Riverwood Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 5320 Carrington Circle, Stockton, California 95210
- CMS Provider Number
- 555496
- Inspections on file
- 32
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 60
Citation history
Health deficiencies cited at Riverwood Health Care during CMS and state inspections, most recent first.
The facility failed to prevent resident-on-resident physical abuse when two roommates with a known history of arguments were left together without adequate interventions, resulting in one resident with severe cognitive impairment and multiple neurologic conditions being struck in the back of the head by the other resident. Staff had prior knowledge that one resident became easily agitated and that the pair had repeated disagreements over lights and TV volume, but these behaviors and conflicts were not documented or care planned. On the day of the incident, a CNA heard yelling, temporarily separated the residents and notified an LN that they should be kept apart, but after returning the cognitively impaired resident to the shared room, the other resident got up from bed and hit him from behind, leading to staff intervention and post-incident assessment.
Two residents with a history of disagreements were involved in an incident where one struck the other in the back of the head after staff had earlier observed and reported escalating verbal conflict and suggested the residents be separated. The subsequent abuse investigation was incomplete: only two staff were interviewed with no follow-up questions, prior arguments and behavioral concerns were not documented or reported, and the incident itself was not entered into the medical records. The DON, who had no prior training or experience in conducting abuse investigations, shared limited investigative duties with the ADON, resulting in a failure to uncover prior incidents or fully understand the events leading to the abuse, contrary to the facility’s abuse policy requiring thorough investigation and documentation.
The facility failed to timely notify the State Agency (SA) of a change in the DON position for a census of 85 residents. The DON began the role but the required change-of-DON application and written notice were not completed and mailed until weeks later, as confirmed by the DON’s and acting ADM’s interviews and the dated documents. The ADM reported being unaware of the required timeframe for notification, and SA records showed the DON application was received several days after it was mailed, delaying SA verification of the DON’s qualifications.
A resident with multiple comorbidities was admitted on oxygen and IV antibiotics with hospital discharge orders for oxygen at 2 L/min for SOB or low O2 saturation with immediate MD notification, and weekly CBC and Chem 7 labs. The weekly CBC order was never transcribed into facility orders, and there was no evidence that CBCs were drawn. One morning, the resident complained of SOB and had an O2 saturation of 88%; an LVN administered ordered albuterol and independently increased oxygen from 2 L/min to 4 L/min, despite regulations prohibiting LVNs from adjusting oxygen flow and facility policy requiring prompt MD notification for significant changes in condition. The LVN did not notify an RN or the MD/NP of the change in condition, and there was no oxygen therapy care plan in place. Later that morning, the NP found the resident unresponsive with CPAP still on, initiated a code, and EMS pronounced the resident deceased, with the MD and NP confirming they had not been notified earlier of the resident’s SOB and low O2 saturation.
A resident admitted with multiple complex conditions, including sepsis, sleep apnea, and morbid obesity, arrived with hospital discharge instructions and MD orders for continuous O2 at 2 L/min via nasal cannula and specific parameters for use and physician notification. Although the facility noted and carried out the hospital discharge orders and had a policy requiring a baseline care plan within 48 hours that includes necessary healthcare information, the baseline care plan summary did not include O2-related interventions or instructions. The DON confirmed that no specific O2 care plan was developed for this resident, resulting in a failure to create a person-centered baseline care plan for oxygen therapy.
Staff, including CNAs and LNs, used a group messaging app on personal smartphones to communicate resident names, room numbers, and medical information, despite the app not being HIPAA-compliant. The DON and ADM acknowledged that the app lacked necessary security controls, and staff were not required to report lost or stolen phones, increasing the risk of unauthorized access to PHI. Facility policy required protection of resident information, but the use of this app directly contradicted those requirements.
Two residents at risk for elopement were not adequately protected due to the facility's failure to implement necessary prevention measures. A resident with dementia exhibited exit-seeking behavior, but the facility did not initiate orders for a wander guard or conduct an elopement risk assessment. The resident's wander guard was not functioning, leading to an elopement and injury. Another resident was found with an expired wander guard, highlighting lapses in monitoring and maintenance of safety devices.
The facility failed to follow safe injection practices by storing pre-drawn, unlabeled flu vaccine syringes in a staff food refrigerator. Additionally, pneumonia vaccines for three residents were documented as administered but were found in the refrigerator intended for medication destruction. The facility did not adhere to its policies on vaccine documentation and storage, leading to these deficiencies.
The facility failed to ensure safe medication use and destruction practices, including undated and unsigned medication destruction logs, improper storage of discontinued medications, and discrepancies in vaccine administration records. These issues could lead to drug diversion and unsafe drug use.
The facility failed to ensure safe medication storage, with prescription medications and vaccines improperly stored in a dorm-style refrigerator alongside personal food items, without temperature monitoring or proper labeling. Additionally, discontinued medications were found in an active storage area in the main medication room. The DON and ADON were unaware of these practices, which violated the facility's policies on medication storage and disposal.
A facility failed to provide a written discharge notice to a resident's responsible party, resulting in a deficiency. The RP was verbally informed of the discharge when the resident was sent to the hospital, but no written notice or information on appeal rights was provided. The facility administrator confirmed the lack of documentation in the resident's medical record.
A resident with multiple diagnoses was sent to a hospital on a 5150 hold due to aggressive behavior. The facility failed to reassess the resident's condition or communicate with the hospital about the resident's needs for returning. Interviews and hospital notes revealed a lack of documentation and communication, potentially impacting the resident's psychosocial well-being.
The facility exceeded the acceptable medication error rate, with two residents receiving plain multivitamins instead of the prescribed multivitamins with minerals. The errors were made by an LVN who was unclear about the different types of multivitamins, despite clear physician orders. The DON and Administrator emphasized the need for staff to accurately follow medication orders.
A facility failed to follow physician's orders for a resident's medication administration, leading to carvedilol being given when the resident's SBP was below 130 mmHg and midodrine when SBP was above 120 mmHg. Nursing staff misunderstood the parameters, resulting in multiple instances of incorrect medication administration.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. Despite training and posted signage, a CNA entered the resident's room wearing only gloves and a mask, omitting the required gown. The Director of Nursing and Administrator confirmed that staff had been trained on EBP and expected to follow the PPE guidelines.
A facility failed to carry out a physician's order to reduce a resident's gabapentin dosage, resulting in the resident refusing several doses and leaving the facility against medical advice. The ADON and DON confirmed that the order was communicated but not executed, and the nurse should have checked the physician's note and clarified the order.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. Resident 2, who had epilepsy, depression, muscle weakness, unsteadiness on feet, and a traumatic brain injury, and who was assessed with a BIMS score of 7 indicating severe cognitive impairment, was sharing a room with Resident 1. Staff were aware that Resident 1 could become easily agitated, upset, and rude, and that the two residents had a history of disagreements and arguments about lights and television volume at night. These prior conflicts were not documented or reported in the medical record, and no behavior concerns for Resident 1 were care planned or communicated to leadership. On the day of the incident, CNA 1 was preparing Resident 2 for a shower when Resident 1 began yelling at Resident 2. CNA 1 moved Resident 2 into the hallway to prevent escalation and notified Resident 1’s nurse that Resident 1 was upset and yelling, and that the residents should be separated. CNA 1 then escorted Resident 2 to the shower and returned with him about 15 minutes later. She positioned Resident 2 in his wheelchair in front of his bed toward the back of the room, with his back to the door and to Resident 1’s bed, while she stood along the back wall at Resident 2’s nightstand. While CNA 1 was at the nightstand, she observed Resident 1 get up from his bed, approach Resident 2 from behind, and hit him in the back of the head with a fist. CNA 1 called for help, and staff responded and separated the residents. LN 1 arrived and saw Resident 1 standing between the two beds; both residents were yelling, and Resident 2 reported he had been “sucker punched” in the back of the head and was upset. LN 2, the nurse assigned to both residents that day, later assessed Resident 2 for injuries; Resident 2 stated that Resident 1 came over and hit him in the back of the head and appeared surprised, scared, and startled. The DON and Social Services Director confirmed there was no documentation of prior disagreements or behavior issues in either resident’s record, despite staff knowledge of previous arguments and Resident 1’s tendency to become easily agitated.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident abuse following an incident in which one resident hit another. On the day of the incident, a CNA reported that while preparing one resident for a shower, she heard the roommate yelling and upset, moved the resident into the hallway to prevent escalation, and notified the assigned nurse that the residents should be separated. After completing the shower and returning the resident to the room, the CNA observed the roommate get up from his bed and strike the resident in the back of the head with a closed fist, then called for help and staff separated the residents. The assigned nurse later confirmed he was told the residents were fighting and that the struck resident reported being hit in the back of the head, but he did not document the incident in either resident’s medical record because the ADON and DON were already present taking statements. The facility’s investigation was limited and did not capture key information about prior behaviors and conflicts between the two residents. The ADON confirmed that only two staff members were interviewed and that he asked the CNA only what happened and what she witnessed, without follow-up or clarifying questions, and he could not recall receiving formal training on taking statements or investigating abuse. Another CNA reported she had been told in morning report that the resident who later hit his roommate could become easily agitated, upset, and rude. A nurse reported that the two residents had a history of disagreements and arguments about lights and television volume at night, occurring a few times after they were roomed together, and that the resident who later hit his roommate was known to yell out for staff and be impatient; however, she did not document or report these prior arguments because she felt she had resolved them. The DON stated that when a nurse is notified of residents arguing, she expected the nurse to address it immediately to prevent escalation, and that it was her expectation that staff document and share all incidents between residents that could lead to abuse. Upon review of both residents’ medical records, the DON confirmed there was no documentation of previous disagreements between the two residents and no documented concerns with the aggressor’s behaviors, and she had no knowledge of any prior incidents between them. The DON was assigned by the previous Administrator to complete the abuse investigation and the five-day follow-up report to the State Agency, confirmed it was her first time fully completing an investigation, shared investigative duties with the ADON, and reported she had not been trained in how to complete an abuse investigation. The facility’s abuse policy required that suspected or alleged abuse be immediately reported, thoroughly investigated, and completely documented, with a verification of incident investigation report completed within five working days, but the investigation did not meet these standards and did not reveal several past incidents or provide a full picture of events leading to the abuse.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide timely written notice to the State Agency (SA) of a change in the Director of Nursing (DON) position for a census of 85 residents. The current DON reported in an interview that she began her role on 12/10/25 and that corporate staff requested her licensing information, but she did not know when the leadership change notification was sent to the SA. During a concurrent interview and record review, the acting Administrator (ADM) confirmed that the change-of-DON documents were dated and mailed on 1/7/26, rather than at the time the change occurred, and stated he was not aware of the time requirement for notification. A facility letter to the SA dated 1/7/26, signed by the DON the same day, referenced a “CHANGE OF DIRECTOR OF NURSING Application,” and SA database records showed the DON application was received on 1/13/26. This delay in notification postponed the SA’s verification that the DON was qualified to lead clinical services, which the report states had the potential to compromise resident safety and regulatory compliance for all 85 residents. The deficiency centers on the facility’s inaction in promptly notifying the SA of the DON change at the time it occurred, as required by rules on disclosure of ownership and administrative personnel changes. The DON’s start date, the later date of the application and mailing, and the ADM’s lack of awareness of the time requirement are specifically documented as the factors leading to the late reporting.
Failure to Provide Timely Respiratory Assessment, Physician Notification, and Lab Follow-Through After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate respiratory care, timely clinical assessment, and appropriate physician notification for a resident with complex medical conditions, including sepsis, facial cellulitis, type 2 diabetes, hypertension, morbid obesity, sleep apnea, and blindness. The resident was admitted from the hospital with discharge instructions that included oxygen at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification, and weekly CBC and Chem 7 labs after SNF admission. The facility signed that these hospital discharge orders were noted and would be carried out, but the weekly CBC order was never transcribed into the facility’s physician orders, and there was no evidence that CBC labs were ever drawn. The DON confirmed that the CBC order was not transcribed or completed, despite the resident being on IV antibiotics for infection. On the morning of the incident, the resident was in bed with CPAP and oxygen at 2 L/min via nasal cannula. Around change of shift, a CNA informed LVN 1 that the resident was complaining of shortness of breath and had an oxygen saturation of 88%. LVN 1 assessed the resident, confirmed shortness of breath and low oxygen saturation, administered two puffs of albuterol as ordered, and increased the resident’s oxygen from 2 L/min to 3 L/min and then to 4 L/min via nasal cannula, using her own nursing judgment. LVN 1 documented that the oxygen saturation improved to 94–95% by 8:15 a.m. and stated she remained in the room monitoring the resident until that time. LVN 1 acknowledged that this was a change in condition and that she did not notify the physician, explaining that she was passing medications and did not get the chance to call. The SBAR and progress notes showed that the physician was not notified of the change in condition until after the resident was found unresponsive. The facility’s DON stated that it was not within an LVN’s scope of practice to perform a full clinical assessment for a change in condition or to adjust oxygen flow rates under the updated respiratory care regulations. The DON confirmed that LVN 1 did not escalate the resident’s care to an RN for a full assessment and that LVN 1 should not have titrated the oxygen without a physician’s order. The DON also confirmed that there was no oxygen therapy care plan developed for the resident, despite the resident being on oxygen therapy. Later that morning, at approximately 10:10 a.m., the NP found the resident in bed unresponsive, with no pulse and no respirations, and the CPAP still in place even though the order specified CPAP off at 7 a.m. A code was called, CPR was initiated, and 911 was contacted, but paramedics pronounced the resident deceased at 10:26 a.m. The NP and Medical Director both stated that staff should not have titrated oxygen without an order and that they were not notified of the resident’s earlier change in condition involving shortness of breath and low oxygen saturation. The facility’s written policy on change in resident condition required prompt notification of the attending physician when there is a significant change in the resident’s physical condition, including specific instructions to notify the physician of changes in condition. The facility’s in-service education and regulatory guidance from the Respiratory Care Board and the Board of Vocational Nursing and Psychiatric Technicians specified that LVNs may not initiate or adjust oxygen liter flow or concentration and must work under the supervision of an RCP, RN, or physician. Despite these policies and regulations, LVN 1 independently adjusted the resident’s oxygen flow, did not notify an RN or physician of the change in condition, and the facility did not ensure transcription and implementation of the hospital’s weekly CBC orders. These combined failures resulted in the physician not being aware of the resident’s change in condition, a delay in adequate assessment and potential identification of the need for a higher level of care, and delay in adequate care and treatment, and the resident died within two hours of the documented change in condition.
Failure to Develop Baseline Oxygen Care Plan on Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the interventions and instructions needed to provide effective and person-centered oxygen therapy for a newly admitted resident. The resident was admitted with multiple diagnoses, including acute osteomyelitis, sepsis, cellulitis and abscess of the mouth, type 2 diabetes, essential hypertension, bilateral blindness, depression, sleep apnea, morbid obesity, and anxiety. Hospital inpatient discharge instructions directed that oxygen be started at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification for specified respiratory changes and abnormal findings. The facility signed the hospital discharge orders as noted and carried out, and the physician’s orders dated shortly after admission included continuous oxygen at 2 L/min via nasal cannula every shift. Despite these orders, review of the resident’s care plans showed that no oxygen care plan was developed. The DON confirmed during interview and concurrent record review that the resident was admitted with oxygen therapy and that the baseline care plan summary, which the facility used as the resident’s baseline care plan, did not include specific interventions and instructions for oxygen therapy. The DON acknowledged that a specific oxygen care plan was not developed for this resident. Review of the facility’s “Baseline Care Plan Summary” policy, revised in October 2025, indicated that the facility was required to develop and implement a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but this was not done for the resident’s oxygen needs.
Unauthorized Disclosure of PHI via Non-Compliant Messaging App
Penalty
Summary
Facility staff failed to ensure the privacy and confidentiality of residents' personal and medical records by communicating protected health information (PHI) through a group messaging platform (GMP) installed on staff members' personal smartphones. Multiple interviews and observations confirmed that both licensed nurses and certified nursing assistants routinely used this application to share resident names, room numbers, medical updates, and care needs. The GMP was not password-protected once the phone was unlocked, and staff were not required to report if their phones were lost or stolen, increasing the risk of unauthorized access to PHI. The Director of Nursing (DON), Administrator (ADM), and other staff acknowledged that resident identifiers and medical information were shared through the GMP, and that the application was not HIPAA-compliant. The DON admitted that there was no way to control or monitor who could access the information if a staff member's phone was compromised. Staff interviews revealed that the expectation was to use the GMP for communication about resident care, and some staff expressed concerns about the privacy implications, with at least one nurse refusing to install the app due to HIPAA concerns. Facility policies reviewed indicated that PHI should only be disclosed as permitted by law and that employees are responsible for protecting resident information from unauthorized release. However, the use of the GMP, which lacks necessary security features and is not HIPAA-compliant, directly contradicted these policies. The facility's own leadership acknowledged the risks and lack of control over PHI once it was shared via staff personal devices.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement adequate elopement prevention measures for two residents at risk for elopement. Resident 1 exhibited exit-seeking behaviors, but the facility did not initiate orders for a wander guard device or conduct an elopement risk assessment as outlined in the resident's care plan. Additionally, Resident 1's wander guard was not functioning at the time of elopement, and there was inconsistent documentation of the device's placement in the resident's chart. These oversights led to Resident 1's elopement, resulting in a head injury, hospital visit, and stitches. Resident 1, who had a history of dementia and wandering behavior, was not adequately monitored or protected despite having a care plan in place. The care plan included interventions such as frequent monitoring and the use of a wander guard device, but these were not effectively implemented. The facility's staff, including licensed nurses and the Director of Nursing, acknowledged the lack of necessary orders and assessments, which contributed to the resident's ability to leave the facility unsupervised. Furthermore, Resident 3 was found wearing an expired wander guard, indicating a lapse in the facility's monitoring and maintenance of safety devices. The Maintenance Assistant and a licensed nurse confirmed the expiration, and the Director of Nursing acknowledged the risk of elopement due to non-functional devices. The facility's failure to ensure the functionality and timely replacement of wander guards posed a significant risk to residents' safety.
Improper Vaccine Storage and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for safe injection practices, as evidenced by the improper storage and handling of vaccines. The Infection Preventionist (IP) stored pre-drawn, unlabeled, and undated flu vaccine syringes in a staff food refrigerator, which also contained personal food items. The IP admitted to preparing these syringes without labeling them, as she intended them for staff use, and acknowledged that the refrigerator's temperature was not monitored. This practice was deemed unsafe by the Director of Nursing (DON), who was unaware of the situation until it was brought to her attention. Additionally, pneumonia vaccines for three residents were documented as administered, yet the actual vaccines were found in the same refrigerator, intended for medication destruction. The Assistant Director of Nursing (ADON) could not explain how these vaccines, documented as given nearly a year prior, were still present in the refrigerator. The facility's policy required documentation of vaccine lot numbers and expiration dates in residents' medical records, which was not adhered to in these cases. The facility's policies on administering medications and vaccinations were not followed, as evidenced by the improper storage and lack of documentation. The DON and Administrator could not provide a reason for storing discontinued medications in a refrigerator instead of a designated medication cabinet. The facility's failure to comply with its policies and CDC guidelines for vaccine administration and storage contributed to the deficiencies identified during the survey.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure safe medication use and destruction practices, as evidenced by several deficiencies. Firstly, the prescription medication destruction and disposition logs were not properly dated, witnessed, or co-signed by licensed staff. During an inspection of the main medication room, it was found that the binder for medication destruction was overfilled with pages lacking dates and co-signatures. The Director of Nursing (DON) was unsure about the need for a witness co-signature and when the last medication destruction occurred. The facility's Consultant Pharmacist confirmed that all prescription destructions should be documented and witnessed by two licensed nurses. Additionally, a discontinued medication, semaglutide, prescribed to a resident who had been discharged, was improperly stored in an active storage area. The medication was never used, as the resident's treatment was changed to insulin. Despite the facility's policy requiring discontinued medications to be stored in a locked cabinet until destruction, the semaglutide was found in the medication refrigerator. The Assistant Director of Nursing (ADON) acknowledged that the resident's discontinued medications should have been stored securely until destruction. Furthermore, three pneumonia vaccines belonging to different residents were found in a staff food refrigerator, despite being documented as administered in the Medication Administration Record (MAR). The ADON could not explain how these vaccines were found in the refrigerator or why they were documented as administered. The facility's policy requires proper documentation of vaccine administration, including lot numbers and expiration dates, but this was not adhered to. These failures could contribute to the risk of drug diversion and unsafe drug use.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed in a dorm-style refrigerator located in an office shared by the Director of Staff Development (DSD), Infection Preventionist (IP), and the staffing coordinator. This refrigerator contained personal food items alongside a drawer full of prescription injectable medications, including vaccines and unlabeled pre-drawn syringes of a flu vaccine. There was no temperature monitoring performed for this refrigerator, and the DSD was unaware of how long the medications had been stored there. The DSD acknowledged the improper storage of medications with personal food and indicated that the medications might belong to facility staff. The IP admitted to preparing the pre-drawn syringes for staff administration and acknowledged the lack of labeling and temperature monitoring. In the main medication room, the refrigerator stored opened vials of flu vaccine and Tuberculosis testing agent without any marking for a beyond-use date. Additionally, discontinued medications belonging to a discharged resident were found in an active storage area in the refrigerator. The Director of Nursing (DON) was unaware of these storage issues and expressed concern over the unsafe practices, including the presence of pre-drawn flu vaccine syringes without labels. The Assistant Director of Nursing (ADON) confirmed that discontinued medications should not have been stored in the unsecured office refrigerator and should have been kept in a locked cabinet in the medication room. The facility's policies on medication labeling and storage, as well as discarding and destroying medications, were not adhered to. The policies require that all medications and biologicals be stored in locked compartments under proper conditions and that discontinued medications be stored in a locked cabinet until destruction. The failure to follow these policies resulted in unsafe medication storage practices, posing a risk to the safety of the residents and the potential for drug diversion.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated discharge for a resident, resulting in a deficiency. The resident's responsible party (RP) was verbally informed of the discharge when the resident was sent to the hospital, but no written notice was provided. This omission meant that the RP was not informed of the appeal rights or the process to contest the discharge decision, nor was contact information for the appeal unit and the ombudsman provided. The RP only became aware of these rights through a hospital social worker. The facility administrator acknowledged that a written 30-day notice of discharge was not sent to the RP and confirmed the absence of documentation in the resident's electronic medical record. The discharge was due to the resident's psychotic episodes, and the verbal notice was given to the RP because the resident was developmentally delayed. The facility's policy requires documentation of appropriate notice in the medical record, which was not adhered to in this case.
Failure to Reassess Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to determine if a resident could return to the facility after being transferred to an acute care hospital. The resident, who had been admitted with diagnoses including heart failure, bipolar disorder, schizophrenia, depression, and anxiety disorder, was sent to the hospital on a 5150 hold due to aggressive behavior. There was no documented evidence that the facility communicated with the hospital to assess the resident's condition or to determine if the facility could meet the resident's needs upon discharge from the hospital. Interviews with the resident's responsible party and facility staff revealed that the facility did not attempt to reassess the resident's readiness to return. The facility's Social Services Director and Case Manager were unsure if anyone from the facility had visited the hospital to evaluate the resident. The resident's primary physician confirmed that neither he nor anyone from the facility had assessed the resident at the hospital. Hospital notes indicated that the facility had communicated with the hospital, stating that the resident was discharged and would not be accepted back. The facility's policy requires documentation and communication of the resident's needs and the facility's inability to meet those needs, but there was no evidence of such documentation. This lack of communication and documentation had the potential to negatively impact the resident's psychosocial well-being.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. Two errors were identified out of 26 opportunities, involving two residents. Resident #23, who has a medical history of multiple sclerosis and intact cognition, was prescribed a multivitamin with minerals but was administered a plain multivitamin instead. Similarly, Resident #82, with severe cognitive impairment and a history of anemia and moderate protein-calorie malnutrition, was also prescribed a multivitamin with minerals but received a plain multivitamin. The errors were attributed to Licensed Vocational Nurse (LVN) #5, who admitted to administering the incorrect medication due to confusion over the different types of multivitamins. Interviews with the Nurse Practitioner and Director of Nursing (DON) confirmed that the physician's orders were not followed, as the residents were supposed to receive multivitamins with minerals. The DON and Administrator both expressed expectations that staff should review and follow medication orders accurately, highlighting the importance of adhering to the specific details of physician prescriptions.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of medications for a resident with a history of end-stage renal disease, hypertensive heart, and chronic kidney disease with heart failure. Specifically, the facility did not follow the order to hold carvedilol when the resident's systolic blood pressure (SBP) was below 130 mmHg and to refrain from administering midodrine when the SBP was above 120 mmHg. This oversight was identified for one resident among five sampled for unnecessary medications. The Medication Administration Record (MAR) showed that carvedilol was administered on multiple occasions when the resident's SBP was below the specified threshold, and midodrine was given when the SBP exceeded the prescribed limit. Interviews with nursing staff revealed a misunderstanding of the parameters, with one nurse mistakenly believing the hold parameter for carvedilol was an SBP below 100 mmHg instead of 130 mmHg. The Director of Nursing and the Administrator both expressed that they expected nurses to follow medication orders and parameters as prescribed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. The policy, dated April 5, 2024, mandates that staff perform hand hygiene and don a gown and gloves before engaging in high-contact resident care activities, such as dressing. Resident #196, admitted on July 17, 2024, had a medical history that included a gastrostomy tube and was at risk for aspiration. An order for enhanced standard precautions related to the gastrostomy tube was in place for every shift. On July 22, 2024, a Certified Nursing Assistant (CNA) entered the resident's room wearing only gloves and a mask, despite signage indicating the need for a gown, gloves, and mask. The CNA acknowledged that she had been trained on EBP and was aware of the requirement to wear a gown when providing care to residents with a gastrostomy tube. The Director of Nursing confirmed that staff had been in-serviced on EBP and that signage was posted to guide staff on the necessary personal protective equipment (PPE). The Administrator also expected staff to adhere to the training and signage instructions.
Failure to Carry Out Physician's Order for Medication Adjustment
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality when a physician's order to reduce gabapentin for a resident was not carried out. The resident, who had multiple diagnoses including surgical aftercare following surgery on the nervous system and diabetes mellitus, had an active order for gabapentin 400 mg every eight hours. On 4/6/24, the physician ordered to taper the gabapentin to 300 mg daily, but this order was not executed. The resident subsequently refused several doses of the medication, citing that the current dosage was too high and caused trouble for her legs. The resident left the facility against medical advice on 4/8/24. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the physician's order to reduce the gabapentin dosage was communicated but not carried out. The ADON and DON both stated that the nurse should have checked the physician's note for new orders and clarified the order when the resident refused the medication. The facility's policies on medication orders and administering medications were reviewed, indicating that medications should be administered as prescribed and that a current list of orders must be maintained in the clinical record of each resident.
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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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