Pine Grove Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 126 N. San Gabriel Blvd., San Gabriel, California 91775
- CMS Provider Number
- 055056
- Inspections on file
- 38
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Pine Grove Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to prevent non-consensual sexual contact between two residents with severely impaired cognition who were seated side by side in wheelchairs in a hallway. A visitor observed a male resident’s hand inside the front of a female resident’s pants and reported this to an LVN, while video footage later reviewed by the ADM and DON showed the male resident attempting to place his hand under and in front of the female resident’s pants and the female resident swaying his hand away. Another staff member in housekeeping was told by the visitor that one resident was touching the other but, not fully understanding, did not report the concern to nursing or other staff. The ADM acknowledged that the facility was not able to prevent the sexually inappropriate touching, that residents did not have consent for such contact, and that everyone is a mandated reporter, while facility policy stated that no form of resident abuse is condoned.
A resident with dementia, legal blindness, severe cognitive impairment, and significant physical limitations was identified as a fall risk with restlessness while in bed, yet the care plan interventions to monitor and document sleep patterns, notify the physician of insomnia or anxiety, and provide individualized fall-prevention measures were not implemented. Staff confirmed there was no documented sleep monitoring, no related orders on the MAR, and no sedative orders in place despite ongoing nighttime restlessness, moaning, and screaming. The resident, who could not use a call light or verbalize needs, did not have a bed alarm, even though nurses and the ADON stated a bed alarm should have been ordered and could have alerted staff when the resident was no longer in a safe position. On a night when the resident was noted to be especially restless and constantly moving in bed, the resident was later found on the floor beside the bed with a forehead abrasion, and the IDT attributed the fall to severe cognitive impairment, restlessness, and physical limitations.
The facility did not complete required antibiotic time-outs (ATO) within 48 to 72 hours for two residents who were prescribed antibiotics for infections, as mandated by facility policy. Medical records and staff interviews confirmed that ATOs were not documented within the specified timeframe after antibiotic initiation, despite both residents receiving their prescribed antibiotics. Staff acknowledged the omission and confirmed that the ATOs should have been completed according to the facility's antibiotic stewardship protocols.
The facility failed to maintain room temperatures between 71 to 81 degrees Fahrenheit for three residents, causing discomfort and potential negative impacts on their quality of life. Despite complaints from the residents and confirmation from maintenance staff, the rooms remained excessively hot, with temperatures recorded as high as 92 degrees Fahrenheit. The facility's policies to ensure a comfortable environment were not adequately followed.
The facility was found deficient in maintaining sanitary food handling and storage practices. A rusted can opener, uncovered non-stick spray oil, and improperly sealed and unlabeled cheese were observed in the kitchen. The dietary consultant and DON confirmed these practices were against the facility's policies, which require proper labeling, sealing, and sanitization to prevent contamination.
The facility failed to ensure dumpsters were closed and not overflowing, as required by its Waste Management Policy. Observations revealed dumpsters overflowing with PPE and kitchen trash, which the Dietary Supervisor acknowledged could attract pests and pose an infection control concern. The Administrator confirmed non-compliance with policies designed to reduce contamination risk.
The facility failed to maintain an effective water management program to prevent Legionnaire's disease, as they did not conduct initial or ongoing testing for legionella. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of testing, despite facility policies and national guidelines emphasizing the importance of environmental testing to validate control measures. This oversight placed residents at risk for severe respiratory infections.
The facility failed to ensure a safe and sanitary environment by not properly insulating bed control wires for two residents and allowing trash cans in three rooms to overflow with waste and PPE. Staff confirmed these issues, which could lead to safety and infection control problems.
A resident with multiple health conditions was unable to go outside for over a month due to the lack of a suitable wheelchair. The available wheelchair was too snug, ripped, old, and dusty, leading to the resident feeling sad and starting to get depressed. Despite staff acknowledgment of the issue, no appropriate wheelchair was provided, highlighting a deficiency in accommodating the resident's needs.
Two residents with language barriers were not provided with communication boards as required by their care plans. One resident, with dementia and muscle weakness, and another with a spinal fracture and muscle weakness, both lacked the necessary communication aids to express their needs. Observations confirmed the absence of communication boards, and staff interviews corroborated this deficiency, which contravened the facility's policy on accommodating residents' communication needs.
Two residents in the facility, both dependent on staff for personal hygiene due to severe cognitive impairments and physical limitations, were observed with dirty and crusted fingernails. Despite facility policies requiring hand cleaning to prevent infection, these residents did not receive adequate grooming services, as confirmed by staff observations and interviews.
A resident with severe cognitive impairment and multiple health conditions did not receive their prescribed medications, amlodipine and Vitamin C, at the scheduled time due to a delay caused by the attending LVN. The medications were administered 1 hour and 18 minutes late, exceeding the facility's policy of a one-hour window for medication administration.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a med pass. A resident with cardiomegaly, heart failure, and diabetes received Amlodipine and Vitamin C 1 hour and 18 minutes late due to an LVN attending a call light. This was against the facility's policy of administering meds within one hour of the scheduled time.
An expired bottle of Osmolite 1.5 Cal was found in a medication room at nurse station 2, posing a risk to residents if administered. The DSD and DON acknowledged that licensed staff should ensure medications are not expired, as per facility policy, which requires immediate removal and disposal of outdated items.
A facility failed to coordinate care with hospice staff for a resident with a terminal prognosis, resulting in an inaccurate medical record. The resident's hospice binder lacked documentation of visits by hospice staff, including an RN and Spiritual Counselor, from December to February. This failure could potentially impact the resident's receipt of necessary hospice care.
The facility failed to ensure call lights were within reach for two residents, both with significant cognitive and physical impairments. One resident's call light was found hanging on the wall behind their bed, while another's was wrapped around a bed rail, both out of reach. This oversight could delay assistance and increase fall risk, contrary to facility policy.
The facility did not post accurate and complete nurse staffing information in a prominent location accessible to all residents and visitors. On one occasion, the information was only visible in the red zone for COVID-19 positive residents, and on another, the posted information was outdated. The administrator confirmed these deficiencies, which violated the facility's policy requiring daily, accurate postings.
The facility failed to meet the square footage requirement of 80 sq. ft. per resident in 13 rooms. Despite this, CNAs and residents reported no issues with space for care and mobility. A room waiver was recommended by the Department.
A resident with cognitive impairment and medical conditions was improperly restrained by a CNA using a white sheet as an abdominal binder to prevent self-scratching and pulling out a G-tube. This action violated the facility's policy, which requires restraints to be used only for medical necessity with proper authorization. Staff interviews confirmed the inappropriate use of the restraint.
A resident with cognitive impairment was subjected to physical restraint by a CNA, who wrapped a sheet around the resident's stomach to prevent access to their abdominal area. The incident was reported by an LVN to an RN, but the RN failed to inform the Administrator, delaying the required reporting to authorities. This breach of protocol violated the facility's policy on timely reporting of abuse and restraint incidents.
Failure to Prevent and Report Non-Consensual Sexual Contact Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents in a hallway. Resident 1, who had dementia and severely impaired cognitive skills for daily decision-making, required partial to moderate assistance for mobility and was not self-responsible, with a representative designated as responsible party. On the date of the incident, Resident 1 was seated in a wheelchair in the hallway next to Resident 2. An SBAR and Change in Condition Evaluation completed that afternoon documented that Resident 1 was at risk for emotional distress related to alleged inappropriate touching and that a witness had reported Resident 1 was being touched inappropriately by Resident 2 while seated in the hallway. Resident 2 was also not self-responsible and had severely impaired cognitive skills for daily decision-making, with diagnoses including muscle weakness, gait mobility issues, and dysphagia. Resident 2 required partial to moderate assistance for sit-to-stand and walking. An SBAR and Change in Condition Evaluation for Resident 2 on the same date documented an allegation of inappropriate sexual behavior toward Resident 1, manifested by inappropriate touching, and that Resident 2 was being monitored for inappropriate behavior manifested by touching Resident 1. The Administrator later stated that Residents 1 and 2 did not have consent to touch, especially in the private area or for any sexual interaction with another resident, and that if sexual inappropriate touching was not consensual, it was considered sexual abuse. The events leading to the deficiency were corroborated by witness interviews and video review. Visitor 1 reported seeing two wheelchairs side by side in the hallway, with Resident 1 closest to the wall and Resident 2 next to Resident 1, and observed Resident 2’s hand down the front inside of Resident 1’s pants, moving. Visitor 1 reported this to LVN 1 at the nurse’s station. The Administrator and DON reviewed surveillance footage from the hallway, which showed the two residents sitting side by side in wheelchairs, Resident 2 attempting to place a hand under and in front of Resident 1’s pants, and Resident 1 swaying Resident 2’s hand away; the exact hand location was not visible on the video. Housekeeping staff (HK1) stated that Visitor 1 told him something about Resident 2 touching Resident 1 and pointed toward the residents, but HK1 did not fully understand and did not report it to nursing or other staff. The Administrator acknowledged that the facility was not able to prevent Resident 2’s sexually inappropriate touching and stated that everyone is a mandated reporter required to report even alleged abuse. The facility’s abuse and neglect policy stated that the facility does not condone any form of resident abuse and that its purpose is to address the health, safety, welfare, dignity, and respect of residents.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate accident prevention interventions, including use of a bed alarm, monitoring and documentation of sleep patterns, and timely physician notification of insomnia or anxiety, for a resident assessed as at risk for falls. The resident was admitted with dementia, hypertension, and legal blindness, and was identified on a Fall Risk Evaluation as at risk for falls, with intermittent confusion, bedbound/incontinent status, and poor vision. The MDS documented severely impaired cognitive skills for daily decision making, bilateral upper extremity impairment, unilateral lower extremity impairment, and dependence or significant assistance needed for all ADLs, including rolling in bed. The care plan identified the resident as at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unawareness of safety needs, and restlessness while in bed, and also included a care plan for coronary artery disease with an intervention to monitor and document sleeping patterns, inform the physician of any insomnia or anxiety, and give sedatives as ordered. Despite these identified risks and care plan directives, the facility did not implement or document monitoring of the resident’s sleep pattern, and there was no sedative order in place. Multiple staff interviews, including with RN 1, LVN 2, and the ADON, confirmed there was no documented evidence that the resident’s sleep pattern had been monitored, even though it was listed as a care plan intervention. Staff also stated that if sleep monitoring was part of the care plan, it should have been ordered and reflected on the MAR so that licensed nurses could document hours of sleep. RN 1 acknowledged that the care plan was not resident-centered and that the intervention to monitor/document sleep pattern and notify the physician of insomnia or anxiety had not been carried out. The DON verified that the intervention to monitor and document sleep pattern was not implemented. The facility also failed to provide a bed alarm for this resident, despite the resident’s severe cognitive impairment, blindness, restlessness, and inability to use the call light or verbalize needs. LVN 1 stated the resident did not have a bed alarm and should have had an order for one to alert staff when the resident was no longer in a safe position in bed. LVN 2 and the ADON similarly stated that a bed alarm could have helped prevent a fall by alerting staff when pressure was off the bed. Staff interviews described the resident as usually restless at night, not sleeping like other residents, and moving or squirms frequently in bed. On the night of the incident, documentation and interviews indicated the resident was restless, screaming, moaning, and constantly moving in bed from around 1–2 AM, with repositioning and distraction attempts for comfort. At approximately 5:30 AM, the resident was found on the floor on the right side of the bed, face down between the bed and nightstand, with a 2 cm abrasion on the left forehead. The IDT progress notes identified the likely root causes of the fall as severe cognitive impairment, restlessness, and significant physical limitations, and the DON confirmed that the fall care plan did not include a specific intervention to address the resident’s restlessness while in bed and instead contained only a general directive to follow the facility fall protocol.
Failure to Complete Timely Antibiotic Time-Outs for Two Residents
Penalty
Summary
The facility failed to ensure that an antibiotic time-out (ATO), a structured process for reviewing and assessing the need for ongoing antibiotic therapy, was completed within 48 to 72 hours for two residents who were prescribed antibiotics. According to the facility's policy, an ATO should be performed within this timeframe to reassess the necessity of the antibiotic based on clinical and laboratory data, and to communicate findings with the prescribing physician. However, record reviews and interviews confirmed that ATOs were not completed for these residents within the required period after antibiotic initiation. One resident was admitted with chronic kidney disease, urinary tract infection, and enterocolitis due to Clostridium difficile, and was prescribed metronidazole. The medication administration records showed that the resident received the antibiotic as ordered, but there was no documentation of an ATO being completed within the 48 to 72-hour window. Another resident, admitted with heart failure, bacteremia, and end-stage renal disease, was prescribed ciprofloxacin following a surgical procedure. Similarly, the records indicated the antibiotic was administered as ordered, but an ATO was not documented within the required timeframe. Interviews with the Infection Preventionist, Registered Nurse Supervisor, and Director of Nursing confirmed that the ATOs for both residents were not completed as per facility protocol. The staff acknowledged that the ATOs should have been performed within 48 to 72 hours after starting the antibiotics, as outlined in the facility's policies on antibiotic stewardship and ATO procedures. The absence of timely ATOs was verified through both electronic medical chart reviews and staff statements.
Failure to Maintain Appropriate Room Temperatures
Penalty
Summary
The facility failed to maintain the room temperatures within the required range of 71 to 81 degrees Fahrenheit for three residents, leading to discomfort and potential negative impacts on their quality of life. Resident 126, who was in an isolation room, experienced excessive heat, causing her to sweat profusely and have difficulty sleeping. Despite her complaints about the room being too hot, the temperature was recorded at 92 degrees Fahrenheit by the maintenance staff. Resident 126 expressed that the heat exacerbated her insomnia, and she was unable to sleep due to the uncomfortable conditions. Resident 63 also reported discomfort due to the high temperature in his isolation room. He expressed that the room was too hot, which was confirmed by the maintenance staff who measured the temperature. Similarly, Resident 36, who had a history of polyneuropathy and other medical conditions, complained about the persistent heat in his room. Despite having the window partially open, he felt the room was excessively hot and had repeatedly informed various staff members, including the Maintenance Supervisor, about the issue without any resolution. The maintenance staff and Infection Control Nurse acknowledged the residents' complaints but failed to effectively address the temperature issues. The Maintenance Supervisor stated that he could control the thermostat remotely and was not notified of any extreme temperatures by the monitoring app. However, the residents continued to experience discomfort, and the facility's policies and procedures aimed at providing a comfortable environment were not adequately followed, resulting in the deficiency.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary manner, as observed during a survey. A can opener in the kitchen was found to be rusted, which was acknowledged by the dietary consultant (DC) as a potential source of cross-contamination. Additionally, a non-stick spray oil was observed without a lid, and cheese in the refrigerator was not properly sealed or labeled with an open or use-by date. These observations were confirmed by the DC, who noted the importance of sealing and labeling to prevent contamination. The Director of Nursing (DON) reviewed the facility's policies and procedures (P&P) and confirmed that the observed practices were not in compliance. The P&P required that all food items be labeled and dated, and that open products be stored in containers with tight-fitting lids. The can opener was also required to be sanitized between uses according to the manufacturer's guidelines. The DON emphasized that these measures are crucial to prevent food contamination and ensure resident safety.
Improper Waste Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure that three dumpsters in the parking lot were closed and not overflowing, as required by the facility's Waste Management Policy and Procedure. During observations and interviews conducted on two separate days, the dumpsters were found to be overflowing with personal protective equipment (PPE) and kitchen trash. The Dietary Supervisor acknowledged that the dumpsters should not be overflowing, as this could attract insects and rodents, posing an infection control concern. The facility's Administrator confirmed that the facility was not compliant with its Policies and Procedures, which were designed to reduce the risk of contamination from regulated waste. The policy indicated that biohazard containers should have closed lids and that food waste should be placed in covered garbage cans. The Administrator noted that when dumpsters are left open and overflowing with kitchen waste, it could lead to unpleasant odors and attract pests, further emphasizing the infection control issues.
Failure to Implement Effective Water Management Program for Legionella
Penalty
Summary
The facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease. During interviews, the Maintenance Supervisor (MS) admitted that the facility does not conduct any testing for legionella, neither initially nor on an ongoing basis, to confirm the effectiveness of their control measures. The Infection Preventionist (IP) also acknowledged the lack of testing for legionella or other waterborne pathogens, despite suggesting that testing would validate the effectiveness of the facility's control measures. A review of the facility's policy and procedure on Water Management indicated that the facility should develop and utilize water management strategies to reduce the risk of legionella and other water-borne pathogens. However, the facility did not follow through with environmental testing for pathogens as part of their verification and validation process. The CMS and CDC guidelines, as well as ASHRAE standards, emphasize the importance of environmental testing for legionella to validate the effectiveness of control measures, especially in healthcare facilities serving at-risk populations. The facility's failure to implement these testing protocols placed residents at risk for developing severe respiratory infections.
Deficiencies in Environmental Safety and Waste Management
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents by not ensuring that the bedside control wires for their beds were properly insulated. The exposed wires were observed in the rooms of two residents, one of whom had severe cognitive impairment and a history of falling, while the other had moderate cognitive impairment and a history of falling and depression. The Director of Nursing confirmed the presence of exposed wires, which could pose a risk of fire, shocks, and accidents. Additionally, the facility did not manage waste disposal effectively, as observed in three rooms where trash cans were overflowing with trash and used personal protective equipment. This was confirmed by interviews with staff, including a certified nursing assistant, an infection preventionist, and a licensed vocational nurse, who acknowledged that overflowing trash cans could lead to infection control issues. The facility's policies and procedures required trash cans to be closed and waste bags to be removed when three-quarters full, but these guidelines were not followed, contributing to an unsanitary environment.
Failure to Provide Suitable Wheelchair for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences regarding a wheelchair that was comfortable for his size and in good condition. The resident, who was admitted with multiple diagnoses including polyneuropathy, type 2 diabetes with diabetic polyneuropathy, end-stage renal disease, anemia, and dysphagia, expressed his desire to go outside for fresh air and sunlight. However, he was unable to do so because the facility did not have a wheelchair that fit him properly, and the available wheelchair was described as too snug, ripped, old, and dusty. The resident reported feeling sad and starting to get depressed due to being confined to his bed for over a month. Despite his requests and the facility staff's acknowledgment of the issue, no suitable wheelchair was provided. Interviews with various staff members, including the Director of Nursing, Certified Nursing Assistant, Social Service Director, and Occupational Therapy staff, confirmed the lack of an appropriate wheelchair and the resident's inability to be transferred safely and comfortably. The facility's policies and procedures, including those related to maintenance, resident rights, and infection control, emphasize the importance of maintaining equipment in good condition and accommodating residents' needs. However, the failure to provide a suitable wheelchair for the resident highlights a deficiency in adhering to these policies, potentially impacting the resident's psychosocial well-being and safety.
Failure to Provide Communication Boards for Residents with Language Barriers
Penalty
Summary
The facility failed to provide communication boards to two residents, Residents 66 and 225, who had language barriers and were dependent on staff for communication. Resident 66, diagnosed with dementia and muscle weakness, was admitted to the facility and was noted to be dependent on staff for various activities of daily living. The care plan for Resident 66 indicated the need for adaptive equipment, such as a communication board, to address the language barrier. However, during multiple observations, no communication board was found in Resident 66's room, and staff confirmed the absence of such a device. Similarly, Resident 225, who had a wedge compression fracture and muscle weakness, was also identified as having a language barrier. The care plan for Resident 225 included the provision of a communication board or translator to facilitate communication. Observations revealed that no communication board was present in Resident 225's room, and the resident reported frequent misunderstandings with staff due to the lack of communication aids. Staff interviews confirmed the absence of communication boards for Resident 225. The facility's policy on accommodating residents' communication needs requires the provision of adaptive devices like communication boards for residents with language barriers. The Director of Nursing acknowledged that the absence of communication boards for these residents placed them at risk of being unable to express their needs effectively. This deficiency highlights the facility's failure to adhere to its own policy and ensure that necessary communication aids are readily accessible to residents with language barriers.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services for two residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. Resident 53, who was admitted with diagnoses including sepsis, dysphagia, and muscle weakness, was observed with dirty and crusted fingernails. The resident's cognitive skills were severely impaired, and they were totally dependent on staff for personal hygiene, as indicated in their care plan. Despite these needs, observations revealed that the resident's nails were not maintained, which was confirmed by a licensed vocational nurse who noted the potential for bacteria harboring under the nails. Similarly, Resident 57, who had diagnoses including dysphagia, muscle weakness, and paraplegia, was also observed with unkempt fingernails. This resident required substantial assistance with eating and was dependent on staff for personal hygiene. During an observation, the resident's fingernails were noted to have a dry, crusted, yellowish-blackish substance. The facility's administrator acknowledged that it was unacceptable for residents to have dirty fingernails and that the facility's policy was to clean residents' hands when dirty, especially before and after meals, to prevent the spread of infection.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 64 by not administering medications as prescribed. Resident 64, who was admitted with diagnoses including cardiomegaly, heart failure, and diabetes, had a physician's order for amlodipine 5 mg and Vitamin C 250 mg to be administered at 9 AM. However, during a medication pass observation, it was noted that the medications were administered at 10:18 AM, which was 1 hour and 18 minutes after the scheduled time. The Licensed Vocational Nurse (LVN) responsible for administering the medications stated that the delay was due to attending to another resident's call light. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but the administration in this case exceeded that window. The facility's administrator confirmed that the medications should have been administered between 8 AM and 10 AM, indicating a failure to adhere to the facility's medication administration policy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69% during a medication administration observation. This deficiency was identified when two medication errors occurred out of 25 opportunities, specifically involving a resident who was administered medications outside the prescribed time frame. The medications, Amlodipine 5 mg and Vitamin C 500 mg, were given 1 hour and 18 minutes after the scheduled 9 AM administration time, which was beyond the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had significant medical conditions, including cardiomegaly, heart failure, and diabetes, which required careful management of their medication regimen. The Licensed Vocational Nurse (LVN) responsible for the medication pass attributed the delay to attending to a call light during the medication administration process. The facility's policy and procedures emphasized the importance of adhering to the scheduled administration times to ensure compliance with dose guidelines, but this was not followed in this instance, leading to the identified deficiency.
Expired Osmolite 1.5 Cal Found in Medication Room
Penalty
Summary
The facility failed to remove expired Osmolite 1.5 Cal, a therapeutic nutrition product, from one of its medication rooms, specifically at nurse station 2. During an observation with the Director of Staff Development (DSD), a bottle of Osmolite 1.5 Cal was found with an expiration date that had already passed. The DSD acknowledged that expired enteral feeding bottles should not be present in the medication room, as their administration could lead to residents becoming ill and potentially requiring hospitalization. The Director of Nursing (DON) confirmed that licensed staff are responsible for checking expiration dates before administering any medication or enteral feeding bottles to residents. The facility's policy on medication storage mandates the immediate removal and proper disposal of expired, contaminated, or deteriorated medications. However, the presence of the expired Osmolite 1.5 Cal in the medication room indicates a lapse in adherence to this policy, posing a risk to resident health.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, resulting in an inaccurate medical record. The resident, who was admitted with a terminal prognosis and under hospice care, did not have hospice staff visit progress notes maintained in their medical record. Additionally, hospice staff did not sign in on their flow sheet in the resident's hospice binder, which is considered part of the medical record. This lack of documentation could potentially lead to the resident not receiving the necessary hospice care and services. The resident, identified as having severe cognitive impairment and being dependent on assistance for daily activities, was admitted to the facility with serious health conditions, including a dissection of the ascending aorta and type 1 diabetes. Despite the care plan indicating the need for cooperation with the hospice team to meet the resident's needs, the hospice binder lacked documentation of visits by the hospice RN and Spiritual Counselor from December 2024 to February 2025. The Director of Nursing confirmed the absence of required documentation, which was against the facility's policy and procedure for hospice care of residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents, leading to a potential delay in receiving assistance. Resident 8, who was admitted with type 2 diabetes and dementia, was observed with their call light hanging on the wall behind the head of their bed, out of reach. This resident was noted to have severe cognitive impairment and was dependent on staff for daily activities, making the accessibility of the call light crucial for their safety and communication needs. Certified Nursing Assistant 1 confirmed the call light's placement was not within the resident's reach. Similarly, Resident 44, diagnosed with metabolic encephalopathy and multiple sclerosis, was found with their call light wrapped around the back part of their bed's side rail, also out of reach. This resident's care plan specifically indicated the need for the call light to be within reach due to their risk of falls and dependency on staff for assistance. Licensed Vocational Nurse 2 acknowledged the call light's improper placement and its importance for resident communication. The Director of Nursing emphasized the risk posed by inaccessible call lights, as residents might attempt to move independently, increasing the risk of falls or unmet needs. The facility's policy mandates that call lights be placed within residents' reach, which was not adhered to in these cases.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information in a prominent location accessible to residents and visitors, as required by their policy and procedure. On February 4, 2025, the nurse staffing information was only posted in the red zone, which is designated for residents who tested positive for COVID-19, and was not visible to other residents or visitors outside this area. This oversight was confirmed during an observation at the facility's entrance and lobby, where the staffing information was not accessible to those in the yellow and green zones. Additionally, on February 5, 2025, the Daily Nurse Staffing form posted in the lobby was found to be outdated, displaying the previous day's date, thus rendering it inaccurate. The facility's administrator acknowledged that the staffing information was not updated and confirmed that the posting did not comply with the facility's policy, which mandates that the information be accessible to all staff, residents, and visitors, and must be accurate. The facility's policy, revised in July 2018, requires daily posting of the facility name, current date, and total number of actual hours worked by licensed and unlicensed nursing staff per shift in a clear, readable format in a prominent location.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 of 35 resident rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. During an initial observation, it was noted that rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23 did not meet this requirement. Despite this, residents were able to ambulate and move around in their wheelchairs freely, and nursing staff had enough space to provide safe quality care. The facility had a room waiver indicating that the rooms with three beds were in accordance with the needs of the residents and did not adversely affect their health and safety. Interviews with Certified Nursing Assistants (CNAs) and residents revealed that there were no concerns regarding the room sizes. CNAs stated that there was enough room to provide proper and safe care to the residents. Additionally, residents did not express any concerns about the size of their rooms. The Department recommended the room waiver for the specified rooms as requested by the facility.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. A Certified Nurse Assistant (CNA) wrapped the resident's torso with a white sheet, using it as an abdominal binder, which restricted the resident's normal access to their body. This action was taken to prevent the resident from self-scratching and pulling out their gastrostomy tube (G-tube) or incontinent brief. The resident, who was cognitively impaired and required substantial assistance for daily activities, was unable to understand or make decisions due to their medical conditions, including hemiplegia and dementia. The facility's policy mandates that restraints should only be used when necessary for medical treatment and require a physician's order, assessment, and consent. The CNA's action was not in compliance with this policy, as it was done for convenience rather than medical necessity. Interviews with the staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that the use of the sheet as a restraint was inappropriate and not authorized. The facility administrator also emphasized that restraints should only be used as a last resort and in accordance with the resident's assessment and plan of care.
Failure to Timely Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to report a suspected case of abuse and physical restraint involving a resident to the appropriate authorities within the required timeframe. The incident involved a resident who was cognitively impaired and required substantial assistance for daily activities. The resident was found with a white sheet wrapped around their stomach, which was used by a CNA to prevent the resident from accessing their abdominal area. This action was reported by an LVN to an RN, but the RN failed to report the incident to the facility's Administrator as required by the facility's policy. The Administrator was only informed of the incident during a staff meeting several days later, which delayed the reporting to the State Survey Agency, Law Enforcement, and the LTC Ombudsman. The facility's policy mandates that such incidents be reported within two hours, but this was not adhered to, potentially placing the resident at risk for further abuse and delaying the investigation. The facility's policies on restraint and abuse prevention clearly outline the procedures for reporting such incidents, which were not followed in this case.
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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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