Piners Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Napa, California.
- Location
- 1800 Pueblo Ave, Napa, California 94558
- CMS Provider Number
- 555207
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Piners Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, COPD, and other comorbidities was converted from scheduled hydrocodone-acetaminophen to a fentanyl 25 mcg/hr transdermal patch despite not meeting FDA-defined opioid-tolerant criteria, and without documented risk assessment for advanced age and chronic lung disease. The resident’s actual morphine equivalent (ME) exposure was significantly below the 60 mg/day threshold required for initiating this fentanyl dose. Later, after several days without a patch and variable PRN opioid use, the fentanyl dose was doubled to 50 mcg/hr soon after the resident received Norco and lorazepam 0.5 mg for restlessness and anxiety, contrary to manufacturer titration guidance and the facility’s own policy to avoid or closely monitor opioid–benzodiazepine combinations. The resident subsequently developed acute shortness of breath, hypoxia, somnolence, slow shallow respirations, and pinpoint pupils, required naloxone by EMS, and was diagnosed in the ED with accidental opiate overdose and hypoxia.
A resident became upset during a Bingo activity, threatened another resident, and was escorted away while yelling, which drew the attention of the Administrator and DON. Later, while the resident was nearby in the lobby, the DON approached the nurses’ station in an emotional and aggressive manner, stating that the resident was out of control and needed to be sent out, within earshot of the resident. A confidential witness reported that the DON’s physically and verbally aggressive behavior felt like bullying, and the resident began sobbing. Progress notes documented the resident’s emotional distress, including facial redness, shaking, SOB, and crying, and the resident was sent to the ED for further evaluation. The facility’s policy requires staff to treat all residents with kindness, respect, and dignity.
A resident with dementia, traumatic brain injury, chronic pain, bipolar disorder, and other comorbidities had her fentanyl patch increased and her Seroquel regimen intensified, including a higher scheduled dose and a PRN order, without her representative being informed or providing consent, despite the medical director’s determination that the resident lacked decision-making capacity. Nursing documentation showed the discontinuation of a 25 mcg/hr fentanyl patch and initiation of a 50 mcg/hr patch, as well as increased Seroquel dosing, but no evidence of notification to the family or signed informed consent. The family member later discovered the changes after the resident experienced respiratory distress and appeared overly sedated, and staff interviews confirmed that the representative had not been notified, contrary to facility policies on resident rights, psychotropic medication use, and person-centered care planning.
A resident with dementia, bipolar disorder, anxiety disorder, epilepsy, chronic pain, and prior stroke had a PRN Seroquel 25 mg order for agitation related to anxiety that remained active well beyond the 14-day limit set by facility policy for PRN psychotropic medications. The MAR showed multiple PRN administrations, and observations later noted the resident in a wheelchair with eyes closed, chin on chest, and tongue hanging out. Nursing staff could not locate any documentation that the attending physician or a mental health provider had re-evaluated and documented the continued need for the PRN antipsychotic, and the MD was unsure about the 14-day documentation requirement. The pharmacist reported she had recommended discontinuation of the PRN Seroquel during a medication regimen review. This constituted a failure to prevent potential chemical restraint by not ensuring timely re-evaluation and documentation for continued PRN antipsychotic use.
A facility failed to investigate and report an alleged abuse incident involving a resident who reported physical abuse by a CNA, resulting in a hand discoloration. Despite the facility's policy requiring investigation and reporting, no documentation or investigation summary was provided to the State Department of Health, potentially delaying further investigation.
The facility failed to maintain the final rinse temperature of the dishwasher at the required 180 degrees Fahrenheit, compromising the sanitization of dinnerware and cooking utensils. Dietary staff confirmed the issue had been ongoing for several months, leading to the use of disposable plates and utensils as a temporary measure.
The facility failed to ensure hand hygiene for six residents before meals, did not conduct ongoing infection surveillance, and did not follow physician's orders for changing a resident's oxygen equipment weekly. Staff did not routinely offer hand hygiene, infection control documents were incomplete, and the resident's oxygen equipment was not labeled or changed as required.
The facility failed to consistently perform antibiotic stewardship, leading to potential inappropriate or unnecessary antibiotic treatment. The new Infection Preventionist (IP) had not seen previous documentation except for a folder on Antibiotic Stewardship, and the Director of Nursing (DON) stated that infection control documents could not be located. No antibiotic surveillance tracking was completed from August to December 2023, and the IP had not conducted in-services with staff on antibiotic stewardship.
A resident with dementia and dry eye syndrome had a large, bleeding growth on her nose that was not properly diagnosed or treated by the facility. Despite observations and interviews indicating the growth's consistent increase in size and bleeding, the facility only applied a band-aid and did not pursue further treatment or accurate monitoring. The resident's Responsible Person had declined further diagnosis based on age and perceived lack of pain, but had not seen the current state of the growth.
The facility failed to ensure that a resident received the RNA program as ordered by the physician, resulting in inconsistent delivery of prescribed exercises. Staffing shortages and reassignment of RNA staff to CNA duties contributed to this deficiency, which was confirmed by both the resident and staff.
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. Licensed staff reviewed meal tray cards and dietary orders but did not check the actual food consistency before serving it to residents. Unlicensed staff were observed delivering meal trays without the required checks when the responsible licensed staff member was on a break. Interviews revealed a lack of formal documentation or training on this task, and the DON was unaware of the issue.
The facility failed to ensure a safe and functional kitchen environment due to unrepaired cracks and missing tiles on the floor. Cracked tiles were observed in front of the dry good storage, by the washing sinks, the exit door, and another dry good storage entrance. The Certified Dietary Manager acknowledged the non-compliance.
The facility failed to perform annual performance reviews for two CNAs. The Director of Staff Development acknowledged the reviews were behind due to a three-day work schedule, with 2023 reviews not yet completed for all unlicensed staff. Human Resource files confirmed the absence of reviews for 2023 and 2024.
Failure to Follow FDA Fentanyl Patch Dosing Guidelines Resulting in Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to follow FDA Black Box Warnings and manufacturer dosing specifications for a fentanyl transdermal patch in an elderly resident with COPD and multiple comorbidities. The resident, in her late 70s, had diagnoses including dementia, chronic pain, vertebral compression fractures, bipolar disorder, anxiety disorder, COPD, and cerebral infarction. Prior to fentanyl initiation, the resident was receiving hydrocodone-acetaminophen (Norco) 5-325 mg on a scheduled basis, with a regimen that allowed for up to five tablets per day, but the MAR showed multiple instances where doses were refused or held due to sedation. Based on the consultant pharmacist’s review and morphine equivalent (ME) calculations, the resident’s actual opioid exposure at the time fentanyl was started was approximately 20–25 mg ME per day, below the FDA-defined threshold of at least 60 mg oral morphine daily for at least one week to qualify as opioid-tolerant. The record contained no documented justification for switching from Norco to a fentanyl patch or any risk assessment addressing the resident’s advanced age, COPD, and sub-threshold opioid exposure in relation to the FDA Black Box Warning and manufacturer guidance. On 11/26/25, an order was written for a fentanyl (Duragesic) 25 mcg/hr transdermal patch to be applied every 72 hours for chronic pain, and Norco was changed to PRN two days later. The consultant pharmacist later confirmed that, according to the Duragesic dosing guidelines, a 25 mcg/hr starting dose should only be used in patients already receiving at least 60 mg oral morphine equivalents daily for a minimum of seven days, which this resident did not meet. The facility’s own pain management policy stated that pain medications should be selected based on pertinent treatment guidelines, that the lowest possible effective opioid dose should be used with ongoing monitoring, and that combining opioids and benzodiazepines should be avoided or closely monitored for respiratory depression. Despite these standards and the resident’s COPD and geriatric status, the fentanyl patch was initiated without documentation that the resident was opioid-tolerant as defined by the FDA labeling, and without a documented risk assessment. Subsequently, the resident’s fentanyl dose was increased from 25 mcg/hr to 50 mcg/hr on 1/30/26, after a period in late January when the 25 mcg/hr patch had been removed and not replaced for several days due to unavailability. During January, the resident’s PRN Norco use ranged from one to three tablets per day, with nine days of no Norco administration, and pain scores varied from 0 to 9. On 1/29/26, nursing documentation showed the resident was restless and unable to be consoled, leading to a new order for lorazepam 0.5 mg for anxiety, which was administered at 5:20 p.m., following a Norco dose at 4:00 p.m. The next day, the fentanyl patch dose was doubled to 50 mcg/hr. The consultant pharmacist verified that, at the time of this dose increase, the resident was receiving only 5–15 mg of supplementary morphine equivalents per day, far below the 45 mg ME per day that the manufacturer’s titration guidelines associate with a 12.5 mcg/hr increase, and that lorazepam and Norco had been administered shortly before the fentanyl dose escalation, creating a potential for respiratory depression. On 2/1/26, nursing notes documented that the resident began screaming for help and reported, “I can’t breathe, I can’t talk, I can’t swallow.” The nurse applied supplemental oxygen, but the resident’s oxygen saturation dropped to 77%, and her temperature was 100.1°F. The medical director was notified and ordered transfer to the emergency department. ED triage documentation indicated shortness of breath, slow shallow respirations, pinpoint pupils, and a positive response to naloxone administered by EMS, with the fentanyl patch removed by EMS. The ED history and physical described somnolence presumed due to opioid overdose and shortness of breath, and the ED physician’s note characterized the event as an iatrogenic occurrence requiring re-evaluation of the resident’s pain management strategy. The ED diagnoses included accidental or unintentional opiate overdose and hypoxia. Throughout interviews, the consultant pharmacist confirmed that both the initial fentanyl dose and the subsequent dose increase did not meet FDA and manufacturer criteria for opioid tolerance and dose titration, while the medical director stated he believed he had followed fentanyl dosing guidelines but could not identify the cause of the resident’s respiratory distress.
Failure to Treat a Resident With Dignity and Respect During Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with kindness, respect, and dignity. A confidential witness (CW) reported that during an activities session in January 2026, a resident became upset during Bingo after observing another resident not covering a called number. According to a progress note dated 1/9/26 at 3:34 p.m., the resident stated that if someone did not know how to play, they should not be playing, and was informed by staff that assistance is provided to all residents. As the staff member removed the resident from the table, the resident threatened to slap another resident and threw two Bingo chips against the wall while being escorted down the hall, yelling loudly enough to draw the attention of the Administrator and the DON, who then took over the situation. The CW stated that later that afternoon, while at the nurses’ station, they observed the DON approach the nurses’ station in a very emotional and aggressive manner, saying that the resident was out of control and that something needed to be done, including that the resident needed to be sent out. This interaction occurred within earshot of the resident, who was only a few feet away in the lobby, and upon hearing the DON’s comments, the resident began sobbing. The CW described the DON’s behavior as physically and verbally aggressive and perceived it as bullying the resident. A subsequent progress note dated 1/9/26 at 5:20 p.m. documented that the resident had facial redness, shaking, shortness of breath, emotional distress, and crying, and was sent to the ED for further evaluation. The facility’s Resident Rights policy, last reviewed 3/31/26, states that employees shall treat all residents with kindness, respect, and dignity.
Failure to Inform Resident Representative of Pain and Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s family member of significant changes to the resident’s treatment plan for pain and behaviors, despite the resident lacking capacity to make healthcare decisions. The family member reported receiving a call that the resident was in respiratory distress after an increase in her fentanyl patch dose to 50 mcg/hr, and stated that he would not have agreed to this increase because the resident was already on multiple central nervous system depressants. He also reported that the resident’s Seroquel dose had been doubled in the hospital and continued upon her return to the facility without any discussion with him, even though the resident had delirium and was not at her baseline during the hospitalization. The family member described finding the resident slumped over in a chair and slurring her words, and later learned via text communication with the physician that there was also a PRN Seroquel order that he had not been informed about. Record review showed that the resident had multiple diagnoses including dementia with behavioral disturbance, epilepsy, chronic pain, traumatic brain injury, bipolar disorder, anxiety disorder, and cerebral infarction. The face sheet listed the resident as her own responsible party, but the medical director had previously informed surveyors that the resident did not have capacity to make healthcare decisions and confirmed that this had not changed and no county conservator had been arranged. Physician orders and MARs showed a fentanyl patch 25 mcg/hr ordered in November and discontinued in late January, with a new order for a fentanyl patch 50 mcg/hr dated 1/30 and administered on 1/30, as well as Seroquel 25 mg three times daily for agitation and later Seroquel 50 mg three times daily with an added PRN Seroquel 25 mg every six hours for agitation. Nursing progress notes documented discontinuation of the 25 mcg patch and initiation of the 50 mcg patch but contained no documentation that the family member was notified of this change. Interviews with facility staff confirmed the lack of family notification and informed consent. One licensed nurse stated that the family member was not informed of the decision to increase the fentanyl patch at the end of January. Another licensed nurse verified there was no informed consent signed for the increased Seroquel dose or the PRN Seroquel order and acknowledged that a new consent should have been obtained when the dose was increased and a PRN dose added in the hospital. The medical director confirmed that the resident still lacked decision-making capacity and stated that residents’ families have the right to participate in the plan of care and that he expected nursing staff to have informed the family member of the fentanyl dose increase. Facility policies on resident rights, psychotropic medication use, and comprehensive person-centered care planning required resident or representative participation in treatment decisions and care planning, informed consent for psychotropic medication changes, and documentation when resident or representative participation in care planning was not practicable, which did not occur in this case.
Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy and procedures when a resident reported an incident of alleged physical abuse by a certified nursing assistant (CNA). The resident claimed that the CNA pulled on her arms, resulting in a 2.5 cm x 2 cm discoloration on her left hand near the thumb. Despite this report, the facility did not conduct an investigation nor document any findings related to the incident. The resident's medical record contained a nurse's note documenting the alleged abuse, but there were no additional notes or interdisciplinary team (IDT) documentation addressing the incident. During interviews, facility staff confirmed the absence of documentation related to an in-house investigation or IDT notes regarding the incident. The facility's policy requires that all allegations of abuse be investigated and reported within the timeframes required by federal requirements. However, the facility did not provide a 5-day investigation summary to the State Department of Health, as required. This lack of action and documentation potentially delayed the Department's independent investigation of the incident.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. During an observation and interview, it was noted that the final rinse temperature of the high-temperature dishwasher was only 150 degrees Fahrenheit, significantly below the required 180 degrees Fahrenheit. Dietary Aides E and F confirmed that the dishwasher frequently failed to reach the necessary temperature, and they had to run the dishwasher multiple times in an attempt to achieve the correct temperature. Despite these efforts, the dishwasher still did not consistently reach 180 degrees Fahrenheit, leading to the use of disposable plates and utensils as a temporary measure. A review of records revealed that the issue with the dishwasher's final rinse booster heater had been ongoing for several months. The monthly Consultant Dietitian Report Card indicated that the dishwasher was not holding temperature as early as January, with subsequent reports in February and March noting continued issues with the booster heater leaking and failing to maintain the required temperature. This prolonged failure to address the malfunctioning dishwasher compromised the facility's ability to properly sanitize dinnerware and cooking utensils, posing a risk of food contamination and potential foodborne illness among residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure hand hygiene was practiced by six of 15 sampled residents before meals. Observations revealed that staff did not offer or remind residents to wash or wipe their hands before eating. Interviews with staff confirmed that they did not routinely offer hand hygiene to residents, and moist wipes were not included on meal trays as previously done. The facility's policy on hand hygiene did not specify that staff should remind or offer hand hygiene to residents before meals, contributing to this oversight. The facility also failed to conduct ongoing analysis of infection surveillance. The newly appointed Infection Preventionist (IP) had not seen the infection prevention folders except for the one on Antibiotic Stewardship. Surveillance logs for the past 12 months were incomplete, and there was no documentation of data analysis or infection rate plotting. The Director of Nursing (DON) acknowledged that the infection control documents could not be located or had been misplaced, and the current IP had not started the process of overseeing infection surveillance. Additionally, the facility did not ensure that physician's orders were followed for one resident who was on oxygen therapy. The resident's nasal cannula and oxygen humidifier were not changed weekly as required, with the last documented change occurring nearly two months prior. Observations confirmed that the nasal cannula tubing and humidifier were not labeled with the date of the last change. Interviews with staff indicated that the responsibility for changing the equipment was not clearly assigned, and the DON admitted to not realizing the equipment had not been changed as scheduled.
Failure to Consistently Perform Antibiotic Stewardship
Penalty
Summary
The facility failed to consistently perform antibiotic stewardship, which had the potential to result in inappropriate or unnecessary antibiotic treatment. During an interview and records review, the Infection Preventionist (IP) stated she had only been working at the facility for three weeks and had not seen the previous IP's folders except for the one on Antibiotic Stewardship. The folder contained documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics from January to April 2024, but none for the past months. The Director of Nursing (DON) stated that infection control, surveillance, and monitoring documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs indicated no antibiotic surveillance tracking was completed from August to December 2023, as there were no line listing surveillance logs for those months. The IP's job description indicated responsibility for the antibiotic stewardship program (ASP), including in-servicing, tracking, reporting, and educating families, employees, and physicians as needed. However, the IP stated she had not conducted in-services with staff on antibiotic stewardship. The facility's Antibiotic Stewardship policy, updated in January 2024, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. All clinical infections treated with antibiotics were supposed to undergo review by the IP or designee, but this was not consistently done, leading to the deficiency.
Failure to Diagnose and Treat Resident's Growth
Penalty
Summary
The facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose. Resident 29, who has a history of dementia and dry eye syndrome, was observed with a large growth on her nose that had been bleeding. Unlicensed and licensed staff indicated that the growth had been consistently growing, and Resident 29 would scratch it, causing it to bleed. Despite these observations, the facility's staff only cleaned the area with saline solution and applied a band-aid, without pursuing further treatment or monitoring the growth's size and condition accurately. The Social Services Director (SSD) and various licensed staff members revealed that there had been a canceled plastic surgeon appointment and a dermatology appointment where Resident 29 became combative, preventing assessment. The Responsible Person (RP) for Resident 29 had decided against further diagnosis or treatment based on the resident's age and perceived lack of pain. However, the RP had not seen the current state of the growth, which had become larger and more prone to bleeding. The facility's weekly skin assessments failed to document the changing size and bleeding events of the growth accurately. The Director of Nursing (DON) was not aware of the growth's increase in size and its proximity to the lower eyelid. The facility's policies on charting, documentation, and skin and wound management were not followed accurately, leading to incomplete and inaccurate records. The lack of a comprehensive healthcare team approach and proper monitoring increased the risk of infection and discomfort for Resident 29.
Failure to Administer RNA Program as Ordered
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) program was being administered according to physician orders for Resident 33. Resident 33, who was admitted with diagnoses including cerebral infarction, major depression disorder, and hemiplegia, had a care plan that included passive and active range of motion exercises to be performed 3 to 5 times per week. However, the records indicated that these exercises were not consistently provided, with significant gaps in the frequency of the sessions over multiple months. For example, in one six-week period, Resident 33 received the exercises only twice, whereas they should have been offered at least 12 times. Similar deficiencies were noted in subsequent periods, with the resident receiving the exercises far less frequently than ordered by the physician. This inconsistency in care delivery was corroborated by Resident 33, who expressed that promises to take him to the gym were not always kept and that he felt forgotten about. The Rehab Manager and the RNA staff confirmed that staffing shortages and the reassignment of RNA staff to CNA duties contributed to the failure to provide the ordered exercises. The facility's policies on restorative nursing services and resident mobility and range of motion were not adhered to, resulting in a failure to maintain or improve Resident 33's functional mobility and muscle strength as required by the care plan.
Failure to Ensure Appropriate Dietary Consistency in Resident Meals
Penalty
Summary
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. During an observation, a licensed staff member was seen reviewing meal tray cards and dietary orders in the electronic medical record but did not check the actual food consistency before serving it to residents. The licensed staff member indicated that the meals were not uncovered to avoid touching the food. This process was common practice at the facility, and the staff member acknowledged the importance of checking meal trays to prevent residents from choking or aspirating on improperly prepared food. However, during another observation, unlicensed staff were seen delivering meal trays without the required checks, as the licensed staff member responsible was on a break and not available to perform the task. Interviews with various staff members, including the Director of Nursing (DON), revealed that there was no formal documentation or training on how to perform the task of checking meal trays for appropriate consistency. The DON was unaware that meals were not being checked by licensed staff before being served to residents and emphasized the importance of this safety measure to prevent aspiration. The facility's policy and procedure on tray line procedures indicated that assigned staff should deliver the cart to the nurses' station and announce its arrival, but it did not specify the need for checking meal consistency before serving.
Unrepaired Cracks and Missing Tiles in Kitchen
Penalty
Summary
The facility failed to ensure a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial tour of the kitchen, cracked tiles were observed in front of the entrance to the dry good storage. Further observations revealed more cracks and missing tiles by the washing sinks, the exit door to the back of the building, and the entrance to another dry good storage. The Certified Dietary Manager acknowledged the non-compliance when informed about the findings. The Food Code 2017 indicates that materials for indoor floor surfaces should be smooth, durable, and easily cleanable, which was not adhered to in this case.
Failure to Perform Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNAs). During an interview, the Director of Staff Development (DSD) acknowledged that the annual performance reviews for Unlicensed Staff P and Unlicensed Staff Q were outstanding. The DSD indicated that the reviews were behind due to a three-day work schedule and that the facility was still working on completing the reviews for the current year of 2024, with 2023 reviews not yet completed for all unlicensed staff. A review of the Human Resource files for Unlicensed Staff Q and Unlicensed Staff P confirmed the absence of annual performance reviews for the year 2023 and, in the case of Unlicensed Staff P, also for 2024.
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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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