River Valley Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 2490 Court Street, Redding, California 96001
- CMS Provider Number
- 056258
- Inspections on file
- 55
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at River Valley Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with chronic kidney disease and intact cognition went more than 14 hours without documented urination, yet staff did not recognize or act on this lack of urine output in a timely manner. The last recorded void was late one evening, and no further output was documented before the resident was transferred to the hospital the following afternoon. The transfer form completed by an LN did not note the absence of urine output, although a later communication to the physician stated there had been no urine since the previous day. At the hospital, catheterization drained 2,000 mL of urine, far above normal bladder capacity. The DON acknowledged that nursing staff did not recognize the prolonged absence of urination across two shifts, that an order for intermittent catheterization could have been obtained but was not, and that the facility lacked a urinary retention policy.
A gastroenteritis outbreak occurred, with multiple residents experiencing vomiting and diarrhea over several days. The facility's policy required reporting such outbreaks to CDPH within 24 hours, but notification was delayed despite clear evidence of an outbreak. The delay was confirmed by the IP and DON during interviews and record review.
Three residents with Foley catheters did not have their urine output documented as required by facility policy and physician orders. Despite complex medical conditions and explicit instructions to monitor and record urinary output every shift, staff failed to document this information in the residents' records. The DON confirmed that this documentation was not completed for any of the affected residents.
A resident's representative was not informed of a change in the resident's condition requiring oxygen administration, as per facility policy. The resident, with poor decision-making skills, was given oxygen due to low saturation levels. The oversight was confirmed by staff and acknowledged by the DON, with no documentation of notification to the representative.
A resident with severe cognitive impairment received oxygen without a physician's order, contrary to the facility's medication administration policy. The resident, with a history of metabolic encephalopathy and severe malnutrition, had an oxygen saturation of 88%, prompting a nurse to administer oxygen at 2 liters by nasal cannula. Both the nurse and DON confirmed that oxygen requires a physician's order, highlighting a breach in protocol.
A resident with bipolar disorder did not receive their prescribed Depakote due to unavailability, and the facility failed to notify the physician as required by policy. Despite multiple missed doses documented in the MAR and progress notes, there was no evidence of communication with the physician. Interviews with LVNs and the DON revealed a lack of awareness and documentation, leading to a significant lapse in care.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their assessments and care plans. A resident was incorrectly noted to use restraints, while another's CPAP use was not documented. Two residents with serious mental health conditions requiring Level II PASRR were not accurately reflected in their MDS assessments. The MDS Coordinator and DON acknowledged these oversights, emphasizing the importance of accurate documentation.
The facility failed to accurately complete PASRR Level I screenings for two residents, resulting in deficiencies in documenting their mental health diagnoses. One resident's PASRR did not reflect their bipolar disorder, depression, and anxiety, while another's omitted similar diagnoses and psychotropic medication use. The MDS Coordinator acknowledged the inaccuracies, and the DON expected accurate documentation, which was not met.
The facility failed to include essential elements in the care plans of two residents, leading to deficiencies. One resident's care plan omitted the use of a CPAP machine despite its documented use, while another resident's care plan lacked the inclusion of a Level II PASRR and its recommendations. Staff interviews confirmed these omissions, highlighting a lapse in adhering to the facility's care planning policy.
A resident's CPAP equipment was not cleaned or stored properly, as required by facility policy. Observations showed the CPAP machine on the nightstand with debris in the mask and an empty humidifier chamber. Staff interviews confirmed the equipment was not maintained according to policy, which required cleaning and storage in a bag for infection control.
A resident with bipolar disorder did not receive their prescribed Depakote in a timely manner, resulting in multiple missed doses. Despite facility policy requiring timely medication receipt, interviews with LVNs revealed inconsistent actions and communication failures. The Medical Director and DON were unaware of the issue, and the Medical Records Supervisor confirmed a lack of documentation regarding physician notification.
A facility failed to notify a physician of pharmacy consultant recommendations for a resident receiving escitalopram for depression. The consultant pharmacist suggested evaluating the therapy for a possible dose reduction or discontinuation, but there was no documentation of follow-up. The DON acknowledged the lapse in following up on the recommendations.
Two residents experienced falls, but their care plans were not updated as required by the facility's policies. Despite the facility's procedures mandating care plan updates after falls, the care plans for these residents were not revised. Interviews with LNs and the DON confirmed the oversight, highlighting a lapse in following established protocols.
The facility failed to ensure proper infection control procedures in COVID-19 positive rooms. LVN A and RN B were observed not wearing appropriate eye protection, with LVN A not using an eye shield and RN B using prescription glasses instead. The IP confirmed the need for reeducation on PPE protocols.
The facility did not follow its abuse policy by failing to submit the results of an abuse investigation to the State Survey Agency within five working days. This involved two residents, one with high blood pressure and anxiety, and another with memory loss due to a stroke. The interim Assistant Director of Nurses confirmed the absence of the required report, and the interim Administrator acknowledged the oversight by the previous Administrator.
A resident with severe cognitive decline and a history of elopement was not adequately monitored or protected by the facility. Despite being identified as an elopement risk, the resident was able to leave the facility unsupervised and was found at a nearby park. The facility failed to follow its policies for monitoring the resident's wander guard and did not update the care plan to address specific elopement triggers or schedule regular activities.
The facility did not report the results of an abuse investigation involving two residents to CDPH within the required timeframe. Although the incident was initially reported, the follow-up report detailing findings and corrective actions was not submitted, as confirmed by the ADON during a review. This failure to comply with state law and facility policy could leave residents at risk of continued abuse.
A resident's mail was not delivered within 24 hours and was opened by facility staff without permission, violating the facility's policy. The resident, who had intact cognition, reported the delay and unauthorized opening of her package. The Social Service Director and Assistant Director of Nursing confirmed the breach of protocol, noting that the resident was capable of handling her own mail.
A resident with a surgical wound was admitted to the facility but refused to have the wound assessed by staff. The facility waited two weeks for an orthopedic follow-up to obtain wound care orders, despite policies requiring a skin assessment upon admission. The resident, who was cognitively intact, insisted the brace should not be removed, and the facility did not assess the wound until after receiving orders from the follow-up appointment.
A resident was not provided with an activities schedule or newsletter for two months, leaving them uninformed about facility activities and news. The resident, with conditions including epilepsy and depression, expressed frustration over the lack of information. The facility administrator acknowledged that during a period without an activities director, these materials were not distributed.
A facility failed to respect a resident's dignity when a CNA did not stop moving her despite her request, causing fear due to her PTSD. The resident, with a complex medical history and weighing 470 pounds, required extensive assistance for bed mobility. The CNA, unfamiliar with the resident and unprepared for her size, attempted the task alone, contrary to the care plan's requirements. The facility's Administrator highlighted the expectation for CNAs to communicate and seek help when needed.
A CNA at a LTC facility failed to provide adequate assistance during incontinence care for a resident with mobility issues and morbid obesity, leading to the resident's discomfort. The CNA, unfamiliar with the resident's needs, attempted to reposition the resident without a second person, despite the resident's protests. The facility lacked proper communication and training, as the CNA was not informed of the required assistance level, and the Director of Staff Development was absent.
The facility failed to provide meals and conduct necessary pre, during, and post-dialysis assessments for residents requiring dialysis. A resident did not receive meals before, during, or after dialysis, and assessments were not consistently documented for four residents. This oversight was confirmed through staff interviews and record reviews.
Failure to Recognize and Manage Urinary Retention Leading to Delayed Treatment
Penalty
Summary
The deficiency involves the facility’s failure to appropriately recognize and manage urinary retention for one resident, resulting in delayed treatment. The resident had chronic kidney disease and was cognitively intact with a BIMS score of 15, indicating he could make his own decisions. Facility documentation showed that his last recorded urination occurred at 11:32 p.m. on 12/8/25, and there was no further documented urine output for over 14 hours prior to his transfer to the hospital on 12/9/25 at 2:08 p.m. The facility’s own intermittent catheterization policy stated that intermittent catheterization would be used when medically necessary, and nationally recognized resources cited in the report indicated that acute urinary retention can be life-threatening and that treatment involves draining the bladder with a urinary catheter. Despite this, the SNF/NF to Hospital Transfer Form completed by LN A did not mention that the resident had not urinated for over 14 hours. A subsequent communication note with the physician at 2:39 p.m. documented that the resident had no urine output since the previous day. At the hospital, a urinary catheter was inserted and 2,000 mL of urine was drained, significantly exceeding normal bladder capacity as described in the National Library of Medicine reference. During interviews, the DON acknowledged there was no documentation of urination for over 14 hours, that LN A could have obtained an order for intermittent catheterization but did not realize the resident had not urinated until later, and that the lack of recognition occurred over two shifts. The DON also stated that the facility did not have a urinary retention policy.
Delayed Reporting of Gastroenteritis Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to report an outbreak of gastroenteritis to the California Department of Public Health (CDPH) in a timely manner. According to the facility's records, multiple residents began experiencing symptoms of gastroenteritis, including vomiting and diarrhea, over several days. Specifically, two residents vomited on one day, three more on another, and five more on a subsequent day, with a total of 12 residents showing symptoms between the first and fifth of the month, and an additional seven residents experiencing symptoms in the following week. The facility's policy required that unusual occurrences, such as suspected outbreaks, be reported to the appropriate agencies within 24 hours. However, the CDPH was not notified until several days after the initial cases were identified. The Infection Preventionist confirmed that the line list documented the progression of symptoms among residents, and the Director of Nursing acknowledged that the suspicion of a gastrointestinal outbreak was not reported promptly. This delay in reporting was identified during interviews and record reviews, where it was confirmed that the facility did not adhere to its own policy or state guidelines regarding timely notification of communicable disease outbreaks. The failure to report the outbreak in a timely manner had the potential to allow the infection to spread among residents, staff, and the community.
Failure to Document Foley Catheter Output per Policy and Orders
Penalty
Summary
The facility failed to monitor and document the output of Foley catheters for three residents as required by both facility policy and physician orders. The policy specified that nursing staff must assess urinary drainage for signs and symptoms of infection, including cloudiness, color, sediment, blood, odor, and the amount of urine, and document these findings every shift. Physician orders for each of the three residents also required staff to document the amount of urine output from the Foley catheter every shift. Record reviews revealed that for all three residents, there was no documentation of urine output on their Intake and Output records or Bladder reports during their respective stays. The Director of Nursing confirmed that no output was documented for these residents, despite the presence of physician orders and facility policy mandating this documentation. The lack of documentation was acknowledged as a failure to follow both the facility's catheter care policy and the specific physician orders for these residents. The residents involved had significant medical histories, including obstructive and reflux uropathy, atrial fibrillation, metabolic encephalopathy, urinary retention, congestive heart failure, benign prostatic hyperplasia, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, irritable bowel syndrome, and constipation. Despite these complex conditions and the presence of Foley catheters, the required monitoring and documentation of urinary output was not performed for any of the three residents.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to inform the representative of a resident about a change in the resident's condition, which required the administration of oxygen. The facility's policy mandates that licensed nurses notify family or surrogate decision-makers of any changes in a resident's condition as soon as possible. However, in this case, the resident's representative was not informed when the resident was given oxygen due to low oxygen saturation levels. The resident, who had poor decision-making skills and memory recall, was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, and severe protein-calorie malnutrition. The deficiency was identified during a review of the resident's medical records and interviews with the resident's representative and facility staff. The resident's medication administration record indicated that oxygen was administered, but there was no documentation of notification to the resident's representative. The licensed nurse on duty confirmed the oversight, and the Director of Nurses acknowledged the lack of documentation regarding the notification of the resident's representative.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility administered oxygen to a resident without a physician's order, which is a violation of their medication administration policy. The policy, dated January 1, 2012, clearly states that medication, including oxygen, should only be administered by a licensed nurse upon the order of a physician or licensed independent practitioner. However, on December 28, 2024, a licensed nurse administered oxygen to a resident at a rate of 2 liters by nasal cannula due to an oxygen saturation level of 88%, which is below the normal range of 92 to 100%. The nurse confirmed that no physician's order was obtained prior to administering the oxygen, considering it an acceptable nursing intervention for immediate treatment. The resident involved had a severe impairment in memory and decision-making ability, as indicated by a Brief Interview for Mental Status score of 2 out of 15. The resident's medical history included diagnoses of metabolic encephalopathy, urinary tract infection, and severe protein-calorie malnutrition. During a review of the resident's Medication Administration Record and Physician's Orders for December 2024, both the licensed nurse and the Director of Nurses confirmed that oxygen is considered a medication and requires a physician's order for administration. This oversight in following the facility's policy had the potential to lead to negative clinical outcomes for the resident.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician when a medication, Depakote, was not available for administration to a resident diagnosed with bipolar disorder. The resident was admitted to the facility with a history of bipolar disorder and was prescribed Depakote to be administered at bedtime. However, the medication was not available on multiple occasions, as documented in the Medication Administration Record (MAR) and progress notes, spanning from late September to mid-October 2024. Despite the facility's policy requiring the prescriber to be contacted when a medication is unavailable, there was no evidence that the physician was notified about the unavailability of Depakote for the resident. Interviews with several Licensed Vocational Nurses (LVNs) revealed that they were aware of the protocol to notify the physician via fax or phone call and document it in the resident's medical record. However, none of the LVNs recalled notifying the physician, and the Medical Records Supervisor confirmed the absence of any faxes regarding the issue. The Director of Nursing (DON) and the Administrator were also unaware of the situation, indicating a breakdown in communication and documentation. The Medical Director, who receives numerous faxes daily, did not recall receiving any notification about the resident's missed doses of Depakote. This lack of communication and documentation led to the resident missing several doses of a critical medication, which was not addressed in a timely manner by the facility staff.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments and care plans. Resident #8 was admitted with a history of heart failure and diabetes, among other conditions. The MDS inaccurately indicated the use of physical restraints, which was not observed during multiple assessments. The MDS Coordinator admitted to mistakenly entering this information, highlighting a lack of accuracy in the assessment process. Resident #44, with a history of sleep apnea and oxygen dependence, was not accurately coded for the use of a CPAP machine on their MDS. Despite having an order for CPAP therapy and evidence of its use, the MDS did not reflect this, indicating a failure to accurately capture the resident's care needs. The MDS Coordinator acknowledged the oversight, emphasizing the importance of accurate MDS coding for effective care planning. Residents #25 and #52 both had serious mental health conditions requiring Level II Preadmission Screening and Resident Review (PASRR), which were not accurately reflected in their MDS assessments. Despite having documentation supporting the need for specialized services, the MDS for both residents failed to include their PASRR status. This oversight was confirmed by the MDS Coordinator and the Director of Nursing, who both stressed the critical nature of accurate MDS documentation in reflecting the residents' needs and guiding their care plans.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in the documentation of their mental health diagnoses. Resident #6 was admitted with a medical history of bipolar disorder, major depressive disorder, and generalized anxiety disorder. However, the PASRR Level I Screening indicated no serious mental illness, which was inaccurate. The MDS Coordinator acknowledged that the PASRR should have been updated to reflect the resident's psychiatric diagnoses, but this was not done. The Director of Nursing (DON) and the Administrator both expected accurate documentation, which was not met in this case. Similarly, Resident #18's PASRR Level I Screening was also found to be inaccurate. The resident had a history of bipolar disorder, major depressive disorder, and anxiety disorder, but the PASRR screening did not document these mental illnesses or the use of psychotropic medications. The MDS Coordinator admitted that the PASRR was incomplete and should have triggered a Level II PASRR, which was not conducted. The DON reiterated the expectation for accurate PASRR documentation, which was not fulfilled for Resident #18. Interviews with the Business Office Manager (BOM) and the MDS Coordinator revealed a lack of clarity regarding the responsibility for ensuring PASRR accuracy. The BOM was unsure who was responsible for checking the PASRR, while the MDS Coordinator stated it was her responsibility to ensure all diagnoses were included and accurate. Despite this, the necessary updates to the PASRRs were not made, resulting in deficiencies in the residents' documentation.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for two residents, leading to deficiencies in their care. For one resident, who had a medical history of obstructive sleep apnea and was dependent on supplemental oxygen, the care plan did not include the use of a non-invasive mechanical ventilator, specifically a CPAP machine. Despite having an order for CPAP therapy and documentation of its nightly use, the care plan only mentioned oxygen therapy. Interviews with staff, including the MDS Coordinator, LVNs, and the Director of Nursing, confirmed that the use of a CPAP machine should have been included in the care plan. Another resident, with a medical history of anxiety disorder, depression, PTSD, and bipolar disorder, had a Level II PASRR that was not included in their care plan. The PASRR report contained individualized recommendations for specialized services, such as increased family contact and addressing weight concerns, which were not reflected in the care plan. The MDS Coordinator acknowledged the oversight and stated that the Level II PASRR and its recommendations should have been care planned. The facility's policy on care planning emphasizes the need for person-centered, comprehensive, and interdisciplinary care plans that meet residents' health, safety, psychosocial, behavioral, and environmental needs. However, the failure to include critical elements such as the CPAP machine and Level II PASRR recommendations in the care plans of the two residents indicates a lapse in adhering to this policy. Interviews with facility staff, including the Administrator, highlighted an expectation for care plans to include all necessary information to guide staff in providing appropriate care.
Improper Cleaning and Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of non-invasive mechanical ventilation equipment for a resident with obstructive sleep apnea and dependence on supplemental oxygen. The facility's policy required CPAP equipment to be cleaned and stored in a plastic bag or container labeled with the resident's name when not in use. However, observations revealed that the CPAP machine was left on the resident's nightstand with the tubing and mask attached, and dried debris was found in the mask. Additionally, the humidifier chamber was found empty on multiple occasions, contrary to the order that specified it should be filled with distilled water every night. Interviews with staff, including LVNs and the Director of Nursing, confirmed that the CPAP equipment was not being cleaned or stored according to the facility's policy. Staff members acknowledged that the equipment should be stored in a bag for infection control and cleaned after each use. The Director of Nursing stated that the CPAP mask should be cleaned daily, the headgear weekly, and the filter changed every two weeks. The Administrator deferred to the Director of Nursing on care-related subjects but acknowledged that staff should follow facility policies and procedures.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure that medications were received from the pharmacy in a timely manner for a resident diagnosed with bipolar disorder. The resident, who had intact cognition, was admitted to the facility with a care plan that included the use of psychotropic medications. The medication administration record indicated that the resident's prescribed Depakote was not available on multiple occasions, leading to missed doses over several days. Interviews with various Licensed Vocational Nurses (LVNs) revealed a lack of consistent action in addressing the unavailability of the medication. While some LVNs attempted to locate the medication within the facility or contact the pharmacy, there was no evidence of consistent communication with the physician or the Director of Nursing (DON) regarding the missed doses. The facility's policy required timely receipt of medications, but this was not adhered to, resulting in the resident missing critical doses of their mood stabilizer. The Medical Records Supervisor confirmed the absence of documentation regarding communication with the physician about the medication issue. The Medical Director was unaware of the situation and noted the potential impact on the resident's mood stability. The Pharmacy Representative indicated that the medication was delivered upon request, but there was no record of earlier orders. The DON and Administrator were not informed of the ongoing issue, highlighting a breakdown in communication and protocol adherence within the facility.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the physician of pharmacy consultant recommendations for a resident reviewed for unnecessary medications. The facility's policy required that all findings and recommendations from the consultant pharmacist be reported to the director of nursing, the attending physician, the medical director, and the administrator. However, the facility did not follow this policy for a resident who had been receiving escitalopram for depression. The consultant pharmacist's report recommended evaluating the therapy to determine if a lower dose or discontinuation was appropriate, but there was no documentation that the prescriber had signed or dated the report, indicating a lack of follow-up on the recommendation. The resident in question had a history of major depressive disorder and was receiving escitalopram daily. The resident's care plan included monitoring the effectiveness and side effects of the antidepressant medication. Despite the consultant pharmacist's recommendation for a gradual dose reduction or discontinuation, the facility did not document any follow-up actions. Interviews with the Director of Nursing revealed that the follow-up for the pharmacy recommendations was not found, indicating a lapse in the facility's process for addressing pharmacy consultant recommendations.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update care plans for two residents after they experienced falls, as required by their policies. The facility's policy on Fall Prevention and Management Program, revised on 8/1/14, mandates that care plans be initiated or updated following a resident's fall. Additionally, the Comprehensive Person-Centered Care Planning policy, revised on 11/1/18, requires updates to the care plan based on the resident's assessed needs. However, the care plans for Residents 2 and 7 were not updated after their falls, which was confirmed during interviews with Licensed Nurses (LNs) and the Director of Nursing (DON). Resident 2, who was admitted with diagnoses including dementia and epilepsy, had a fall on 10/14/24, but no Actual Fall care plan was initiated. Similarly, Resident 7, who had a history of syncope and amputation, fell on 10/2/24, yet their care plan was not updated to reflect this incident. Interviews with LN A and LN C revealed that LNs were responsible for initiating or revising care plans after a fall, using a fall packet checklist. The DON confirmed the absence of updated care plans for both residents, acknowledging that the necessary updates were not made as per the facility's procedures.
Inadequate PPE Usage in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed in COVID-19 positive resident rooms. During an observation, it was noted that eight rooms had isolation signs indicating the need for specific personal protective equipment (PPE) including gowns, N95 masks, eye protection, and gloves. However, two staff members were observed not adhering to these requirements. Licensed Vocational Nurse (LVN) A was seen exiting an isolation room wearing an N95 mask but without an eye shield, despite acknowledging the presence of COVID-19 positive residents in the room. LVN A admitted to not wearing an eye shield because she did not believe it was necessary. Similarly, Registered Nurse (RN) B was observed leaving another isolation room wearing an N95 mask and her own prescription glasses, which had slid down her nose, instead of proper eye protection. RN B confirmed the room was for COVID-19 isolation but mistakenly thought her glasses sufficed as eye protection. The Infection Preventionist (IP) later clarified that prescription glasses do not qualify as eye shields and expressed the need to reeducate staff on the correct PPE protocols for isolation rooms.
Failure to Report Abuse Investigation Results Timely
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not providing the State Survey Agency (SA) with the results of an investigation into an alleged abuse incident within the required five working days. This incident involved two residents, one with high blood pressure and anxiety, and the other with memory loss due to a stroke. The facility's policy, revised on January 8, 2014, mandates that the Administrator or their designee must submit a written report of the investigation findings to the appropriate agencies within five working days of the incident. The deficiency was identified during a review of the facility's records and interviews with staff. The interim Assistant Director of Nurses (IADON) confirmed that the file related to the alleged abuse did not contain the required 5-day investigation report. Additionally, the interim Administrator (IADMIN) acknowledged that the previous Administrator had failed to provide the SA with the necessary report. This oversight placed residents at risk for further potential abuse, as the facility did not comply with its own procedures for reporting and investigating abuse allegations.
Failure to Manage Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to adequately address the elopement risk of a resident, identified as Resident 1, who had a history of severe cognitive decline and was not his own responsible party. Despite being identified as an elopement risk after a previous incident on 7/30/24, the facility did not implement effective interventions or monitor the resident's wander guard for functionality. The resident eloped again on 9/7/24, walking to a nearby park without staff supervision, which was not documented or reported to the responsible party or state agencies as required by the facility's policies and procedures. The facility's policies and procedures for managing elopement risks were not followed. The interdisciplinary team did not review or update the care plan to address the resident's specific elopement triggers or schedule regular walks and activities as interventions. Additionally, the licensed nurses were not informed of the resident's elopement risk during shift changes, and there was no documentation of the wander guard's functionality checks or skin assessments, which were supposed to be conducted weekly. Interviews with staff revealed a lack of awareness and communication regarding the resident's elopement risk and the procedures for testing the wander guard. The interim Assistant Director of Nurses confirmed that the facility staff did not document or monitor the wander guard's functionality, and the care plan was not updated to reflect the resident's individual risks or root causes for elopement. The facility's failure to follow its policies and procedures placed the resident at an increased risk for continued elopement and potential injury.
Failure to Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an investigation into an abuse incident involving two residents to the California Department of Public Health (CDPH) within the required five working days. The incident occurred when one resident slapped another on the arm, and although the facility reported the incident itself to CDPH, they did not follow up with a written report detailing the findings and any corrective actions taken. This omission was identified during a review of the facility's policy and procedure on reporting abuse, which mandates that such a report be submitted within the specified timeframe. During an interview and record review with the Assistant Director of Nursing (ADON), it was confirmed that no follow-up report had been prepared or submitted to CDPH regarding the altercation between the two residents. The facility's policy, dated January 18, 2014, clearly states that the administrator or their designee must provide a written report of the investigation's findings within five working days if the alleged violation is verified. The lack of this report indicates a failure to comply with both state law and the facility's own policies, potentially leaving residents vulnerable to continued abuse without proper oversight.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened and within 24 hours, as per the facility's policy. The policy stated that mail should be delivered to residents unopened and within 24 hours of delivery to the premises. However, a resident reported that a package was delivered to the facility on a Friday and was not received by her until the following Tuesday. The package had been opened by facility staff before it was given to the resident, which was confirmed by the Social Service Director and the Assistant Director of Nursing. The resident involved had a diagnosis that included bone infection, anxiety, cancer, and homelessness, and her cognitive status was intact as indicated by a BIMS score of 15. The Social Service Director noted that the resident was capable of opening her own mail and that staff should not open it unless asked. Despite this, the package was opened by a Licensed Nurse who found medication inside and locked it up. There was no documentation in the resident's care plan indicating a need for supervision when opening mail, and the Assistant Director of Nursing confirmed that the package was opened without the resident's knowledge or permission.
Failure to Assess and Obtain Wound Care Orders
Penalty
Summary
The facility failed to effectively assess and obtain a wound care treatment order for a surgical wound for a resident who was admitted with a surgical wound. The resident refused to have the wound assessed by staff, and the facility waited two weeks for an orthopedic follow-up appointment to obtain an order for the resident's wound care and treatment. This inaction occurred despite the facility's policies requiring a skin assessment upon admission and the attending physician to provide routine care orders. The resident was admitted with diagnoses including osteomyelitis, cellulitis, and MRSA infection. The resident was cognitively intact and made their own decisions, as indicated by a BIMS score of 15/15. The resident was adamant that the brace on their leg should not be removed, and the facility staff did not assess the wound until after the orthopedic follow-up appointment. The resident expressed that they might have allowed the wound to be assessed if shown an order from the doctor. The facility administrator acknowledged that treatment was expected and needed, but the wound was not assessed prior to receiving orders from the follow-up appointment.
Failure to Provide Activities Schedule and Newsletter
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the activities schedule and facility news, which is a violation of the resident's right to be informed and make decisions regarding their activities. The deficiency was identified when it was observed that the resident did not receive an activities schedule or newsletter for the months of June and July 2024. The resident, who was admitted with diagnoses including epilepsy, muscle weakness, difficulty walking, and depression, expressed that the absence of these materials left them unaware of the scheduled activities and current news within the facility. During interviews and observations, it was noted that the resident's room had a clear plastic wall sign holder that was intended to display the activities calendar, but it had been empty since June 2024. The resident mentioned that there was a new activities director, and although activities were being conducted, they were not informed about the timing or nature of these activities due to the lack of a calendar. The facility administrator confirmed that during the period without an activities director, the weekly activities room calendars and newsletters were not being produced or distributed to residents.
Failure to Respect Resident's Dignity and Assistance Needs
Penalty
Summary
The facility failed to honor the dignity and respect of Resident 2 when Certified Nursing Assistant (CNA) X did not stop moving the resident despite her request. Resident 2, who suffers from Post Traumatic Stress Disorder (PTSD), felt afraid during the incident. The resident's medical history includes depression, morbid obesity, epilepsy, PTSD, developmental delay, previous nervous system surgery, and mobility difficulties. At the time of the incident, Resident 2 weighed 470 pounds and required extensive assistance from one to two persons for bed mobility. CNA X attempted to roll Resident 2 in bed alone for incontinence care, despite the resident's request to stop and get help. CNA X, who was unfamiliar with Resident 2 and typically worked night shifts, was unprepared for the resident's size and did not know the required assistance level. The CNA's written account indicated that other CNAs were busy, and she completed the task alone. The facility's 5-Day Report acknowledged that CNA X took accountability for handling the resident insensitively. Resident 2's care plan specified the need for extensive assistance with one to two persons for bed mobility. Documentation showed varying levels of assistance required for rolling in bed, with most instances needing substantial or maximal help. The facility's Administrator stated that CNAs could access information on required assistance levels through care plans or by consulting the resident's nurse, emphasizing the expectation for CNAs to communicate and seek help when needed.
Inadequate Assistance During Incontinence Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had the necessary knowledge and assistance to provide appropriate care for a resident, resulting in the resident experiencing unnecessary discomfort. The incident involved CNA X, who was responsible for providing incontinence care to Resident 2, a resident with multiple diagnoses including morbid obesity, epilepsy, and mobility difficulties. During the care, CNA X attempted to reposition Resident 2 without the assistance of a second person, despite the resident's protests and expressions of pain. Resident 2's medical records indicated a need for substantial assistance with mobility, including rolling in bed, due to her weight and impaired range of motion. The Minimum Data Set (MDS) and Activities of Daily Living (ADL) chart documented that Resident 2 required significant help for such activities. However, CNA X, who was relatively new to the facility and unfamiliar with Resident 2, was not informed of the specific assistance requirements and attempted to perform the task alone, leading to the resident's discomfort. Interviews with facility staff revealed that CNA X was not adequately prepared or informed about the level of assistance required for Resident 2. The facility's administrator acknowledged that CNAs should refer to care plans or consult with nurses to determine the necessary assistance for residents. The absence of the Director of Staff Development, who was responsible for staff training and competencies, further contributed to the lack of proper guidance and support for CNA X.
Failure to Provide Meals and Conduct Dialysis Assessments
Penalty
Summary
The facility failed to adhere to its dialysis policy and procedure for four residents who required dialysis services. Resident 1 was not provided with meals before leaving for dialysis, during the dialysis session, or upon returning to the facility. This oversight was confirmed through interviews with staff and the resident, as well as a review of meal documentation, which showed no recorded meals for Resident 1 on the day of her dialysis appointment. Additionally, the facility did not consistently complete pre, during, and post-dialysis assessments for Residents 1, 3, 4, and 5. The facility's policy required these assessments to be documented, but reviews of electronic medical records and paper records revealed missing assessments for multiple dialysis sessions. Interviews with nursing staff and the Director of Nursing confirmed the lack of documentation for these critical assessments. The failure to provide meals and conduct necessary assessments for residents undergoing dialysis had the potential to negatively impact their health. The facility's policy outlined the need for communication between the dialysis center and the facility, as well as the responsibility of licensed nurses to perform and document these assessments, which was not consistently followed.
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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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