Professional Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 81 Professional Center Parkway, San Rafael, California 94903
- CMS Provider Number
- 555214
- Inspections on file
- 50
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Professional Post Acute Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and dysphagia, who had previously indicated he did not want to self-administer medications, was found with a medicine cup labeled for a different bed on his overbed table containing three unidentified pills. The resident reported he had not requested to self-administer medications, was unsure if the pills were his, and had difficulty taking medications without assistance. An LN confirmed the cup was labeled for another resident and was unsure what the medications were, while another LN acknowledged that policy prohibits leaving medications at bedside or allowing self-administration without an IDT assessment. The interim DON verified there was no assessment authorizing self-administration for this resident and stated that, without such an assessment, staff should not allow the resident to self-administer medications, consistent with facility policies requiring physician and IDT determination of safety before self-administration.
Surveyors found that a resident with hemiplegia, hemiparesis, and dysphagia had a medicine cup labeled with the room number containing three pills left on the overbed table, and the resident reported not knowing if the medications were theirs or when they were left there. An RN confirmed the medications were at the bedside and stated staff should not leave medications unattended, while another nurse stated medications must be administered under observation. The IDON acknowledged that leaving medications at the bedside was not allowed under facility policy, which requires medications to be administered safely and stored securely, with any unauthorized bedside medications turned over to the charge nurse.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
A resident with mobility limitations was found to have their commode bucket covered with a blanket instead of a lid, as staff had not provided a proper cover. Both staff and the Infection Preventionist confirmed this practice was unsanitary and not in accordance with infection control policy, resulting in a breach of safe and sanitary environment standards.
A resident with a history of urinary tract infections and incontinence experienced bladder pain and blood-tinged urine for about a month, but nursing staff did not notify the provider, obtain a urinalysis, or monitor the hematuria as required by the care plan and facility policy. The resident was eventually sent to the hospital, where a UTI was diagnosed. Staff interviews confirmed that necessary assessments and notifications were not completed.
A resident with severe cognitive impairment was physically abused by another resident, resulting in bruising and pain. The incident was witnessed by staff, who intervened and reported the abuse. The facility's abuse prevention policy was not effectively implemented, leading to a substantiated abuse allegation.
A facility failed to implement a pharmacist's recommendation for a resident's medication monitoring. The resident, with a history of hemiplegia and cerebral infarction, was on atorvastatin and clopidogrel. The pharmacist recommended monitoring specific lab tests, but the RN Supervisor confirmed no orders were made. Interviews with staff revealed the facility's process for implementing pharmacy recommendations was not followed, resulting in the deficiency.
A medication error rate of 7.41% was identified when an LVN administered the wrong medication to a resident with anemia. The resident was prescribed ferrous fumarate but received ferrous sulfate instead. The error was confirmed by the Consultant Pharmacist and acknowledged by the LVN, who failed to notice or report the discrepancy. The facility's policy requires medications to be administered as prescribed, and this failure led to the deficiency.
A resident with a history of hallucinations was slapped by another resident with severe cognitive impairment, despite having a care plan to reduce noise levels to prevent aggressive behavior. The incident was witnessed by a CNA and reported to CDPH, but there was a delay in reporting, violating the facility's policy on immediate abuse reporting.
A CNA witnessed a resident slap another resident, but the incident was not reported to the State Survey Agency within the required two-hour timeframe. The resident who was slapped had a history of hallucinations, while the resident who slapped had severe cognitive impairment. Despite staff awareness of the incident, the report was delayed, violating federal reporting requirements.
The facility failed to maintain functional door locks for three residents, as observed during a complaint investigation. The Maintenance Supervisor confirmed the sliding and screen door locks were broken, and makeshift locks were ineffective. The Administrator was unable to locate missing parts for the makeshift locks, contradicting the facility's policy on providing a safe environment.
A resident with cognitive impairments eloped from a facility due to an unsecured gate in the courtyard, which was not alarmed or equipped with an auto-closure mechanism. The staff, including the Maintenance Director and nursing personnel, were unaware of the resident's whereabouts and the functionality of security devices. The facility lacked effective implementation of safety policies, and environmental safety rounds were not conducted as claimed.
A resident with chronic pain did not receive scheduled doses of Hydromorphone due to pharmacy delivery failures and inadequate facility processes. The resident experienced severe pain and withdrawal symptoms, and the physician was not informed of the issues. Staff reported ongoing problems with medication delivery and accessing the emergency medication supply.
The facility failed to prevent the worsening of a resident's pressure ulcer by not obtaining a doctor's order for wound treatment, not documenting the wound's status, and not conducting a comprehensive nutritional assessment. This led to the development of necrotic tissue and an increase in the wound's size.
The facility failed to provide adequate supervision for a resident who required extensive one-person physical assistance with transfers and ambulation. The resident, who had severe cognitive impairment and multiple diagnoses, was found lying in the hallway, resulting in a right femoral fracture and significant functional decline. Staff confirmed the resident's need for extensive assistance, which was not provided, leading to the incident.
The facility failed to ensure regular care plan conferences for two residents, resulting in their inability to participate in their person-centered plans of care. One resident's representative was not consistently invited, and another resident did not have quarterly meetings as required.
The facility failed to update care plans for a resident's decline in functional status, leading to inadequate care and supervision. The resident, with conditions including Diabetes Mellitus and Neurocognitive Disorder, experienced a fall and developed a pressure ulcer. Despite needing extensive assistance, the care plans inaccurately indicated the resident could ambulate and reposition independently.
A resident's sacral wound was treated with Medihoney by an LPN without a documented physician's order, contrary to facility policy. The DON confirmed that nurses must obtain a doctor's order before administering any treatment, following the five rights of medication administration.
The facility failed to provide timely rehabilitation screening and follow-up on a STAT X-ray request for a resident who fell and complained of hip pain. The resident did not receive a rehabilitation screening until 20 days after the fall, and the X-ray, which revealed a femoral neck fracture, was delayed by eight days. Additionally, the facility waited another eight days to obtain a weight-bearing precaution order, during which the resident was allowed to perform sit-to-stand activities.
Unassessed Medication Self-Administration and Misplaced Medication Cup
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to professional standards and facility policy when a resident was effectively left to self-administer medications without a required assessment. The resident, admitted in 1/2019 with hemiplegia, hemiparesis, and dysphagia, had an admission/readmission data tool dated 8/14/24 indicating he did not want to self-administer medications. A BIMS completed on 2/6/26 showed intact cognition with a score of 14. On 3/4/26 at 8:53 a.m., surveyors observed a medicine cup labeled for bed 18B containing three pills on top of the overbed table of the resident in bed 18C. The resident confirmed he occupied bed 18C, stated he was not sure if the medications were his, and reported that no nursing staff had assessed whether it was safe for him to take medications without supervision. The resident reported he had not requested to self-administer medications or to have medications left at his bedside and that he did not take the medications because he had difficulty taking them without assistance. During interviews, LN A verified the medicine cup labeled 18B with three pills was on the overbed table of the resident in 18C and acknowledged uncertainty about what the medications were. LN B stated she was not sure if the resident was safe to self-administer medications and confirmed that facility policy did not allow medications to be left at bedside or residents to self-administer without an assessment by the IDT. The interim DON verified that the admission/readmission data tool indicated the resident did not want to self-administer medications and that there was no assessment indicating it was safe for the resident to do so. The interim DON stated that, in the absence of such an assessment, staff should not allow the resident to self-administer medications and that allowing this could result in accidents such as choking. Facility policies on administering medications and self-administration required that residents may self-administer only if the attending physician and IDT determined it was clinically appropriate and safe.
Unsecured Bedside Medications Left Unattended
Penalty
Summary
Surveyors identified a deficiency in medication security and administration when a resident’s medications were left unattended at the bedside. The resident, admitted in 1/2019 with diagnoses including hemiplegia, hemiparesis, and dysphagia, was observed with a medicine cup labeled "18B" containing three pills on top of the overbed table. During the observation, the resident stated they were not sure if the medications were for them and did not know when the medications had been left there. The resident further reported that staff left medications on the overbed table all the time and that they had not requested staff to leave medications at the bedside. A concurrent observation with a licensed nurse confirmed the presence of the medicine cup with three pills on the resident’s overbed table. The nurse stated that staff should not leave medications at residents’ bedsides and acknowledged that medications should be administered under staff observation. Another licensed nurse similarly stated that medications should not be left at the bedside because staff were supposed to watch residents take their medications and that leaving them was a safety risk. The Interim DON stated that staff should not leave medications at the bedside and that this practice was not allowed per facility policy. Review of the facility’s policies on administering medications and self-administration of medications showed requirements that medications be administered safely and stored in a safe, secured place not accessible by other residents, and that any medications found at bedside and not authorized for self-administration be given to the charge nurse.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to the deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Improper Commode Bucket Covering Breaches Infection Control
Penalty
Summary
A deficiency was identified when a resident's commode bucket was found covered with a blanket instead of a proper lid. The resident, who had been admitted with pain in the right knee and difficulty walking, reported that staff had not provided a commode with a lid and instead used a blanket to cover the bucket. This was confirmed during observation and interviews with both the resident and unlicensed staff, who acknowledged that using a blanket in this manner was unsanitary and not in line with infection control practices. Further interviews with the Infection Preventionist and the Minimum Data Set coordinator confirmed that covering the commode bucket with a blanket was not acceptable, as it could lead to cross contamination and infection. The facility's infection control policy, which aims to maintain a safe and sanitary environment, was not followed in this instance. The blanket used to cover the commode was considered contaminated and posed a risk for the spread of bacteria.
Failure to Monitor and Report UTI Symptoms Resulting in Delayed Diagnosis
Penalty
Summary
Nursing staff failed to provide care consistent with professional standards and the resident's individualized care plan for a resident with a history of urinary tract infections and urinary incontinence. Over approximately one month, the resident experienced symptoms consistent with a urinary tract infection, including bladder pain and blood-tinged urine. Despite these symptoms being documented in the medical record, nursing staff did not ensure that the resident's provider was notified, a urinalysis was obtained, or that the hematuria was monitored as required by the care plan and facility policy. The resident's care plan specifically directed staff to monitor and document signs and symptoms of UTI, such as pain and blood-tinged urine, to minimize the risk of septicemia. On one occasion, nursing staff documented blood-tinged urine and blood in the vaginal area, and the nurse practitioner on call ordered continued monitoring and a gynecology consult. However, there was no evidence that a urinalysis was performed or that the hematuria was further monitored. The nurse practitioner later stated he was not informed of the hematuria or bladder pain, and would have ordered a urinalysis if he had been made aware. The resident continued to experience symptoms, including increasing pain, nausea, vomiting, and dizziness, until she was eventually sent to the hospital, where she was diagnosed with a UTI caused by E. coli. Interviews with facility staff confirmed that the required assessments and notifications were not completed, and facility policies requiring identification, documentation, and reporting of UTI symptoms were not followed.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident squeezed her left arm, resulting in bruising and pain. Resident 1, who has severe cognitive impairment due to radiculopathy and unspecified psychosis, was found crying with a bruise and scratch on her left forearm after the incident. The incident was witnessed by a CNA who reported that Resident 2, also with severe cognitive impairment due to unspecified dementia, was the aggressor. The CNA intervened and brought Resident 1 to a nurse for evaluation. Interviews with staff and another resident confirmed that Resident 2 had a history of aggressive behavior and had to be physically separated from Resident 1 during the incident. The facility's abuse prevention policy, which states that residents have the right to be free from abuse, was not effectively implemented in this case. The administrator confirmed that the abuse allegation was investigated and substantiated, indicating a failure to ensure the safety and well-being of Resident 1.
Failure to Implement Pharmacy Recommendations for Resident's Medication Monitoring
Penalty
Summary
The facility failed to act upon pharmacy recommendations for a resident reviewed for unnecessary medications, psychotropic medication, and medication regimen review. The facility's policy required that a consultant pharmacist perform a comprehensive medication regimen review at least monthly, with recommendations to be acted upon and documented by facility staff or the prescriber. However, for one resident, the facility did not implement the pharmacist's recommendation to monitor specific laboratory tests, despite the recommendation being signed by the physician. The resident in question had a medical history of hemiplegia and hemiparesis following a cerebral infarction, among other conditions, and was taking atorvastatin and clopidogrel. The consultant pharmacist recommended monitoring a lipid panel, comprehensive metabolic panel, and complete blood count, but the RN Supervisor confirmed that no orders for these laboratory tests were made. Interviews with facility staff, including the RN Supervisor, Senior Director of Clinical Operations, and the Administrator, revealed that the facility's process for ensuring the implementation of pharmacy recommendations was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate during a medication administration observation. This deficiency was identified when a Licensed Vocational Nurse (LVN) administered the wrong medication to a resident. The resident, who had a medical history including iron deficiency anemia and osteoarthritis, was prescribed ferrous fumarate for anemia. However, the LVN mistakenly gave the resident ferrous sulfate instead, which, although containing iron, is a different salt compound than what was ordered by the physician. The error was confirmed during an interview with the Consultant Pharmacist, who stated that any medication not given as ordered is considered a medication error. The LVN acknowledged the mistake upon reviewing the medication orders and admitted to not noticing the discrepancy or reporting it. The Senior Director of Clinical Operations and the Administrator both confirmed that the LVN did not follow the physician's orders, which constituted a medication error. The facility's policy requires medications to be administered as prescribed, and the LVN's failure to adhere to this policy led to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 1, from physical abuse by another resident, identified as Resident 2. Resident 1, who had a history of yelling and screaming due to hallucinations, was slapped on the left side of her face by Resident 2. Resident 2 had a care plan intervention to modify her environment by reducing noise levels due to a potential for aggressive behavior. Despite this intervention, Resident 2 entered Resident 1's room and slapped her, resulting in visible redness and scattered petechiae on Resident 1's left cheek. The incident was witnessed by Certified Nursing Assistant C, who reported seeing Resident 2 intentionally slap Resident 1. The report indicates that Resident 2 had severe cognitive impairment, as evidenced by a BIMS score of 3, and had a history of physical behaviors related to dementia. The facility's policy requires that allegations of abuse be reported immediately or within two hours, but there was a delay in reporting the incident to the California Department of Public Health (CDPH). The facility's Administrator confirmed that the abuse allegation was substantiated and that the incident was reported to CDPH. However, there was a discrepancy in the timing of the report, as the facility was unable to provide fax confirmation that the SOC 341 form was sent within the required timeframe. The facility's policy emphasizes the residents' right to be free from abuse, neglect, and exploitation, but this incident highlights a failure to adhere to these standards.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving two residents to the State Survey Agency within the required timeframe. On the afternoon of August 25, 2024, a Certified Nursing Assistant (CNA) witnessed one resident slap another resident on the left side of her face. The incident was reported to a Licensed Nurse, who then delayed reporting the incident to the State Survey Agency until later that evening, more than five hours after the event occurred. This delay in reporting did not comply with the federal requirement to report such incidents immediately, or within two hours if they involve abuse. The residents involved in the incident had specific behavioral and cognitive challenges. The resident who was slapped had a care plan indicating she experienced hallucinations that caused her to yell and scream due to fear. The resident who committed the act of slapping had a care plan noting a potential for physical behaviors related to dementia, with a BIMS score indicating severe cognitive impairment. Despite these documented issues, the facility did not take immediate action to report the incident, which could have prevented further escalation or recurrence of abuse. Interviews with facility staff revealed that the CNA reported the incident to two Licensed Nurses during a shift change. However, the Licensed Nurse responsible for reporting the incident to the State Survey Agency did not do so until several hours later. The facility's policy requires that allegations of abuse be reported immediately or within two hours, but this protocol was not followed. The facility's Administrator confirmed the delay in reporting and acknowledged the failure to meet the required reporting timeframe.
Broken Door Locks Compromise Resident Safety
Penalty
Summary
The facility failed to ensure a safe and functional environment for three of seven sampled residents in a specific room, as the sliding door and screen door locking mechanisms were broken. This issue was identified during a complaint investigation by the California Department of Public Health. The Maintenance Supervisor, during an observation and interview, confirmed that the sliding door locks were broken and could not be locked. Additionally, the screen door was bent and unable to lock, posing a potential risk to the residents' safety. The Maintenance Supervisor was unaware of the issue until the surveyor's visit. Further observations with the facility Administrator revealed that makeshift locking systems were in place for the sliding doors in the affected rooms. However, one of these makeshift locks was missing a part, rendering it ineffective. The Administrator attempted to locate the missing part but was unsuccessful. The facility's policy on providing a safe and homelike environment was reviewed, which emphasized the importance of safety and comfort for residents, but the current state of the door locks contradicted this policy.
Resident Elopement Due to Unsecured Facility Gate
Penalty
Summary
The facility failed to ensure the safety of a resident who eloped from the premises and was found by the police 0.4 miles away. The facility is located on a hill with a steep incline and moderate traffic, and the courtyard area had an unsecured gate that allowed unsupervised passage to the street. The Maintenance Director acknowledged that the gate was not alarmed and could be easily opened by a resident, and the door leading to the courtyard was not equipped with an alarm system. The Maintenance Director also admitted to not knowing if the resident had a security device on the day of the elopement and was unaware of the manufacturer's instructions for the security alarms. The nursing staff demonstrated a lack of awareness regarding the resident's whereabouts and the functionality of the security devices. Licensed Nurse B was unaware of any safety concerns for the resident and did not check the security device, while Licensed Nurse A stated that the resident usually walked around independently and was not assigned a 1:1 observation. The Social Services Director confirmed that the resident had lowered cognition and liked to walk around the building, but did not think the resident had a security device alarm at the time of the elopement. The Director of Nursing stated that the facility did not conduct a Root Cause Analysis for the elopement and admitted that the resident was not wearing a security device at the time. The facility's policies and procedures for resident safety and supervision were not effectively implemented. The Administrator stated that the staff followed facility policies and procedures when the resident eloped, but there was no facility policy for resident safety. The environmental safety rounds were not conducted daily as claimed, and there was no timeline in place to address the identified elopement and safety risks. The facility's documentation indicated that the environment and assistive equipment were not checked for potential issues that could have contributed to the event, and the gate remained unsecured 12 days after the elopement.
Pharmacy Delivery Failures Lead to Missed Pain Medication
Penalty
Summary
The facility's pharmacy failed to provide timely pharmaceutical services to a resident, resulting in missed doses of Hydromorphone, a pain medication. The resident, who had a history of diabetes, paraplegia, amputation, phantom limb syndrome with pain, and chronic pain syndrome, was prescribed Hydromorphone to manage his chronic pain. However, the medication was not administered as scheduled on multiple occasions, including a 24-hour period where six doses were missed. The reasons documented for the missed doses included waiting for supplies and awaiting delivery, indicating a failure in the pharmacy's delivery system and the facility's medication management process. The resident experienced increased pain, symptoms of narcotic withdrawal, and emotional distress due to the missed doses. The resident reported feeling suicidal, hopeless, and out of control, and his pain levels were documented as severe during the periods when the medication was not administered. Despite these issues, there was no documentation of a nursing care plan for pain management in the resident's medical record, and the physician was not informed of the ongoing medication delivery and administration problems. Interviews with facility staff and the consulting pharmacist revealed that medication delivery issues were an ongoing problem, with nursing staff having to make multiple calls to the pharmacy to request medications. The facility's emergency medication supply (e-kit) was not utilized effectively due to discrepancies in prescription dosages and a lack of communication with the physician for one-time orders. The Director of Nursing confirmed the lack of documentation and escalation of the issue, indicating a breakdown in the facility's processes for ensuring timely medication administration and communication with healthcare providers.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to assess and provide necessary services to prevent the worsening of a facility-acquired pressure ulcer for a resident. The resident was found to have an open wound on her sacrum and coccyx, but the facility did not obtain a doctor's order for routine wound treatment when the wound was identified. Additionally, the facility did not assess and document the status of the wound perimeter, wound bed, and healing progress as part of the pressure ulcer care plan. This led to the worsening of the resident's sacral wound, which developed thick adherent devitalized necrotic tissue and increased in size. The facility's progress notes indicated that the resident's sacral wound was treated with Medihoney without a written doctor's order. The Director of Nursing confirmed that nurses are expected to obtain a doctor's order before administering any medication or treatment. The treatment nurse also failed to document any changes in the wound's condition, and there were no notes indicating that the physician was notified of the wound's worsening condition prior to the wound doctor's visit. Furthermore, the facility did not conduct a comprehensive nutritional assessment for the resident after the identification of the sacral pressure ulcer. The Registered Dietician confirmed that the resident was not included in the list of residents being monitored for pressure ulcers and that there was no comprehensive nutritional assessment conducted for the resident in November. The facility's policy on the prevention of pressure injuries and nutritional assessment requires a comprehensive nutritional assessment for residents at risk of pressure injuries or with existing pressure injuries.
Failure to Provide Adequate Supervision for Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who required extensive one-person physical assistance with transfers and ambulation. The resident, who had diagnoses including Diabetes Mellitus, Hypertension, and Neurocognitive Disorder, was found lying in the hallway after being last observed in bed. This incident resulted in the resident sustaining a right femoral fracture and a significant decline in physical function. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for extensive assistance with transfers and ambulation. Interviews with staff confirmed that the resident required extensive assistance with transfers and ambulation prior to the fall. After the fall, the resident became dependent on staff for transfers and did not ambulate. The Physical Therapy evaluation noted a significant functional decline due to the right hip fracture, and the resident was placed on non-weight bearing status. The facility's policy on Activities of Daily Living (ADL) indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, but this was not adhered to in this case.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to ensure care plan conferences were conducted for two sampled residents, resulting in their inability to participate in the development and implementation of their person-centered plans of care. Resident 1, who had severe cognitive impairment due to dementia, was not represented by his designated representative in most care plan meetings. The representative, Witness C, stated he was not invited to participate in most of the care plan meetings and that these meetings were not multidisciplinary. The Social Service Director (SSD) confirmed that care conferences are held quarterly and as needed, but could not explain why Resident 1 did not have a care conference every three months as required. The SSD also verified that Resident 1 had care conferences on specific dates but did not know why the representative was not consistently invited. Resident 2, who was cognitively intact with a BIMS score of 15 out of 15, also did not have regular care plan conferences. The SSD verified that Resident 2 had care conferences on two specific dates but did not provide a reason for the lack of quarterly meetings. The facility's policy requires that residents and their representatives be informed of their right to participate in care planning and that any impracticality in their participation be documented. However, this policy was not followed, leading to a deficiency in ensuring that residents and their representatives could participate in care planning, thereby affecting their quality of care and quality of life.
Failure to Update Care Plans for Resident's Decline in Functional Status
Penalty
Summary
The facility failed to implement timely revisions to the ADL Self Care Performance Deficit Care Plan for a resident when it did not update the care plan to reflect the resident's decline in functional status. The resident, who was admitted with diagnoses including Diabetes Mellitus, Hypertension, and Neurocognitive Disorder, experienced a fall and developed a pressure ulcer. Despite these changes, the care plan continued to indicate that the resident could ambulate without assistance and move freely in bed, which was inconsistent with the resident's actual need for extensive one-person physical assistance with transfers, bed mobility, and ambulation as noted in the MDS assessment. Additionally, the Pressure Ulcer Care Plan for the resident was not updated to reflect the resident's inability to reposition herself due to requiring extensive assistance with bed mobility. The care plan intervention to encourage the resident to reposition herself was not feasible given her condition. Both the MDS Coordinator and the DON confirmed that the care plans did not accurately reflect the resident's current needs and that the care plans should have been updated to ensure appropriate care and supervision.
Unauthorized Wound Treatment Without Physician's Order
Penalty
Summary
The facility failed to meet nursing professional standards for one resident when a licensed staff member provided wound treatment without a physician's order. Specifically, Resident 1 had a sacral wound treated with Medihoney by Licensed Staff B, who claimed to have received a verbal order from the physician but failed to document it. Upon review, both Licensed Staff B and the Director of Nursing (DON) confirmed that there was no written order for the treatment on the date in question. The DON emphasized that nurses are expected to obtain a doctor's order before administering any medication or treatment, following the five rights of medication administration. Licensed Staff F explained that new skin issues are identified during routine care and that any new wounds should be documented in the resident's medical record, with the physician being notified to obtain a treatment order. The facility's policy on administering medications, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. The failure to follow this policy resulted in a potential risk for Resident 1 of an adverse drug reaction due to the unauthorized use of Medihoney.
Failure to Provide Timely Rehabilitation Screening and X-ray Follow-up
Penalty
Summary
The facility failed to provide necessary services for a resident after a fall incident. The resident, who had diagnoses including diabetes mellitus, hypertension, and neurocognitive disorder, was found lying in the hallway. Despite a recommendation for a rehabilitation screening post-fall, the facility did not perform the screening until 20 days later. The delay was due to the rehabilitation staff not receiving a referral from the nursing staff, and the Director of Rehabilitation, who participated in the post-fall review, did not pass the information to the rehabilitation staff. This resulted in the resident not receiving timely skilled therapy services. Additionally, the facility delayed performing a right hip X-ray for the resident who complained of right hip pain. The request for a STAT X-ray was sent to the primary care physician, but there was no follow-up from the nursing staff until six days later. The X-ray provider did not find the request form, and the X-ray was eventually performed eight days after the initial complaint. The X-ray revealed a right femoral neck fracture, but the facility waited another eight days to obtain an order for weight-bearing precautions. During this period, the resident was allowed to perform sit-to-stand activities multiple times, potentially exacerbating the injury. Interviews with the occupational therapist, physical therapist, and MDS coordinator confirmed the lack of timely rehabilitation screening and follow-up on the X-ray request. The Director of Nursing acknowledged that the nurses should have followed up on the X-ray request and obtained the weight-bearing precaution order sooner. The facility's policy indicated that residents with significant changes should be screened by therapy, but this was not adhered to in this case.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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