issues, as nurses would not be able to identify which resident the medication was intended for. A review of the facility's policy and procedure on medication labeling, revised in February 2023, indicated that medications should be labeled in accordance with federal and state requirements. The policy specifies that labels must include the resident's name, medication name, prescribed dose, route of administration, and appropriate instructions and precautions. The failure to adhere to this policy reduced the facility's potential to ensure safe medication administration for its residents.
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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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