Rocky Point Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeport, California.
- Location
- 625 16th Street, Lakeport, California 95453
- CMS Provider Number
- 055499
- Inspections on file
- 27
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Rocky Point Care Center during CMS and state inspections, most recent first.
Nursing staff failed to follow manufacturer instructions for insulin pen administration for two residents by not maintaining the required hold time after injection, despite prior education from the pharmacy consultant and acknowledgment by the DON that this was necessary to ensure full dosing. Another resident with alcoholic cirrhosis and portal hypertension had an order for rifaximin 550 mg BID for hepatic encephalopathy prophylaxis, but MAR review showed 36 missed doses documented as "medication not available," along with seven doses incorrectly recorded as given even though the drug had not been supplied. The resident reported that his liver medication had been stopped because it was too expensive and described feeling abnormal and excessively sleepy, while chart review revealed no documentation that the MD or DON had been notified of the ongoing omission, contrary to facility policy requiring prompt provider notification of significant medication errors.
A resident with anxiety and depression, who frequently yelled for help, was repeatedly subjected to verbal abuse and threats from another cognitively intact resident with depression. On multiple occasions, the aggressor resident approached the yelling resident in her room and at the nurses’ station, yelled profanities, called her a “bitch,” and made statements such as “suffocate the bitch,” “I’m going to choke you out,” and “I’m going to slap that bitch.” Nursing staff observed the incidents, noted that the victim appeared scared and reported being afraid, and confirmed the accuracy of the documented threats. The aggressor resident later stated he went to the other resident with the intention of making her “shut up,” despite a facility abuse policy that defines and prohibits verbal abuse, including threats and derogatory language toward residents.
The facility failed to report allegations of verbal abuse within the required two-hour timeframe after one cognitively intact resident repeatedly entered another resident’s room and common areas, yelling profanities and making explicit threats to choke, slap, and harm her. Nursing staff documented the incidents in progress notes, SBAR, and the 24-hour report log and notified the DON and ADM, including via text, but the DON told a nurse that an SBAR was not needed because it was only yelling and no one was touched, and instructed that the word “abuse” not be used in documentation. The ADM acknowledged that the incident was not reported to CDPH until the following day by fax, and records show the abuse report form was faxed after multiple episodes of resident-to-resident verbal aggression and threats, contrary to facility policy requiring all alleged abuse to be reported immediately but no later than two hours.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not procure food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards, as observed by surveyors.
Surveyors found that the facility did not provide a homelike, clean, and safe environment, as evidenced by worn and stained carpeting throughout the hallways and damaged walls with exposed drywall in multiple resident rooms. Several residents confirmed the long-standing nature of the damage, and the administrator acknowledged both the wall and carpet issues, noting that the carpeting also hindered wheelchair and equipment movement.
A resident with moderately impaired cognition was physically pushed by another resident during an argument over TV channels, resulting in a fall and injuries to the forearm. The incident occurred when one resident's remote changed both TVs in the room, and no staff were present. The aggressor admitted to the action, and the facility was aware of issues with the TV system but had not addressed them.
A resident with chronic pain syndrome and a tibial fracture reported severe pain but was administered medication for moderate pain, contrary to the Physician's Order. On multiple occasions, the resident received Hydrocodone-Acetaminophen for moderate pain when severe pain was reported, and Acetaminophen for mild pain when moderate pain was reported. This discrepancy was confirmed by several staff members and the MDS Coordinator, highlighting a failure to follow the facility's pain management policy.
The facility failed to serve food that was palatable and at the correct temperature, affecting four residents. One resident with severely impaired cognition and three with intact cognition reported issues with the food being tasteless and cold. Staff confirmed these issues, and a test tray revealed food temperatures below acceptable levels. The facility lacked a policy for acceptable food temperature ranges, contrary to its policy of providing a nourishing and palatable diet.
The facility failed to label and date refrigerated food items, including vanilla extract, chocolate syrup, and sandwiches, which could compromise food safety. Staff confirmed that all food items should be labeled with open and discard dates to prevent serving spoiled food, as per facility policy.
The facility failed to label and date perishable food items brought in by family members for residents, leading to potential safety risks. Observations revealed unlabeled and undated items in the refrigerator, confirmed by the DON. Staff interviews highlighted inconsistencies in understanding the policy, which requires labeling with residents' names and dates to prevent cross-contamination and ensure safety. The facility's policy mandates discarding opened items after three days.
The facility failed to provide proper hand hygiene for residents before and after meals and did not maintain sanitary conditions for utensils and dishes. Observations showed that residents were not offered hand hygiene, and kitchen utensils were stored wet, with a plate found with dried food residue. Staff confirmed these practices violated facility policies, posing a risk of infection.
The facility failed to report abuse allegations within the required timeframe in two separate incidents. In one case, a physical altercation between two residents was reported late, and in another, a family member's report of potential abuse was delayed. Staff interviews revealed inconsistencies in understanding the reporting process, with some unaware of the two-hour requirement for cases involving injury. The facility's policy mandates immediate reporting, but both incidents were reported late.
A facility failed to provide a resident with the required SNF ABN and NOMNC before discharge. The deficiency was identified when the SNF Beneficiary Notification Review Form for the resident was found incomplete, lacking necessary documentation and explanations for the absence of these notices. The Regional Director confirmed the oversight, highlighting a lapse in the notification process.
The facility failed to complete Baseline Care Plans (BCPs) within the required 48-hour timeframe for three residents, leading to potential delays in care. Interviews revealed staff confusion about the BCP completion timeframe, with varying responses from 24 to 72 hours, despite the facility's policy requiring completion within 48 hours. This inconsistency contributed to the late completion of BCPs, potentially affecting resident safety and care.
Three residents experienced significant delays in receiving assistance after activating call lights, with waits ranging from ten minutes to an hour. These delays occurred despite the facility's policies on timely responses and repositioning to prevent skin breakdown. The residents, all with intact cognition, reported waiting for repositioning, incontinence care, and assistance with a bedside commode, potentially affecting their physical and emotional well-being.
A resident with documented dislikes for breaded food was served breaded fried chicken, contrary to his preferences. This oversight was confirmed by dietary staff and the Registered Dietician, who acknowledged the importance of adhering to residents' food preferences to prevent weight loss and malnutrition. The facility's policy requires consideration of residents' dietary preferences, which was not followed in this case.
The facility failed to maintain the kitchen floor in good repair, with the linoleum coming apart in several areas, posing infection control and safety hazards. Staff confirmed the floor's poor condition, which hindered proper cleaning and sanitation, and acknowledged the risk of tripping. The Administrator recognized the need for repairs, aligning with the facility's maintenance policy.
The facility failed to maintain a pest-free kitchen environment, as flies were observed by staff, including the Dietary Supervisor and Registered Dietitian. Staff acknowledged the health risks posed by flies, which could contaminate food and cause illness. The Administrator identified a broken Plexiglas as a potential entry point for the flies, but the facility did not provide a pest control policy when requested.
Failure to Properly Administer Insulin and Provide Ordered Rifaximin Therapy
Penalty
Summary
Licensed nurses failed to ensure residents were free from significant medication errors related to insulin administration and critical medication omissions. During a medication pass observation, one nurse administered 20 units of glargine via an insulin pen to a resident’s abdomen but removed the pen immediately after injection without maintaining the needle in place for the required duration per manufacturer instructions. In a separate observation, another nurse administered 4 units of lispro via an insulin pen to a different resident’s abdomen and withdrew the pen after only 5 seconds, despite being aware this was earlier than required. The DON acknowledged that insulin pens require a specific hold time on the skin to ensure the full dose is delivered and that this topic had been covered in a prior in‑service by the pharmacy consultant, who had instructed staff that long‑acting insulins require at least a 10‑second hold and short‑acting insulins at least 6 seconds. A third resident, admitted with alcoholic cirrhosis and portal hypertension, had a physician’s order for rifaximin 550 mg by mouth twice daily for prophylaxis of hepatic encephalopathy. Review of the MAR showed multiple entries coded as “medication not available,” with 15 missed doses in one month and an additional 14 missed doses in the following month, along with seven doses incorrectly documented as administered despite the medication not being supplied by the pharmacy since an earlier date. The resident reported that staff had stopped giving his liver medication about a month earlier because it was too expensive and stated he was receiving other liver medications that were only part of his full treatment. He also reported feeling that his ammonia level was rising and that he was feeling “weird” and falling asleep at abnormal times during the day. Further record review showed no nursing progress notes indicating that the physician or DON had been notified about the repeated unavailability and omission of rifaximin, despite the facility’s policy defining omission of an ordered drug as a medication error and requiring prompt provider notification of significant errors. The DON later confirmed that there were no notes documenting MD notification, that the seven doses marked as given on the MAR were documented in error, and that a total of 36 doses of rifaximin had been missed. The physician stated that the resident was on the maximum dose of lactulose and that there was nothing more that could be done to stop the decline without rifaximin, emphasizing the necessity of that medication.
Failure to Prevent Repeated Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when another resident repeatedly directed profanities and threats toward her. Resident 1, admitted with anxiety disorder and depression and having a BIMS score of 12 indicating moderate cognitive ability, frequently yelled for help while at the nurses’ station or in her room. Resident 2, admitted with depression and a BIMS score of 15 indicating no cognitive impairment, wheeled himself into Resident 1’s room on one occasion and yelled at her to “shut up” and not yell for help if she did not need it, then stated “suffocate the bitch.” On a later date, while Resident 1 was at the nurses’ station yelling as her baseline, Resident 2 became agitated and verbally aggressive, yelling “Shut the fuck up bitch, there is no reason to be yelling on New Year’s Eve, I’m going to choke you out. Somebody should choke you, I’m going to slap that bitch,” which staff present identified as a threat and as verbal abuse. On another documented occasion, Resident 2 again approached the nurses’ station while Resident 1 was yelling “Help me” and told her to “shut up,” stating “I don’t pay money to hear your bullshit. Tell her to shut up,” and “I’ll tell that bitch to shut up,” after which Resident 1 became quiet. Staff interviews confirmed these events, with one nurse stating Resident 1 looked scared and reported being afraid of Resident 2 after he yelled at her and threatened to choke and slap her, and another nurse confirming the accuracy of the documentation of Resident 2’s prior verbal aggression. Resident 2 acknowledged hearing Resident 1 yell for help daily and stated he went to her with the intention of making her “shut up.” These incidents occurred despite a facility policy on elder/dependent adult abuse that defines verbal abuse as the use of oral or gestured language including threats and disparaging or derogatory terms to or about residents within hearing distance, and requires protection of each resident’s rights, safety, and well-being against all forms of abuse.
Failure to Timely Report Repeated Verbal Abuse Allegations to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of verbal abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 1, who had anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive ability, was the target of repeated verbal aggression and threats from Resident 2, who had no cognitive impairment (BIMS 15). On 12/25/25, progress notes and an SBAR form documented that Resident 2, alert and oriented x4, wheeled into Resident 1’s room, yelled at her to “shut up” for calling out for help, and stated “suffocate the bitch.” The SBAR and 24-hour report log were completed by LN 2, and the DON was expected to review these daily. On 12/31/25, progress notes documented that Resident 1 was at the nurse’s station yelling when Resident 2 approached, became agitated, and verbally threatened her, saying “Shut the fuck up bitch, there is no reason to be yelling on New Year’s Eve, I’m going to choke you out. Somebody should choke you, I’m going to slap that bitch.” LN 1 intervened and notified the DON and Administrator (ADM). LN 3 later confirmed she texted the DON and ADM that Resident 2 had gotten in Resident 1’s face, screamed profanities, and made threats to choke and slap her, and that she asked what else needed to be done. According to LN 3, the DON responded that an SBAR was not needed because there was no change of condition and that the incident was “yelling and no one was touched,” despite LN 3’s statement that it was a verbal threat to harm. On 1/7/26, progress notes showed that Resident 2 again approached Resident 1 at the nurse’s station, told her to “shut up,” complained about paying money to hear her “bullshit,” and stated “I’ll tell that bitch to shut up,” after which Resident 1 became quiet. The ADM acknowledged he reported the incident that happened on 1/7/26 to CDPH but not until the following day via fax, and that no call was made to CDPH within the two-hour window. A SOC 341 form shows the verbal abuse incidents were faxed to CDPH on 1/8/26 at 4:14 p.m. The DON and ADM later confirmed they were aware of the 12/31/25 incident via text and that the initial text described Resident 2’s threats to choke and slap Resident 1. LN 2 stated the DON had called her after the 12/25/25 incident and instructed her not to use the word “abuse” in her progress notes. The facility’s policy required all alleged violations involving any type of abuse to be reported immediately, but not later than two hours, which did not occur in these events.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Homelike and Clean Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for its 57 residents. During multiple observations, carpeting throughout the hallways was found to be worn, matted with dirt, and stained in various sizes and colors, particularly at doorway entries. In several resident rooms, torn wallpaper and wall damage with exposed drywall were noted. Residents interviewed confirmed that the damage had been present for a long time and expressed dissatisfaction with the appearance of their rooms. The facility administrator acknowledged that most resident rooms had wall damage and torn wallpaper, attributing the damage to bed heads hitting the walls. The administrator also confirmed awareness of the old, stained carpeting and stated that the maintenance team was directed to clean it monthly. Additionally, the administrator recognized that the carpeting made it difficult for residents to propel their wheelchairs and for staff to move patient care equipment. The facility's own policy requires a clean, sanitary, and orderly environment to maximize a homelike setting, which was not met according to the findings.
Failure to Protect Resident from Physical Abuse During Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during an altercation over television control in their shared room. Resident 2, whose cognition was moderately intact, deliberately placed his hands on Resident 1's chest and pushed him, causing Resident 1, who had moderately impaired cognition, to fall and sustain a skin tear and abrasion on his left forearm. The incident occurred when Resident 1 changed the television channel using his remote, which also affected Resident 2's television due to the shared control system. There were no staff present in the room at the time of the incident, and the altercation was witnessed by another resident. Interviews and documentation confirmed that Resident 2 admitted to pushing Resident 1 because of the television channel change, and staff acknowledged that the TV remote system allowed one resident's remote to control multiple TVs in the room. The facility's maintenance supervisor was aware of previous complaints about the TV system, but it had remained unchanged. The facility's policy requires protection of residents from all forms of abuse, but this was not upheld in this instance, resulting in physical harm to Resident 1.
Inappropriate Pain Medication Administration
Penalty
Summary
The facility failed to ensure that nurses were following the Physician's Order for pain medication for a resident, identified as Resident 37. The nurses administered pain medication that was not appropriate for the pain level reported by the resident. Specifically, Resident 37, who had diagnoses including Chronic Pain Syndrome, Essential Hypertension, and a right Tibial fracture, reported severe pain levels on multiple occasions, yet was administered medication intended for moderate pain. This discrepancy was noted on several dates in May and June 2024, where the resident reported pain levels of 7 to 10, but received Hydrocodone-Acetaminophen intended for moderate pain levels of 4 to 6. Additionally, there were instances where Resident 37 reported moderate pain levels, yet was administered Acetaminophen intended for mild pain. This occurred on various dates in May and June 2024, where the resident's pain levels were reported between 4 and 6, but the medication given was for pain levels of 1 to 3. The failure to administer the correct medication according to the pain level reported by the resident was verified by multiple licensed staff members and the Minimum Data Set Coordinator during interviews and record reviews. The facility's policy and procedure on Pain Assessment and Management, revised in February 2024, indicated that the medication regimen should be implemented as ordered, with careful documentation of the intervention's result. However, the staff did not adhere to this policy, as evidenced by the repeated administration of inappropriate pain medication. This failure to follow the Physician's Order could result in unrelieved pain and decreased quality of life for the resident, as noted by the licensed staff and the Minimum Data Set Coordinator.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food items served to residents were palatable and at the correct temperature, affecting four sampled residents. Resident 30, with severely impaired cognition, reported that the food was tasteless and cold. Residents 6, 38, and 43, all with intact cognition, also expressed dissatisfaction with the food, describing it as unpalatable, cold, and lacking taste. Observations and interviews with staff confirmed these issues, with staff acknowledging the importance of serving food at the right temperature to prevent weight loss and malnutrition. During a test tray with the Dietary Supervisor, it was found that the temperature of the breaded fried chicken and pureed breaded fried chicken with gravy was below the acceptable range, and the spinach was bland and not at the required temperature. The Registered Dietician noted the absence of an acceptable temperature range policy for food served at meal times. The facility's policy indicated that residents should receive a nourishing, palatable, and well-balanced diet, but this was not adhered to, as evidenced by the findings.
Failure to Label and Date Refrigerated Food Items
Penalty
Summary
The facility failed to ensure that refrigerated items in the kitchen were clearly labeled, easily identified, and dated, which could compromise food safety. During an observation and interview, the Dietary Supervisor verified that several items in the refrigerator, including vanilla extract, chocolate syrup, yellow mustard, and a tub of macaroni salad, had no use-by or discard dates. Additionally, a bin containing sandwiches for lunch alternates was found without labels or dates. The Dietary Supervisor also identified unlabeled items in the freezer, such as pork ribs and crabby cakes, which had been removed from their original packaging and lacked open or discard-by dates. Interviews with various staff members, including a Dietary Aide and a Registered Dietician, confirmed that all food items in the refrigerator and freezer should be clearly labeled with open and discard dates, as per facility policy. The staff emphasized the importance of labeling to ensure the right food is served to residents and to prevent serving spoiled food, which could lead to illnesses such as Salmonella and food poisoning. A review of the facility's policy on food receiving and storage indicated that all food stored in the refrigerator or freezer should be labeled, covered, and dated, highlighting the facility's failure to adhere to its own policies.
Failure to Label and Date Perishable Food Items
Penalty
Summary
The facility failed to ensure that perishable food items brought in by family members and stored in the refrigerator for residents were properly labeled and dated. During an observation, it was noted that several food items, including ice cream, whipped topping, grapes, and nutritional drinks, were not labeled with residents' names or dates of opening and discard. The Director of Nursing (DON) confirmed these items were not labeled correctly and acknowledged that an opened bottle of ranch dressing was past its discard date. Interviews with staff members revealed inconsistencies in their understanding of the facility's policy regarding labeling and discarding perishable food items. Staff members, including unlicensed staff and the Infection Preventionist, emphasized the importance of labeling food with residents' names and dates to prevent cross-contamination and ensure food safety. The Registered Dietician also stated that food items should be discarded after three days to prevent spoilage. The facility's policy, titled "Food from Home," requires that perishable food be labeled with the resident's name and dates of receipt, opening, and discard, and that opened items be discarded after three days. The failure to adhere to this policy poses a risk of serving spoiled or incorrect food to residents.
Inadequate Hand Hygiene and Utensil Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene was offered and provided to seven sampled residents before and after meals. Observations on June 17, 2024, revealed that Residents 18, 29, 28, 10, 54, 1, and 14 were not offered or provided hand hygiene prior to or after eating their meals. Interviews with various staff members, including the Central Supply/Medical Records Assistant, Unlicensed Staff, Licensed Staff, and the Infection Preventionist, confirmed that the facility's policy was not followed, which required hand hygiene to be performed before and after meals to prevent infections. Additionally, the facility did not maintain sanitary conditions for utensils and dishes. Observations on June 17 and June 19, 2024, showed that kitchen utensils were stored while still wet, and a plate on the plate warmer had dried food residue. Staff members, including the Dietary Supervisor, Dietary Aide, and Registered Dietician, acknowledged that storing wet utensils and using unclean plates posed a health hazard and could lead to contamination and illness among residents. The facility lacked a specific infection policy and procedure for dishwashing and storing utensils. The report highlights the facility's failure to adhere to its own policies regarding hand hygiene and utensil sanitation, which are critical in preventing the spread of infections. The lack of compliance with these protocols was confirmed through staff interviews and direct observations, indicating a systemic issue in maintaining infection control standards.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations, as evidenced by two incidents involving residents. In the first incident, a physical altercation occurred between two residents, one with bipolar disorder and cerebellar ataxia, and the other with vascular dementia and Alzheimer's disease. The altercation was not reported to the California Department of Public Health (CDPH), the Ombudsman, and the local Police Department until the following day, exceeding the facility's policy requirement of reporting within two hours if there is an injury. In the second incident, a family member reported a potential abuse case involving a resident with hypertension, depression, and anxiety. The facility delayed reporting this allegation to the CDPH, the Ombudsman, and the local Police Department until the next day, again failing to meet the two-hour reporting requirement outlined in their policy. Interviews with various staff members revealed inconsistencies in their understanding of the reporting process and timeframes, with some staff believing that reporting could occur within 24 hours, while others were aware of the two-hour requirement for cases involving injury. The Director of Nursing and the Administrator confirmed that the facility's policy mandates reporting abuse allegations within two hours if there is an injury. However, both incidents were reported late, indicating a failure to adhere to the policy. The facility's policy, revised in April 2021, clearly states that all alleged violations of abuse, neglect, exploitation, or mistreatment should be reported immediately, but not later than two hours if the alleged violation involves abuse.
Failure to Provide Required Medicare Notifications Before Discharge
Penalty
Summary
The facility failed to provide necessary notifications to a resident prior to discharge, specifically the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). This deficiency was identified during a survey when the Administrator was presented with three SNF Beneficiary Notification Review Forms, one of which, pertaining to Resident 220, was incomplete. The form is intended to document the issuance of these notices or provide an explanation if they were not required. Further investigation revealed that the SNF Beneficiary Protection Notification Review for Resident 220 was not filled out correctly. The Regional Director of Operations confirmed that the necessary documentation, including the Medicare Part A skilled services episode start date and the last covered day of Part A services, was missing. Additionally, there was no documentation to explain why the SNF ABN and NOMNC were not acknowledged by the resident or their representative, indicating a lapse in the facility's notification process.
Failure to Timely Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that staff were aware of the Baseline Care Plan (BCP) completion timeframe, resulting in the late completion of BCPs for three sampled residents. Resident 54, who was admitted with diagnoses including muscle weakness, lymphedema, and dysphagia, had a BCP completed late. Similarly, Resident 60, with diagnoses of primary hypertension, type II diabetes mellitus, and muscle weakness, also had a BCP completed late. Resident 28, who had primary hypertension, muscle weakness, and hyperlipidemia, and exhibited both short-term and long-term memory impairment, experienced the same issue. These delays in completing BCPs had the potential to lead to delayed or omitted care, missed medications or treatments, medical complications, and deconditioning. Interviews with various staff members revealed inconsistencies in their understanding of the BCP completion timeframe. The Director of Nursing was unsure of the facility's policy, while other staff members provided varying timeframes ranging from 24 to 72 hours. The facility's policy, however, clearly stated that a baseline plan of care should be developed within 48 hours of admission. This lack of awareness and adherence to the policy contributed to the deficiencies observed in the timely completion of BCPs for the residents, potentially compromising their safety and care.
Delayed Response to Call Lights and Care Needs
Penalty
Summary
The facility failed to provide timely assistance to three residents, leading to unmet physical, mental, and emotional needs. Resident 2, with a BIMS score indicating intact cognition, reported waiting up to an hour for repositioning assistance after activating the call light. This delay was confirmed by her observation of a wall clock. Resident 38, also with intact cognition, experienced delays ranging from ten minutes to an hour when requesting help to use a bedside commode, although she did not have accidents, she sometimes lost the urgency for a bowel movement. Resident 51, with no cognitive impairment, reported waiting 45 minutes to an hour for incontinence care during the night shift. The facility's Director of Nursing acknowledged the expectation for prompt response to call lights, which was not met according to the facility's policies on answering call lights and repositioning. The policies emphasized timely responses to residents' needs and repositioning as a preventive measure against skin breakdown. The observed delays in responding to call lights and providing necessary care could potentially lead to adverse outcomes, such as skin breakdown and emotional distress, as residents were left in soiled conditions or in the same position for extended periods.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 117, received meals that accommodated his food preferences, specifically his dislike for breaded food items. On June 19, 2024, during lunch, Resident 117 was served breaded fried chicken despite his documented preference against breaded foods. This oversight was confirmed through observations, interviews, and record reviews. The dietary staff member responsible for plating the meal acknowledged the error and confirmed that the meal tray had already been placed in the meal cart before the mistake was realized. Interviews with the Registered Dietician, another staff member, and the Dietary Supervisor further confirmed that Resident 117's dislike for breaded food was known and documented. They emphasized the importance of adhering to residents' food preferences to prevent issues such as weight loss and malnutrition. The facility's policy on Food and Nutrition Services also mandates that residents' dietary preferences be considered to ensure their nutritional needs are met. However, in this instance, the policy was not followed, leading to the deficiency.
Kitchen Floor Disrepair Poses Infection Control and Safety Hazards
Penalty
Summary
The facility failed to maintain the kitchen floor in good repair, as observed by surveyors and confirmed through multiple interviews. The linoleum floor in various parts of the kitchen, including areas by the gas stove, the door leading to the hallway, and the sink, was coming apart with raised edges. This condition was identified as a potential infection control issue due to the difficulty in ensuring the floor was adequately cleaned and sanitized. Additionally, it posed a safety hazard as staff members reported tripping over the damaged flooring. Interviews with various staff members, including a Dietary Supervisor and a Dietary Aide, confirmed the observations. They acknowledged that the deteriorating floor condition was unacceptable for maintaining a clean and sanitary kitchen environment, which is crucial for preventing resident illness. The Administrator also recognized the need for floor repairs, citing the safety hazard it posed to staff. The facility's policy and procedure on maintenance, revised in August 2022, indicated that the Maintenance Department is responsible for keeping the building in good repair, which was not adhered to in this instance.
Presence of Flies in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the presence of flies. During an observation, both the Dietary Supervisor and the Registered Dietitian confirmed the presence of a fly in the kitchen. Further observations and interviews with staff members, including a dietary aide and another staff member, revealed that flies were seen in the kitchen from time to time, which was acknowledged as unacceptable due to the potential for contamination of food. The staff expressed concerns about the health risks associated with flies, noting that they carry germs and bacteria that could lead to residents getting sick if the flies contaminated the food. The Administrator was aware of the issue and identified a broken Plexiglas above the air conditioning unit as a possible entry point for the flies. Despite the acknowledgment of the problem, the facility did not provide a policy and procedure for pest control and management when requested. The presence of flies in the kitchen was recognized as a sanitation and infection control issue, with the potential to cause gastrointestinal illness among residents if the flies contaminated their food.
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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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