Pine Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 45 Professional Center Pkwy, San Rafael, California 94903
- CMS Provider Number
- 055850
- Inspections on file
- 39
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Pine Ridge Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease, dementia, and generalized anxiety was paired as a roommate with another severely cognitively impaired resident who had anxiety disorder and depression. After the room change, staff documented that the second resident did not adjust well, repeatedly yelled at staff and the roommate, and shouted statements such as “Who let this woman in my house,” with ongoing notes of agitation and verbal aggression. Staff and family reported that the aggressive resident frequently cursed, used hateful and derogatory language in Spanish, and called the roommate offensive names such as “son of a b---” and “Get this b--- out of my house,” leading staff to move the affected resident out of the room during the day because the two residents fought and disturbed others. Nursing staff, the DON, and the Administrator acknowledged that such name‑calling and cursing directed at another resident could be verbal abuse if it caused emotional distress, and family reported the affected resident became angry and upset when sworn at, consistent with the facility’s abuse policy definition of verbal abuse.
The facility failed to accurately code a resident’s MDS for verbal behavior symptoms when documentation and staff interviews showed ongoing yelling and verbal aggression toward staff and a roommate. The resident, with anxiety, depression, and severe cognitive impairment, had a change-of-condition note describing increased yelling and verbal aggression, and the MAR documented Lorazepam use for constant yelling causing exhaustion, with behavior monitoring every shift. A nurse who spoke Spanish reported the resident cursed at her roommate using very hateful language, yet the MDS nurse coded Section E as having no verbal behaviors directed toward others, later acknowledging that the documented yelling episodes could meet criteria for behaviors affecting others and that he likely missed this information despite reviewing MARs and progress notes.
A resident with MS, bilateral knee contractures, kyphosis, scoliosis, and edema, and with no cognitive impairment per BIMS, had her personal motorized wheelchair withheld by facility administration after two occasions when she left the facility using specialized public transportation and was unable to return, leading to 911 calls and hospital transports. The Administrator acknowledged that the resident’s motorized wheelchair was kept in the facility but that she was not allowed to use it, and she was instead provided a manual wheelchair that she reported was very uncomfortable, caused her arm to become stuck, and did not allow leg elevation for edema. The resident stated she did not know where her wheelchair was and that staff would not tell her, while facility documents stated residents have the right to retain and use personal possessions unless they affect the rights or health and safety of other residents.
A resident with severe cognitive impairment was struck on the cheek by another resident with dementia while in the dining room. The incident was witnessed by a staff member, and the affected resident was assessed by an LPN, who noted slight redness but no pain. The Social Services Director confirmed the event as abuse and acknowledged the facility's responsibility to keep residents safe, as outlined in the facility's abuse prevention policy.
A resident experienced two falls, and the facility failed to immediately notify the responsible party because the contact number on file was incorrect. Nursing staff attempted to call and left voicemails, but the responsible party did not receive them. The error was only discovered and corrected at the time of the resident's discharge, resulting in delayed notification of the falls.
A resident's responsible party was not provided with a summary of the baseline care plan within 48 hours of admission, as required by facility policy. Review of records and staff interviews confirmed that there was no documentation showing the BCP summary was given to the responsible party, despite the policy mandating this communication.
A resident with Alzheimer's Disease and a history of falls was placed in a wheelchair without an assessment or care plan supporting its use. The resident, previously ambulatory with a cane, slid from the wheelchair and fell. Staff and DON confirmed there was no documentation or evaluation for wheelchair use, and the facility's fall management policy was not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nursing staff failed to promptly initiate CPR and follow emergency response protocols for a resident with a full code status who was found unresponsive and pulseless. Staff were unclear on facility policy, delayed CPR while verifying code status, did not immediately call 911, and lacked access to an AED. Not all licensed nurses were current in CPR/BLS certification at the time of the event.
A resident with multiple medical conditions did not receive all physician-ordered laboratory tests, including a norovirus test and timely repeat labs for magnesium and CMP, despite documentation indicating the orders were noted and supposed to be carried out. Staff confirmed the tests were not completed as ordered, in violation of facility policy requiring adherence to physician orders.
The facility failed to complete quarterly MDS assessments for two residents and did not complete them timely for two others. A resident readmitted in August did not have a subsequent MDS completed, and another admitted in August also lacked a follow-up MDS. The MDS Coordinator was unaware of these needs and acknowledged delays. Additionally, two residents had their MDS assessments completed late, with the MDS Coordinator admitting to struggling with timely completion. The DON and Administrator were unaware of these issues and expected timely completion.
A resident with a history of cerebral infarction and inability to speak was not provided with necessary communication aids, such as a communication board and pointer, as outlined in their care plan. Observations and interviews revealed that the communication board was out of reach and the pointer was missing, which staff were unaware of until informed by a surveyor.
A resident with severe cognitive impairment and a history of chronic pain, acute systolic heart failure, and epilepsy eloped from the facility twice due to inadequate supervision and environmental hazards. The resident's room had a sliding door that allowed them to exit without staff knowledge. Despite initial exit-seeking behavior, the facility did not move the resident to a safer room until after the second elopement.
The facility did not comply with regulatory guidelines for resident room sizes, with seven rooms providing less than the required 80 square feet per resident. Measurements confirmed the deficiency, and while the Administrator was aware of the issue, the DON was not informed about the square footage requirements.
A resident, legally blind and using a walker, was allowed to leave a facility without a physician's order, accompanied by staff to purchase alcohol. The resident consumed the alcohol, became intoxicated, and attempted to leave against medical advice. The facility failed to document the outing or follow its policy requiring a physician's order for such passes, and the incident was not investigated or recorded in the resident's care plan.
The facility failed to report an allegation of abuse within the required two-hour timeframe. A resident reported that a CNA put his hand on her face and around her mouth area. The incident was reported to law enforcement and CDPH the following day, which delayed the timely investigation by authorities.
Failure to Protect Resident From Ongoing Verbal Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a roommate. One resident (Resident 7) had Alzheimer’s disease, unspecified dementia, generalized anxiety, and severe cognitive impairment per a recent MDS. Another resident (Resident 6) had anxiety disorder, depression, and severe cognitive impairment. On 12/10/25, social services moved Resident 6 into a new room to have a Spanish‑speaking roommate, pairing her with Resident 7. Nursing notes beginning 12/11/25 documented that Resident 6 was not adjusting well to the room change, was yelling at staff and her roommate, and was shouting statements such as “WHO LET THIS WOMAN IN MY HOUSE,” with repeated documentation that she was not adjusting to the roommate. Subsequent nursing documentation on 12/12/25 and a change of condition note on 1/9/26 showed ongoing monitoring for emotional distress and continued yelling and verbal aggression by Resident 6 toward staff and her roommate. Staff notes indicated Resident 6 continuously shouted at her roommate and staff and remained agitated. During surveyor observations on 2/10/26, Resident 6 was heard yelling loudly from her bed, saying “This is my house” and “Call the police.” Staff interviews revealed that Resident 6 did not want a roommate, believed the room was her house, and that the two residents “fought all the time,” leading staff to close the room door and to move Resident 7 out of the room during the day because the interactions upset and disturbed others. Family members of Resident 7 reported that Resident 6 did not want anyone in the room and directed offensive words at Resident 7, causing Resident 7 to be angry and upset when sworn at. Nursing staff described Resident 6 as angry, confused, and agitated, and stated that when Resident 7 returned to the room, Resident 6 became agitated and used very ugly and hateful curse words in Spanish, including calling Resident 7 a “son of a b---” and saying “Get this b--- out of my house.” Staff, including an LN and the DON, acknowledged that such name‑calling, cursing, and use of terms like “b---” and “stupid” directed toward another resident could constitute verbal abuse if it upset the recipient. The Administrator stated he would have investigated if he had known residents were using such terms toward each other, recognizing it as potential verbal abuse. The facility’s abuse policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, and required supervisors to immediately correct and intervene in situations in which abuse is at risk for occurring.
Inaccurate MDS Behavior Assessment for Resident With Verbal Aggression
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident when Section E of the MDS indicated the resident had no verbal behavior symptoms directed toward others, despite documentation and staff reports to the contrary. The resident had diagnoses of anxiety disorder and depression and was documented as having severe cognitive impairment on the MDS. A change of condition narrative note dated 1/9/26 described monitoring for increased yelling and verbal aggression toward staff, stating the resident continued to yell toward staff and her roommate. The resident’s MAR for January 2026 documented administration of antianxiety medication (Lorazepam) for behavior manifested by constant yelling causing exhaustion to self, with instructions to monitor behavior every shift. During interviews, a licensed nurse who spoke Spanish reported that the resident cursed at her roommate in Spanish using very ugly, hateful words directed at the roommate. The MDS nurse stated he used various data sources for assessments, including observations, the electronic MAR, and nursing progress notes. Upon reviewing Section E of the resident’s MDS, he confirmed it showed no verbal behavior symptoms directed toward others, and upon reviewing the January MAR, he confirmed the resident was being monitored for yelling that caused exhaustion and had multiple episodes of yelling incidents. He acknowledged that yelling to exhaustion could meet the criteria of behaviors affecting others and stated he did not know why he did not identify this when completing the MDS, indicating he probably just missed it. Facility policy required that the RAI/MDS be completed accurately and used to guide individualized, resident-centered care planning and quality outcomes.
Resident’s Personal Motorized Wheelchair Withheld, Forcing Use of Inappropriate Manual Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions, specifically her personal motorized wheelchair. The resident was admitted with MS, bilateral knee contractures, kyphosis, and scoliosis, and had a BIMS score of 15 indicating no cognitive impairment. She reported that she had been very mobile until about two weeks prior, when she went to a movie using her motorized wheelchair and a specialized public transportation service. When the transportation company did not return to take her back, she called the facility and was instructed to call 911, resulting in transport to a hospital and return to the facility the next morning. Upon her return, the Administrator told her she was “grounded,” and later acknowledged that her personal motorized wheelchair, which had come with her to the facility, was being kept in the facility but that she was not allowed to use it. The Administrator stated that after the first incident, the IDT met and the MD agreed to revoke the resident’s ability to leave on pass, and that after a second similar incident where the resident again left using her motorized wheelchair and specialized transportation and could not get back, he decided the only option to keep her safe was to deny her access to her motorized wheelchair. The resident reported that she did not know where her wheelchair was and that staff would not tell her, and she expressed that she wanted her personal wheelchair because the facility’s manual wheelchair was very uncomfortable. She described her arm getting stuck behind the manual wheelchair and difficulty elevating her legs to address edema. Observations showed her in bed tilted to the side with cushions for positioning. Facility policy and the admission packet stated that residents have the right to use and retain personal possessions unless doing so would infringe upon the rights or health and safety of other residents, but the facility nonetheless withheld her personal wheelchair and substituted an uncomfortable manual wheelchair.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident, also with severe cognitive impairment. According to interviews and record reviews, one resident was struck on the left cheek by another resident as he wheeled past her in the dining room. The incident was witnessed by a staff member, who observed that the resident's cheek was slightly reddened but she did not cry out in pain. The event was reported to a licensed nurse, who assessed the resident and confirmed the redness but noted no complaints of pain. The facility's Social Services Director acknowledged awareness of the incident and agreed that the resident had suffered abuse, confirming the facility's responsibility to ensure resident safety. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse. The report documents that the facility did not ensure this right for the resident involved in the incident.
Failure to Notify Responsible Party of Resident Falls Due to Incorrect Contact Information
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident following two separate fall incidents. The resident, who was admitted in April 2025, experienced falls on consecutive days. Nursing progress notes indicated that attempts were made to contact the RP by calling the number listed on the resident's face sheet and leaving voicemails, but there was no response. It was later discovered that the contact number on the face sheet was incorrect, and the RP did not receive the notifications. The correct number was only updated on the day of the resident's discharge, at which point the RP was informed of the falls. Interviews with licensed nursing staff and the Director of Nursing confirmed that the facility was responsible for ensuring the accuracy of contact information for RPs and for promptly notifying them of changes in condition, such as falls. The staff acknowledged that the failure to update and verify the RP's contact information resulted in the RP not being made aware of the resident's falls in a timely manner. Facility policy required immediate notification of the RP and physician in the event of an accident or change in condition, which was not followed due to the incorrect contact information.
Failure to Provide Baseline Care Plan Summary to Responsible Party
Penalty
Summary
The facility failed to provide a summary of the baseline care plan (BCP) to the responsible party (RP) of a resident within 48 hours of admission, as required by facility policy. A review of the resident's face sheet confirmed the presence of an RP, and the BCP was completed on 4/14/25. However, there was no documentation indicating that the BCP summary was given to the RP. This was verified during an interview and record review with a licensed nurse, who acknowledged the absence of documentation showing the RP received the BCP summary. Further confirmation came from the Director of Nursing (DON), who reviewed the BCP and also found no evidence that the summary was provided to the RP. The facility's policy states that both the resident and their RP should receive a summary of the BCP, and documentation should be maintained in the electronic health record. The lack of documentation indicated that the required communication with the RP did not occur.
Resident Placed in Wheelchair Without Assessment Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a history of falls was placed in a wheelchair without an assessment or care plan indicating the need or safety for wheelchair use. The resident was previously documented as ambulatory with a cane and identified as a fall risk with a history of wandering behavior. The fall care plan did not mention wheelchair use, and the physical therapy evaluation did not recommend or assess for wheelchair safety. Despite this, the resident was found sitting in a wheelchair and subsequently slid from it, landing on their buttocks. Record reviews and staff interviews confirmed there was no documentation of a wheelchair assessment or care plan for wheelchair use for this resident. Both the licensed nurse and the DON verified that the resident should not have been placed in a wheelchair, as there was no evaluation or recommendation supporting its use. The facility's fall management policy requires staff to identify interventions based on evaluations and current data, which was not followed in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Initiate Timely CPR and Emergency Response for Full Code Resident
Penalty
Summary
The facility failed to ensure that nursing staff were knowledgeable and able to correctly state and follow the facility's policy regarding the initiation of Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS). Four out of six nursing staff interviewed were unable to accurately describe the policy, and there was inconsistency among staff regarding who should initiate CPR and how to activate emergency response systems. Some staff were unsure about the use of the paging system and the process for verifying code status, leading to delays in emergency response. A resident with multiple medical conditions, including diabetes, hypertension, and heart disease, was found unresponsive, not breathing, and pulseless in her bed. Despite having a Physician Orders for Life-Sustaining Treatment (POLST) indicating a full code status and a desire for resuscitation, nursing staff delayed the initiation of CPR while attempting to verify the resident's code status. Documentation and interviews revealed that staff did not immediately begin CPR, and there was confusion about who should call 911 and how to summon additional help. The facility's policy required immediate initiation of CPR by certified staff and activation of emergency response, but these steps were not promptly followed. Additionally, the facility did not have an Automated External Defibrillator (AED) available for use during the resuscitation attempt, despite policy and best practice expectations. Only some of the licensed nurses were currently certified in CPR/BLS at the time of the incident. These failures reduced the likelihood of successful resuscitation for the resident and potentially for other residents identified as full code.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to meet professional standards of nursing care by not completing all laboratory tests as ordered by the physician for one resident. The resident, who was admitted with multiple fractures, diabetes, hypokalemia, hypertension, and atherosclerotic heart disease, had physician orders for several laboratory tests, including norovirus, C. diff, COVID, and a KUB x-ray, due to symptoms of loose stools. While documentation indicated that the orders were noted and supposed to be carried out, the norovirus test was not completed, and there was no laboratory report for this test in the resident's records. Multiple staff interviews confirmed that the norovirus test was not performed, despite being ordered and documented as carried out. Additionally, the resident had a critical low potassium value reported, prompting further orders for potassium and magnesium administration, as well as repeat labs for magnesium and a comprehensive metabolic panel (CMP) in two days. However, the repeat labs were not completed within the ordered timeframe, with documentation showing the order administration was late and required rebooking. The facility's policy requires that physician orders be followed and not discontinued without a physician's directive, but in this case, the ordered labs were not completed as required.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments for two residents and did not complete the assessments in a timely manner for two additional residents. Resident #5 was readmitted on 08/22/2024, and Resident #22 was admitted on 08/19/2024, but neither had a subsequent MDS completed after their initial assessments. The MDS Coordinator was unaware of the need for Resident #5's MDS in December 2024 and acknowledged that Resident #22's MDS for November 2024 had not been completed. The Director of Nursing (DON) and the Administrator were both informed of the late assessments and expressed expectations for timely completion. Additionally, Resident #1 and Resident #48 had their quarterly MDS assessments completed late. Resident #1's MDS, with an Assessment Reference Date (ARD) of 10/08/2024, was not signed as completed until 12/02/2024. Similarly, Resident #48's MDS, with an ARD of 10/16/2024, was also completed on 12/02/2024. The MDS Coordinator, who had been in the role since July 2024, admitted to struggling with timely completion of assessments. The DON and Administrator were unaware of the delays and expected the MDS assessments to be completed on time, noting that the MDS Coordinator was new and had not communicated the issues with completing the assessments.
Failure to Provide Communication Aids to Non-Verbal Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to verbally communicate due to a medical history of cerebral infarction, had access to necessary communication aids. The resident was admitted with a diagnosis that required assistance with personal care and had a care plan in place that directed staff to provide a communication board and cards for basic needs. However, during multiple observations, the surveyor noted that the communication board was not within the resident's reach, and there was no pointer available for the resident to use. Interviews with the resident and staff revealed that the resident did not always have access to the pointer, which was essential for their communication. A CNA and an RN both confirmed the absence of the pointer, and the Director of Nursing was unaware of its missing status until informed by the surveyor. The resident indicated a need for the pointer, but it was not provided, leading to a deficiency in ensuring the resident's ability to communicate effectively.
Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an elopement incident. The resident, who had severe cognitive impairment and a history of chronic pain, acute systolic heart failure, and epilepsy, was admitted to the facility and initially assessed as not at risk for elopement. However, the resident was able to exit the facility without staff knowledge on two occasions. On the first occasion, the resident attempted to leave the facility to go to the bank, but staff intervened. On the second occasion, the resident was found by the local police department strolling on a sidewalk outside the facility. The resident's room had a sliding door that provided a means of exit, which was not initially considered a risk by the facility. Despite the resident's exit-seeking behavior being noted after the first incident, the facility did not move the resident to a different room until after the second elopement. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that the facility did not anticipate the resident's exit-seeking behavior and did not take immediate action to mitigate the risk after the initial incident.
Non-Compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident rooms met the required square footage per resident, as mandated by regulatory guidelines. Specifically, seven rooms in the facility did not provide the minimum 80 square feet per resident. Measurements taken by the Environmental Services staff confirmed that the rooms ranged from 70.19 to 74.96 square feet per resident, falling short of the required space. During interviews, the Administrator acknowledged awareness of the non-compliance, while the Director of Nursing was unaware of the square footage requirement for resident rooms.
Resident Safety Compromised Due to Policy Violation
Penalty
Summary
The facility failed to ensure the safety of a resident who was allowed to leave the premises without a physician's order, contrary to facility policy. This resident, who was legally blind and used a walker, was accompanied by a staff member to a convenience store where he purchased three bottles of vodka using his personal money. The resident consumed the alcohol, became intoxicated, and attempted to leave the facility against medical advice. The incident was reported by a member of a mobile crisis team who responded to a police call regarding the resident's behavior. The facility's administrator acknowledged awareness of the incident but admitted to not investigating it or documenting the events leading to it. The administrator stated that the nurse on duty assumed the resident had a pass to leave, which was not verified. The facility's policy requires a physician's order for a resident to leave on a day pass, and the resident must be signed out and back into the facility. However, there was no documentation of the resident's departure or return, indicating a breach of protocol. Interviews with staff revealed a lack of adherence to the facility's policies regarding resident outings and alcohol prohibition. The unlicensed staff member who accompanied the resident did not ensure compliance with the policy, and the nurse failed to verify the necessary physician's order. Additionally, the resident's care plan did not address his history of alcohol dependency or the incident, highlighting a gap in the facility's management of residents with such conditions.
Failure to Report Allegation of Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe. The incident involved a resident who reported that a CNA put his hand on her face and around her mouth area. The alleged event occurred on 3/14/24 at approximately 11:00 a.m., but the report was not made to law enforcement until 3/15/24 at 11:00 a.m., and the form was faxed to CDPH at 1:07 p.m. on the same day. This delay in reporting was confirmed during an interview with the Administrator, who admitted to not realizing the required reporting timeframes as per the facility's abuse policy. The facility's Policy and Procedure titled Abuse Investigation and Reporting mandates that any alleged violation involving abuse must be reported immediately, but not later than two hours if it involves abuse or has resulted in serious bodily injury. The failure to adhere to this policy had the potential to contribute to ongoing resident physical abuse and delayed the timely investigation by authorities. The Administrator's lack of awareness regarding the reporting timeframes was a significant factor in this deficiency.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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