San Gabriel Conv Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 8035 E Hill Drive, Rosemead, California 91770
- CMS Provider Number
- 055181
- Inspections on file
- 27
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at San Gabriel Conv Center during CMS and state inspections, most recent first.
A resident with a history of respiratory failure and COPD, identified as full code, was found unresponsive and not breathing. Facility staff did not promptly activate the emergency response system, delayed calling 911, and failed to perform effective CPR according to policy and professional standards. Instead of chest compressions and rescue breaths, staff performed a chest rub, and there was confusion about emergency procedures. When EMS arrived, the resident was found deceased, with no evidence of effective life-sustaining measures having been provided.
The facility did not ensure that documentation regarding advance directives and POLST forms was accurate and consistent for two residents. In both cases, the information on the POLST forms did not match the Advance Directive Acknowledgment forms, and the Social Services Director confirmed these discrepancies. This failure resulted in unclear records about the residents' wishes for life-sustaining treatment.
The facility did not adequately protect resident privacy when baby monitors used for safety were left on and visible in public or semi-public areas, such as on medication carts and unattended nursing station desks. This allowed unauthorized individuals to view live video feeds of residents, including those with dementia and impaired cognition, contrary to facility policy and privacy expectations.
Surveyors found that three residents receiving oxygen therapy did not receive care in accordance with facility policy and physician orders. Oxygen tubing was observed on the floor and not dated, and staff failed to monitor, assess, and document abnormal vital signs for a resident with acute respiratory failure. There was also a delay in activating the emergency response system and calling 911 when a resident was found unresponsive, and another resident's oxygen equipment was not properly stored or labeled. These deficiencies resulted in one resident being found dead upon EMS arrival.
The facility did not ensure that outdoor refuse containers were closed with tight-fitting lids and kept covered, as required by policy. Multiple containers were overfilled and could not be closed, with staff unaware of container ownership and sharing containers with a neighboring facility, leading to persistent overflow and noncompliance with refuse management procedures.
A resident with multiple chronic conditions developed new swelling, redness, and warmth in the left elbow, but nursing staff did not notify the physician as required by facility policy. Despite observations and assessments by the treatment nurse and LVN, there was no documentation of physician notification or new treatment orders for the condition.
A resident with dementia and psychosis was prescribed quetiapine, but the facility failed to consistently document the specific behaviors justifying its use and did not perform a required gradual dose reduction (GDR) despite a pharmacist's recommendation. Documentation was inconsistent across the care plan, physician orders, and medication records, and there was no evidence of physician follow-up or clinical rationale for not attempting a GDR.
A resident with anxiety and hypothyroidism, who lacked decision-making capacity, did not have their required quarterly MDS assessment completed and submitted to CMS within the mandated timeframe. The MDS was completed and transmitted nearly two months late, as confirmed by facility staff and records, resulting in a failure to provide timely and accurate resident information.
Two residents did not have comprehensive, person-centered care plans addressing their specific communication and sensory needs. One resident's care plan failed to include their primary language, while another's did not address severe hearing impairment or the use of hearing aids. Staff interviews and documentation confirmed these omissions, despite facility policy requiring individualized care planning.
A resident with left-sided hemiplegia and contractures did not receive physician-ordered restorative nursing treatments, including PROM exercises and application of a left AFO and hand splint, for several days. Staff were unable to explain the omission, and observations confirmed the devices were not in use as required by the care plan.
A resident with dementia, Parkinson's Disease, and a recent fall was not provided with a call light within reach or a floor mat as required by their care plan and physician's orders. Staff left the resident alone in a wheelchair without ensuring these fall prevention measures were in place, and interviews confirmed the omissions.
A resident with an indwelling catheter and complex urinary conditions did not receive consistent monitoring or documentation of intake/output and bladder distention as required by facility policy and physician orders. After the initial monitoring period, staff failed to evaluate the need for continued I&O tracking, and nursing notes lacked details on bladder assessments and specific UTI symptoms, even when abnormal findings were present. This led to missed documentation and assessment of significant changes in the resident's urinary status.
A resident with severe hearing and vision impairments did not receive appropriate social services when dissatisfaction with new hearing aids was not addressed. Despite repeated requests from the resident, responsible party, and nursing staff, the Social Service Director failed to arrange an audiology appointment with the resident's preferred provider, leaving the resident without effective hearing assistance and impacting quality of life.
A resident with dementia and psychosis was prescribed quetiapine, and the facility did not respond to a consultant pharmacist's recommendation for a gradual dosage reduction. There was no documentation of physician follow-up, psychiatric care, or a clear rationale for continued use of the medication, and the specific behaviors justifying the prescription were inconsistently documented across records.
A resident with multiple medical conditions and moderately impaired cognition was served a meal containing beef, despite a documented dislike for beef on her care plan, dietary notes, and meal ticket. Staff interviews and observations confirmed that the cook overlooked the resident's food preference, resulting in the resident being served an unwanted meal.
A resident with multiple complex medical conditions experienced a lack of complete and accurate documentation regarding abnormal vital signs and changes in condition. Nursing staff admitted to not consistently recording low or fluctuating blood pressure and oxygen saturation levels, sometimes omitting 'bad' numbers due to fear of being questioned by leadership. This resulted in an incomplete medical record that did not reflect the resident's deteriorating status prior to a fatal event, contrary to facility policy requiring thorough and objective documentation.
A resident with severe cognitive impairment and a gastrostomy was found with an enteral feeding formula bag that was not labeled with the date and time it was opened, contrary to facility policy. The LPN on duty could not confirm when the bag was started or if it was expired, and the DON confirmed that labeling is required to ensure timely formula changes.
A review of room measurements and occupancy revealed that multiple rooms housing three residents each did not meet the required 80 sq ft per resident, with each resident receiving only about 72–74 sq ft. Staff and residents reported sufficient space for care and mobility, but the facility did not comply with the minimum space standard.
A CNA was assigned double shifts despite known incompetency issues, including sleeping during shifts and failing to provide necessary care, leading to a decline in resident well-being. The facility faced staffing shortages and did not use agency staff, resulting in the CNA covering extra shifts.
Two residents with cognitive impairments and mobility issues experienced falls due to inadequate supervision and monitoring. One resident was found on the floor by a CNA who failed to follow protocol, while another fell after attempting to use a commode with a non-functioning bed alarm. Staff interviews revealed communication issues and insufficient training, contributing to the facility's failure to implement effective fall prevention measures.
The facility failed to accommodate the communication and safety needs of three residents, leading to unmet needs and potential neglect. One resident was not provided with a communication board, another had an incorrect communication board, and a third had a call light out of reach, all resulting in significant care deficiencies.
The facility failed to ensure that residents' medical records were updated with documentation that advance directives (AD) were discussed and provided to residents and/or responsible parties. This deficiency was observed in four of the five sampled residents, with missing or improperly stored AD and POLST forms, compromising the residents' rights to make informed decisions about their care and treatment.
The facility failed to complete and submit MDS assessments within the required time frame for four residents, including those with dementia, hyperlipidemia, anemia, and seizures. The delays were attributed to staff being too busy with other tasks, potentially compromising the quality of care.
The facility failed to ensure the quarterly MDS were completed and submitted to the CMS database within the required time frame for four residents. The MDS Nurse and the Director of Nursing attributed the delays to staffing issues, which led to late assessments and submissions, potentially compromising residents' quality of care and safety.
The facility failed to assist four residents with ADLs, including grooming and oral hygiene. Two residents were found with untrimmed, dirty fingernails, and another resident had poor oral hygiene with no assistance provided. Staff interviews and observations confirmed the lack of adherence to care plans and facility policies.
The facility failed to follow proper sanitation and food handling practices, including using a rusted can opener with peeling chrome plating and not properly testing the chlorine level in the dishwasher. These actions could potentially contaminate food and dinnerware used by residents.
A facility failed to meet professional standards by not applying gentle pressure to the lacrimal duct after administering eye drops to a resident with Alzheimer's and hyperlipidemia. The LVN was unaware of this requirement, which was confirmed by the DON.
The facility failed to ensure nurses were competent in maintaining correct settings on low air loss mattresses (LALM) based on residents' weights. Observations and interviews revealed inconsistent knowledge and training among staff, leading to incorrect LALM settings for multiple residents, including one with a physician order for LALM for skin maintenance.
A facility failed to ensure safe pharmaceutical services when an LVN left a medication cart unlocked before entering a resident's room. The DON confirmed that the cart should always be locked unless in use, as per facility policy, to prevent unauthorized access and potential harm.
The facility failed to follow its infection control policy for a resident with a gastrostomy tube (GT) feeding, leading to the use of a contaminated tube. CNAs found the GT feeding port on the floor and reconnected it without proper sanitation, and the RN restarted the feeding without changing the tube. The Infection Prevention Nurse and Director of Nurses confirmed that the protocol was not followed, posing an infection risk.
The facility failed to maintain a functioning call light in a resident's bathroom, leading to potential safety risks. The resident, with a history of falls and moderate cognitive impairment, was unaware of the malfunctioning call light. The issue was confirmed by a CNA and reported to the Maintenance Supervisor, who admitted to relying on staff reports for maintenance issues.
The facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 27 out of 50 rooms. Despite the deficiency, staff and residents reported that the room sizes did not affect their ability to provide or receive care safely. The facility submitted a variance request, indicating that the current room sizes did not adversely affect residents' health and safety.
The facility failed to follow its transfer policy, resulting in a resident's left shoulder fracture and hospitalization. CNAs did not use a mechanical lift or gait belt for a dependent resident, instead holding the resident's armpits to stand up from a wheelchair. The resident, with a history of sclerosis, hemiplegia, and osteoporosis, complained of pain immediately after the transfer. Interviews confirmed the correct procedures were not followed.
A resident with dementia and high fall risk sustained a hip fracture after a fall. The CNA did not report the fall to licensed nurses and moved the resident without assessment. The RN was unaware of the fall and did not conduct an immediate assessment, leading to a delay in care. The resident experienced significant pain and required hospitalization for a hip fracture.
Failure to Provide Immediate and Effective CPR to Full Code Resident
Penalty
Summary
The facility failed to provide immediate, effective, and uninterrupted basic life support (BLS) and cardiopulmonary resuscitation (CPR) to a resident who was identified as full code and found unresponsive and not breathing. Despite the resident's Physician Orders for Life Sustaining Treatment (POLST) indicating full code status, staff did not promptly activate the emergency response system (code blue), initiate the BLS sequence, or call 911 emergency services in a timely manner. There was a delay of 26 to 31 minutes from the time the resident was reported unresponsive to the time 911 was called. During this period, staff did not follow the facility's policy and procedure for CPR, which required immediate action. The staff involved, including an RN and two LVNs, did not perform effective and continuous CPR as required by professional standards and the facility's policy. Instead of performing chest compressions and rescue breaths at the recommended ratio and rate, the RN described performing a chest rub or gentle circular motion on the resident's chest, which does not meet the criteria for effective CPR. There was also no evidence that rescue breaths were provided, and the use of the crash cart and other emergency equipment was inconsistent. Interviews revealed confusion among staff regarding the resident's code status, the sequence of emergency actions, and the proper technique for CPR. The resident had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. The care plans and physician orders indicated the need for close monitoring and immediate intervention in the event of respiratory or cardiac arrest. Despite these directives, staff failed to document abnormal vital signs, did not communicate changes in the resident's condition effectively, and did not adhere to the established emergency protocols. When emergency medical services arrived, the resident was found deceased, with signs of lividity and no signs of life, indicating a significant lapse in the provision of life-sustaining treatment.
Inconsistent Documentation of Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that documentation regarding advance directives and Physician Orders for Life Sustaining Treatment (POLST) was accurate and consistent for two of five sampled residents. For one resident with chronic systolic heart failure and type 2 diabetes, the POLST indicated the presence of an advance directive, while the Advance Directive Acknowledgment form stated otherwise, and no advance directive was found in the medical chart. The Social Services Director confirmed the inconsistency and acknowledged that the information should have been clarified and updated to reflect the resident's wishes. For another resident with chronic respiratory failure and hypertensive heart disease, the POLST indicated no advance directive, but the Advance Directive Acknowledgment form stated that one existed. The Social Services Director was unable to determine which staff member completed the form and confirmed the mismatch between the documents. The facility's policy requires honoring residents' rights to formulate and have advance directives, but the inconsistent documentation failed to ensure that staff would have accurate information about residents' wishes in the event of a medical emergency.
Failure to Protect Resident Privacy with Improper Use of Monitoring Devices
Penalty
Summary
The facility failed to protect the privacy and confidentiality of three residents' personal and medical information by not restricting access to baby monitors used for resident monitoring. Observations revealed that cameras were installed in residents' rooms and the live video feeds were displayed on monitors placed in areas accessible to unauthorized personnel and passersby. For example, one resident's baby monitor was left on top of a medication cart in a public area, allowing anyone passing by to view the resident's bed, even when the resident was not present in the room. Additionally, monitors were left on at nursing stations or desks, sometimes unattended, with the display screens visible to anyone entering or passing by the area, including non-staff individuals. Staff interviews confirmed a lack of consistent understanding and adherence to privacy protocols regarding the use of monitoring devices. Some staff members were unaware of the intended use or placement of the cameras, while others admitted to leaving monitors on and in visible locations for convenience during medication passes or while away from the nursing station. The Director of Nursing acknowledged that the current practice could potentially violate residents' privacy, especially when the monitors captured and displayed images of residents who were not the intended subjects of monitoring. The facility's own policy required that monitoring devices be used solely as safety interventions, with access restricted to authorized staff and in a manner that respects residents' dignity and privacy. However, the observed practices did not align with these requirements, as monitors were left on and visible in public or semi-public areas, and sometimes displayed images of multiple residents without proper consent or notification to responsible parties.
Failure to Provide Safe and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's provision of respiratory care for three residents receiving oxygen therapy. For one resident, oxygen tubing was observed on the floor and not labeled with the date opened, contrary to facility policy, which requires tubing to be dated and kept off the floor to prevent contamination. A certified nursing assistant confirmed the tubing should not touch the floor due to infection control concerns, and the Director of Nursing stated that tubing should be changed if it comes into contact with the floor. Another resident, with a history of acute respiratory failure, pneumonia, and COPD, was not monitored or assessed according to physician orders and the care plan. The nursing staff failed to titrate oxygen as ordered for low oxygen saturation, did not consistently assess or document abnormal vital signs, and did not promptly notify the physician when the resident exhibited low and fluctuating blood pressure and oxygen saturation. Interviews revealed that abnormal blood pressure readings were sometimes omitted from documentation, and there was confusion among staff regarding the resident's code status and the appropriate emergency response. The facility's emergency response system was not activated in a timely manner, and there was a delay in calling 911 after the resident was found unresponsive with critically low oxygen saturation. Additionally, another resident's nasal cannula was not dated or stored in a clean bag when not in use, as required by facility policy. These practices placed residents at risk for infection and, in the case of the resident with acute respiratory failure, resulted in the resident being found dead upon EMS arrival. The facility's policies on oxygen administration, monitoring, and emergency response were not followed, and staff interviews confirmed lapses in documentation, assessment, and adherence to established procedures.
Outdoor Refuse Containers Not Properly Closed or Maintained
Penalty
Summary
The facility failed to ensure that five of five outdoor refuse containers were closed with tight-fitting lids and kept covered, as required by policy. Observations revealed that six outdoor refuse containers were overfilled with trash bags, preventing the lids from closing fully. One container was completely open, while the others could not be closed due to being overfilled. Housekeeping staff were unaware of which containers belonged to the facility, and it was noted that the containers were shared with a neighboring facility, contributing to the overflow. Staff from the neighboring facility also disposed of trash in these containers without clear designation of ownership. The Director of Maintenance confirmed that the containers were overfilled and could not be closed until the waste management company arrived later in the day. There were no labels or signs indicating which containers belonged to the facility, and the issue of shared containers had not been addressed. The facility's policy required all garbage and refuse containers to have tight-fitting lids and to be kept covered when not in continuous use, but this was not followed, as observed during the survey.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident who developed edema, redness, and warmth in the left elbow. The resident had a history of chronic respiratory failure with hypoxia, contractures, and heart failure, and was dependent on staff for all activities. Initial assessments and skin evaluations upon admission and readmission did not document any edema or redness in the left elbow. On a subsequent assessment, the resident was observed to have a red, swollen, and warm left elbow. The treatment nurse and LVN both noted the change but were unsure if the physician had been notified, and there were no active treatment orders for the condition. Review of the resident's records, including physician orders and nursing progress notes, revealed no documentation that the physician had been informed about the new onset of edema or that any interventions had been initiated. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for licensed nurses to thoroughly assess residents and promptly report changes in condition to the physician. The facility's policy and procedure required immediate notification of the physician for changes such as swelling or discoloration. However, there was no evidence that this protocol was followed in the case of the resident's left elbow edema.
Failure to Define Behaviors and Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to properly identify and define specific problematic behaviors related to the use of quetiapine, an antipsychotic medication, for a resident diagnosed with dementia and psychosis. Documentation across the resident's physician orders, care plan, informed consent, and medication administration record was inconsistent, with different descriptions of the behaviors justifying the use of quetiapine. This inconsistency made it unclear why the medication was being used and whether its continued use was necessary for the resident. Additionally, the facility did not perform a required gradual dose reduction (GDR) for the resident's quetiapine therapy. Although the consultant pharmacist recommended a GDR, there was no evidence that the physician considered or responded to this recommendation, nor was there documentation of any clinical rationale for not attempting a GDR. The resident's dose of quetiapine remained unchanged since its initial prescription, and there was no record of psychiatric care or evaluation regarding the ongoing need for the medication. The facility's own policy requires that psychotropic medications be used only for specific, documented behaviors and that GDRs be attempted regularly unless clinically contraindicated. Despite this, the facility did not ensure that the use of quetiapine for this resident was clearly justified or that efforts were made to reduce the dosage as required. The Director of Nursing acknowledged these failures, noting the lack of clear documentation and follow-up regarding the use and monitoring of psychotropic medication for the resident.
Failure to Complete and Submit Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment was updated and submitted to CMS at least once every three months as required. Specifically, a resident who had been readmitted with diagnoses including anxiety and hypothyroidism did not have their quarterly Minimum Data Set (MDS) assessment completed and transmitted within the mandated timeframe. The MDS coordinator confirmed that the quarterly MDS was due but was not completed and transmitted until nearly two months after the target date. The delay was identified during a review of the resident's electronic health records and confirmed by the facility's CMS submission report. The resident in question had a history and physical indicating a lack of capacity to make decisions. Despite this, the required quarterly MDS assessment was not completed and submitted on time, as confirmed by both the MDS coordinator and the DON. The facility's own policy requires comprehensive assessments at intervals designated by OBRA and PPS requirements, but this was not followed in this instance, resulting in a failure to provide CMS with timely and accurate resident information for quality care measure and tracking purposes.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to communication and sensory needs. For one resident with dementia and diabetes, whose primary language was Korean, the care plan did not address the resident's language barrier. Multiple assessments and interviews confirmed that the resident required or preferred communication in Korean and needed an interpreter for interactions with healthcare staff. Observations showed the resident did not respond to English but did respond to Korean, and both nursing staff and family confirmed the importance of addressing the language barrier in the care plan. Despite this, the care plan lacked any mention of the resident's language needs. For another resident with end-stage renal disease, legal blindness, and bilateral lower limb amputations, the care plan did not address the resident's severe hearing impairment or the use of hearing aids (HA). Documentation and staff interviews confirmed the resident was hard of hearing and required HAs, but the care plan did not include interventions or monitoring related to hearing loss or HA use. The resident reported issues with the provided HA, including discomfort from background noise, and had requested follow-up appointments and updates, which had not been addressed. Staff interviews further revealed that the absence of a care plan for hearing impairment was an oversight, and that such a plan should have been developed. Facility policy required that comprehensive, person-centered care plans be developed within a specified timeframe after assessment, including measurable objectives and timetables to meet each resident's needs. The policy also emphasized the importance of culturally competent care and interdisciplinary team involvement. In both cases, the facility did not follow its own policies and procedures, resulting in the failure to address significant communication and sensory needs in the care plans for these residents.
Failure to Provide Ordered Restorative Nursing Treatments
Penalty
Summary
The facility failed to provide restorative nursing treatment as ordered for one resident with a history of left-sided hemiplegia, left hand contracture, and left ankle contracture. Physician orders and the resident's care plan required daily passive range of motion (PROM) exercises and the application of a left ankle-foot orthosis (AFO) and a left resting hand splint for four hours each day. Documentation and interviews revealed that from 5/16/2025 to 5/22/2025, the resident did not receive the ordered application of the left AFO, and from 5/20/2025 to 5/22/2025, the left resting hand splint was also not applied as required. Observations confirmed that the resident was not wearing the prescribed splint or AFO during multiple visits, and both the restorative nursing assistant and certified nursing assistant were unable to explain why the devices were not applied. The resident reported not having the devices on for several days, despite usually wearing them. The Director of Physical Therapy emphasized the importance of following physician orders to prevent further decline in range of motion and foot drop. Facility policy required restorative nursing care to be provided as outlined in the resident's plan of care, which was not followed in this instance.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment for a resident with dementia, Parkinson's Disease, diabetes mellitus, and a recent history of falls. The resident was identified as high risk for falls and was enrolled in the facility's Falling Star/Super Star Program, which required specific interventions such as keeping the call light within reach and placing a floor mat next to the bed as per physician's orders. Despite these documented interventions, staff did not ensure the call light was accessible when the resident was left alone in the room in a wheelchair, and a floor mat was not placed after the room was deep cleaned, contrary to the physician's order and care plan. Observations and interviews confirmed that the call light was not within the resident's reach and that the required floor mat was missing. Staff members acknowledged these omissions, and the Director of Nursing confirmed that staff were responsible for implementing fall precaution interventions, including those not followed in this instance. Facility policy also required these interventions for residents at high risk for falls, but they were not consistently implemented for this resident.
Failure to Monitor and Document Catheter Care and Urinary Output
Penalty
Summary
The facility failed to provide necessary care and services to a resident with an indwelling catheter by not following its own policies and physician orders regarding monitoring and documentation. Specifically, after the initial 30-day period of intake and output (I&O) monitoring, there was no evaluation or documentation to determine if continued I&O monitoring was needed, as required by facility policy. Additionally, the nursing staff did not consistently monitor or document findings related to bladder distention, despite this being indicated in the resident's care plan and physician orders. The resident in question had a complex medical history, including urinary tract infection (UTI), obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, and chronic respiratory failure. The care plan identified the resident as being at risk for alteration in urinary elimination and UTI due to the use of an indwelling catheter. Interventions included monitoring urine characteristics and output, observing for bladder distention, and notifying the physician of any changes. However, after the initial 30 days, there was no record of continued I&O monitoring, and staff interviews revealed that urine output was not measured or reported unless specifically done by CNAs and communicated to nurses. Documentation was also lacking regarding the assessment of bladder distention and specific signs and symptoms of UTI, even when such symptoms were present. For example, on two occasions, the presence of UTI symptoms was noted in the treatment administration record, but no specific symptoms or bladder assessments were documented in the nursing notes. The resident later experienced gross hematuria and required catheter replacement and hospitalization. Staff interviews confirmed that required assessments and documentation were not consistently performed as ordered.
Failure to Provide Medically-Related Social Services for Hearing-Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services for a resident who was hard of hearing and dissatisfied with the provided hearing aids. The resident, who also had end stage renal disease, legal blindness, and bilateral lower limb amputations, was documented as having significant hearing and vision impairments but was cognitively intact. Despite a physician order for an audiology consult as needed for hearing problems, and repeated requests from the resident, responsible party, and nursing staff, the Social Service Director (SSD) did not arrange an appointment with the resident's preferred audiologist (Provider 1) after the resident expressed dissatisfaction with the new hearing aids due to disturbing background noise. Documentation showed that the resident received new hearing aids and initially reported satisfaction, but soon after reported issues with background noise and requested to return the aids and see his previous audiologist. Multiple progress notes and interviews confirmed that the resident, his responsible party, and nursing staff repeatedly asked the SSD for updates and assistance in scheduling an audiology appointment. The SSD acknowledged receiving these requests but did not follow through, citing difficulty contacting the provider and ultimately not making the appointment or providing updates. Observations confirmed that the resident was not using the hearing aids and required staff to raise their voices to communicate. The facility's policies and job descriptions required the SSD to assist with medically-related social services, including arranging for needed services and facilitating communication needs. However, there was no documented evidence that the SSD clarified provider contact information or made the necessary referral, resulting in the resident remaining hearing impaired and negatively impacting his quality of life.
Failure to Respond to Pharmacist's GDR Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation for a gradual dosage reduction (GDR) of quetiapine for a resident diagnosed with dementia and psychosis. The pharmacist made the recommendation on 2/5/25, and although the facility left a message with the psychiatrist on 2/9/25, there was no documented response from the physician or evidence of further follow-up. The resident's clinical record did not contain documentation of psychiatric care or any indication that a physician considered the GDR request, approved a lower dose, or provided a resident-specific clinical rationale for not attempting a GDR. Additionally, the facility did not clearly identify or document the specific behavioral issues related to the resident's use of quetiapine. The problematic behaviors listed in the physician's order and informed consent documentation differed from those in the care plan and medication administration record, making the rationale for continued use of quetiapine unclear. The Director of Nursing confirmed that a GDR was not performed and that there was no documentation to indicate that a GDR attempt was clinically contraindicated, as required by facility policy.
Failure to Honor Resident Food Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preference. The resident, who had diagnoses including hypertension, anemia, osteoarthritis, dementia, and muscle weakness, was admitted and assessed as having moderately impaired cognition and requiring assistance with eating. The resident's care plan and dietary notes specifically indicated a dislike for beef, and the meal ticket on the lunch tray also reflected this preference. Despite these clear indications, the resident was served beef chop suey for lunch, as observed by staff and confirmed by the resident, who stated she did not like beef. Interviews with the restorative nursing assistant, dietary supervisor, and cook revealed that the cook overlooked the meal ticket and served beef to the resident. Both the dietary supervisor and the restorative nursing assistant acknowledged that the resident's food preference should have been honored and that alternative protein options were available. Facility policy and procedure documents reviewed also confirmed the requirement to honor resident food preferences and ensure meal tickets accurately reflect these preferences.
Failure to Accurately Document Resident's Change of Condition and Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurate documentation of all services provided to a resident, as well as progress toward care plan goals and changes in the resident's medical, physical, functional, or psychological condition. The resident in question had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, COPD with exacerbation, chronic kidney disease, dementia, and other comorbidities. The care plan required close monitoring of oxygen saturation, prompt notification of the physician for significant changes, and documentation of all relevant assessments and interventions. Despite these requirements, there was a lack of documented evidence regarding abnormal vital signs, specifically low and fluctuating blood pressure readings and oxygen saturation levels below 90%. Multiple nurses admitted during interviews that they did not consistently document abnormal findings, with some stating they only recorded 'good' numbers or did not document unless a significant event occurred. One nurse reported that she would be questioned by facility leadership if she documented 'bad' numbers. There was also a lack of documentation regarding the resident's change of condition prior to the emergency event, and the physician was not clearly notified of the resident's unstable status. The deficiency resulted in an inaccurate depiction of the resident's care and health status, as critical information about the resident's deteriorating condition was omitted from the medical record. The facility's own policies required objective, complete, and accurate documentation of all changes in condition and interventions, but these were not followed. The lack of documentation was confirmed by both record review and staff interviews, and the resident ultimately experienced a severe event leading to death, with emergency responders noting the resident was dead on arrival and had signs of having been deceased for some time.
Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that the enteral tube feeding formula bag for one resident was labeled with the date and time it was opened and hung, as required by the facility's policy and procedure for enteral feeding monitoring. During observation, an opened bag of Fibersource formula was found hanging from an IV pole next to the resident's bed, with the feeding tubing placed inside the feeding pump and ready for infusion. There was no open date indicated on the formula bag, and the licensed vocational nurse present was unable to state when the bag was opened or if it was expired. The nurse confirmed that the bag should have been labeled with the date and time, and acknowledged not knowing when the current bag was started. The resident involved had a history of dementia and gastrostomy, with severe cognitive impairment and dependence on staff for all activities of daily living. The physician's orders specified the administration of tube feeding at a set rate and schedule. The facility's policy required licensed nurses to write the time, date, and rate on the formula bottle, and to discard closed system formula after 48 hours. The lack of labeling on the formula bag meant staff could not determine if the formula was still safe for use, which was confirmed by both the nurse and the Director of Nursing during interviews.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident for multiple occupancy rooms, as determined through observation, interviews, and record review. Specifically, 27 out of 50 sampled rooms were found to be occupied by three residents each, with total room sizes ranging from 217 to 223.24 square feet, resulting in each resident having less than the required 80 square feet of personal space. The Client Accommodations Analysis form confirmed these measurements, and the rooms in question provided between 72.33 and 74.41 square feet per resident. Despite the deficiency in room size, interviews with staff and residents indicated that they felt there was enough space to perform necessary care tasks, use mobility aids, and maintain privacy. Observations during the survey period also noted that the rooms allowed for adequate movement, nursing care, and use of equipment. However, the facility did not meet the regulatory requirement for minimum room size per resident in the identified rooms.
Incompetent CNA Assigned Double Shifts Despite Warnings
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) demonstrated the necessary competency skills to care for residents as indicated in their care plans. CNA 1 was assigned to work double shifts despite the facility being aware of her incompetency, which included sleeping during work hours, taking longer breaks than scheduled, leaving work without notifying anyone, and failing to change or reposition residents who were found soiled. These actions resulted in residents not receiving the quality of care necessary to achieve their highest potential, leading to a decline in their well-being. The report details that CNA 1 had received written warnings for her performance issues, which were reported by both a Registered Nurse Supervisor and a charge nurse. Despite these warnings, CNA 1 continued to work multiple shifts to cover staffing shortages, as confirmed by the Director of Staff Development (DSD). The DSD acknowledged the staffing shortages and the facility's decision not to use agency staff, which led to CNA 1 working extra shifts. The facility's policy requires sufficient and competent nursing staff, but the DSD did not respond when asked if staff with poor performance warnings were allowed to continue working with residents.
Inadequate Supervision and Monitoring Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 1 and Resident 3, were free from accident hazards and provided with adequate supervision to prevent falls. Resident 1, who was admitted with dementia, difficulty walking, and osteoarthritis, was found on the floor by a CNA who did not follow protocol by calling a nurse before assisting the resident back to bed. The resident's care plan indicated a high risk for falls due to cognitive impairment and unsteady gait, yet the CNA was not informed of the resident's fall risk or the necessary interventions to prevent falls. Resident 3, who had severe cognitive impairment and was dependent on assistance for mobility, was found on the floor with injuries after attempting to use a commode that had been moved away from the bed. The bed alarm, which was supposed to alert staff when the resident attempted to get up, was not functioning. The CNA responsible for Resident 3 admitted to leaving the room and later finding the resident on the floor, indicating a lack of proper supervision and monitoring. Interviews with staff revealed communication breakdowns and inadequate training, as CNAs were not fully aware of residents' fall risks or the interventions required to prevent accidents. The facility's policies on fall risk assessment and accident prevention were not effectively implemented, leading to repeated falls and injuries for the residents involved.
Failure to Accommodate Resident Communication and Safety Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents, leading to significant communication barriers and unmet needs. Resident 88, who has severe cognitive impairment and does not speak the dominant language, was not provided with a communication board. This resulted in the resident being unable to effectively communicate her needs, such as requesting food, which was not understood by the staff. The CNA was unaware of the resident's needs due to the absence of the communication board, leading to unmet needs and potential neglect of care. Resident 98, who also has cognitive impairments and prefers to communicate in his native language, was not provided with a communication board in his preferred language. This led to misunderstandings and refusals of oral care, as the resident did not understand the staff's requests. The CNA used an incorrect communication board, which further confused the resident and resulted in the resident not receiving necessary oral hygiene care. The DON acknowledged that the correct communication board should have been used to ensure the resident's needs were met. Resident 7, who has severe cognitive impairment and is at risk for falls, was found with the call light out of reach. This deficiency could prevent the resident from calling for assistance, especially in emergencies. The CNA and ADM both confirmed that the call light should always be within the resident's reach to ensure safety and timely assistance. The facility's policy also mandates that call lights be accessible to residents at all times, highlighting a failure to adhere to established protocols.
Failure to Maintain Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to indicate documentation that advance directives (AD) were discussed and written information was provided to the residents and/or responsible parties. This deficiency was observed in four of the five sampled residents. For instance, Resident 7's clinical chart lacked a signed Advance Directive Acknowledgement (ADA) form, which was instead stored in an overflow chart, making it inaccessible during emergencies. Similarly, Resident 113's clinical chart did not contain an ADA form, and there was no evidence that the resident or their responsible party was informed about their right to formulate an AD. Resident 107's chart also lacked an ADA form, and it was unclear if the resident or their responsible party was informed about their rights regarding ADs. Additionally, the facility failed to ensure that AD and Physician Orders for Life-Sustaining Treatment (POLST) were current and part of Resident 39's clinical records. Resident 39 had an AD and POLST, but these documents were not present in the resident's chart at the time of review. The Social Service Director acknowledged that the AD and POLST should have been in the resident's chart and that the resident's History and Physical (H&P) needed to be updated to reflect the presence of these documents. The absence of these critical documents in the clinical chart could lead to inaccurate care and treatment, especially during emergencies. The facility's policy and procedure titled
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Sets (MDS) were completed within the required time frame for four sampled residents. Resident 70, who was admitted with dementia and hyperlipidemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/8/24 and submitted on 5/16/24. The MDS Nurse (MDSN) admitted that the assessment was late due to being occupied with other tasks. Similarly, Resident 54, admitted with hyperlipidemia and anemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/10/24 and submitted on 5/16/24. The MDSN acknowledged the delay and cited the same reason for the late submission. Resident 4, who was admitted with dementia and anemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/14/24 and submitted on 5/16/24. The MDSN again admitted that the assessment was late due to other tasks. Resident 100, admitted with seizure and anemia, had an MDS target date of 4/1/24, but the assessment was completed on 5/14/24 and submitted on 5/16/24. The MDSN stated that the assessment was completed late due to being too busy with other tasks. During interviews, the MDSN and the Director of Nursing (DON) both acknowledged that the late assessments could result in delayed treatment and compromised quality of care. The DON emphasized the importance of timely assessments to ensure consistent and quality care for residents. The facility's failure to complete and submit the MDS assessments on time was attributed to staff being too busy with other tasks, which could negatively affect the provision of necessary care and services for the residents.
Failure to Timely Complete and Submit Quarterly MDS
Penalty
Summary
The facility failed to ensure the quarterly Minimum Data Sets (MDS) were completed and submitted to the CMS database within the required time frame for four sampled residents. Resident 70, diagnosed with dementia and hyperlipidemia, had an MDS target date of 1/4/24, but the assessment was completed on 3/28/24 and submitted on 4/3/24. Similarly, Resident 54, with hyperlipidemia and anemia, had an MDS target date of 1/4/24, but the assessment was completed on 3/29/24 and submitted on 4/3/24. Resident 4, diagnosed with dementia and anemia, had an MDS target date of 1/11/24, but the assessment was completed on 3/29/24 and submitted on 4/3/24. Lastly, Resident 100, with seizures and anemia, had an MDS target date of 1/2/24, but the assessment was completed on 2/19/24 and submitted on 5/16/24. All these assessments were completed and submitted late, beyond the 14-day requirement from the assessment reference date (ARD). The MDS Nurse (MDSN) acknowledged the delays and attributed them to staffing issues, which led to the MDSN and the MDS Coordinator being pulled to perform other tasks in the facility, resulting in the late completion and submission of the assessments. During interviews, the MDSN and the Director of Nursing (DON) confirmed that the late assessments could result in delayed treatment, potentially compromising residents' quality of care and safety, especially for those with major condition changes. The DON stated that the facility had staffing issues that affected the timely completion of the MDS and that extra staff was utilized to help catch up with MDS completion. The DON emphasized the importance of timely assessments to ensure consistent and quality care for the residents. The CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicates that the quarterly MDS must be completed no later than 14 calendar days from the ARD and transmitted no later than 14 days from the MDS completion date. The facility's failure to adhere to these guidelines resulted in the late completion and submission of the MDS for the four sampled residents, potentially affecting their care and treatment.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist four of five sampled residents with activities of daily living (ADL), specifically in maintaining good grooming and personal and oral hygiene. Resident 19 and Resident 87, both with severe cognitive impairments and physical contractures, were observed with untrimmed and dirty fingernails. Despite care plans indicating the need for assistance with grooming, including nail trimming, these tasks were not performed by the assigned CNAs. The Director of Nursing (DON) confirmed that nail care is a CNA duty and should be done on bath days and as necessary, as per the facility's policy on nail care. Resident 98, who has moderate cognitive impairment and requires partial assistance for oral hygiene, was found to have poor oral hygiene with red gums, food stuck to the teeth, and no oral care kit available. The resident reported never having received assistance with teeth cleaning since admission. Observations and interviews with staff confirmed that oral care was not consistently provided, despite care plan interventions requiring dental/oral care twice a day. The DON acknowledged that CNAs are expected to provide oral care as part of their daily tasks and should report any issues to the Charge Nurse. The facility's failure to provide necessary grooming and oral hygiene assistance as outlined in the residents' care plans resulted in poor hygiene and discomfort for the residents. The lack of adherence to the facility's policies on nail care and oral hygiene was evident, as confirmed by staff interviews and observations. This deficiency had the potential to negatively impact the residents' quality of life and self-esteem, as well as pose health risks such as infections and dental issues.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation, preparation, and food handling practices, which could prevent the outbreak of foodborne illness. During a kitchen observation, a heavily rusted can opener with peeling chrome plating was found on top of a three-compartment sink. The can opener was used by a kitchen cook to open canned food that morning. The Certified Dietary Manager acknowledged the need to replace the can opener due to its deteriorated condition, which could potentially contaminate the food. The facility's policy indicated that equipment should be kept in proper working condition and any unsafe items should be reported immediately, which was not adhered to in this case. Additionally, during an observation of the dishwashing process, a dietary assistant failed to properly test the chlorine level in the dishwasher. The assistant did not compare the color of the test strip to the color chart in the test strip container, relying instead on memory and experience. The facility's policy and the manufacturer's guidelines required the chlorine level to be between 50-100 PPM, and a chlorine log to be maintained. This failure to follow proper procedures could result in inadequate disinfection of dinnerware used by residents.
Failure to Apply Pressure to Lacrimal Duct During Eye Drop Administration
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 27 by not applying gentle pressure to the lacrimal duct after administering Carboxymethylcellulose sodium ophthalmic solution. This practice is necessary to prevent systemic absorption of the medication. During a medication pass observation, an LVN administered the eye drops without applying the required pressure to the lacrimal duct, despite following other standard procedures such as washing hands, donning gloves, and documenting the administration on the MAR. The LVN admitted to being unaware of the need to apply pressure to the lacrimal duct and only realized the correct procedure after searching for information online during the interview with the surveyor. Resident 27, who has diagnoses including Alzheimer's disease and hyperlipidemia, was admitted to the facility with severely impaired cognitive skills and required moderate assistance with daily activities. The resident's physician had ordered the administration of Carboxymethylcellulose sodium ophthalmic solution four times a day for dry eyes. The Director of Nursing confirmed that the LVN should have applied gentle pressure to the lacrimal duct to prevent the medication from draining away from the eye, as per the instructions on the product package.
Inadequate Training on Low Air Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that nurses were competent in maintaining the correct settings on low air loss mattresses (LALM) based on residents' weights. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident 35, who had a physician order for an LALM for skin maintenance, was observed with incorrect LALM settings on multiple occasions. The Minimum Data Set Nurse (MDSN) found that the LALM settings for at least four residents, including Resident 35, were incorrect during his rounds. Despite the MDSN adjusting the settings, subsequent observations showed that Resident 35's LALM was still set incorrectly. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and the Director of Staff Development (DSD), revealed a lack of consistent knowledge and training regarding the correct settings for LALMs. LVN 3 and LVN 4 admitted to either not knowing how to set the LALM or not recalling any training on the matter. The DSD and the Treatment Nurse (TN) provided conflicting information on whether the LALM should be set to the lower or upper limit based on the resident's weight. This inconsistency in understanding and practice among the staff contributed to the incorrect settings observed. The Quality Assurance Consultant (QAC) and the Director of Nurses (DON) acknowledged that the facility had recently changed the LALM company, and the new devices had different settings from the previous ones. The QAC confirmed that the product's manual did not specify how to adjust the settings, leading to confusion among the staff. The DON admitted that proper guidance and in-service training should have been provided before the new products were rolled out to ensure all staff were aware of the correct guidelines. This lack of training and clear instructions resulted in the improper use of LALMs, potentially compromising the residents' skin integrity and overall well-being.
Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services when one of seven medication carts was left unlocked before a Licensed Vocational Nurse (LVN) entered a resident's room to administer medications. During a medication pass observation, the LVN did not lock the medication cart, which was left unattended in the hallway with two staff members standing nearby and a resident walking past the unlocked cart. The LVN admitted to forgetting to lock the cart and acknowledged the importance of keeping it locked for resident safety. The Director of Nursing (DON) confirmed that the medication cart should always be locked unless in use to prevent unauthorized access. A review of the facility's policy and procedure indicated that medication carts must be kept closed, locked, and secure during medication administration. The failure to lock the medication cart posed a risk of unauthorized access to medications, which could lead to serious harm if ingested by residents.
Failure to Implement Infection Control Policy for Enteral Feedings
Penalty
Summary
The facility failed to implement its infection control policy and procedure for enteral feedings for Resident 6, who was found with a gastrostomy tube (GT) feeding on the floor. Resident 6, who has a history of hypertensive heart disease with heart failure, muscle weakness, and dementia, was observed with the GT feeding tube on the floor, uncovered, and attached to a feeding pump machine that was off. The resident's care plan indicated a risk for infection and required the tubing to be changed per policy or as ordered, and the equipment to be cleaned and disinfected as indicated. Certified Nurse Assistants (CNAs) 3 and 5 were observed assisting Resident 6 and found the GT feeding port on the floor. CNA 5 picked up the uncovered port and reconnected it to Resident 6's GT port, then covered it with a towel. Registered Nurse (RN) 2 was later informed by CNA 3 about the situation and restarted the GT feeding without changing the contaminated tube. RN 2 admitted to not knowing the tube had been on the floor and continued using the same tube. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nurses (DON) revealed that the proper protocol was not followed. The IPN stated that the entire GT feeding system should have been changed if it touched the floor, as it would be considered contaminated. The DON confirmed that the CNA should have notified the Charge Nurse immediately to have the tube feeding system changed to prevent infection risk. The facility's policy on enteral feedings and infection control emphasized maintaining aseptic technique and changing administration sets if contaminated.
Non-Functional Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to provide and maintain a functioning call light in the bathroom for one of the sampled residents, Resident 103. During a tour, it was observed that the call light in Resident 103's bathroom was not functioning due to a rusted and loose metal switch. Resident 103, who has a history of falls and type 2 diabetes mellitus, was unaware of the malfunctioning call light and expressed feeling unsafe using the bathroom without it. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for partial assistance with toileting hygiene and other activities of daily living. Certified Nursing Assistant 1 confirmed the call light issue and reported it to the Maintenance Supervisor, who admitted to performing monthly checks but relied on nursing staff to report problems. The Administrator acknowledged the importance of functional call lights for resident safety and indicated that the Maintenance Supervisor was responsible for ensuring their functionality. The facility's policy emphasized maintaining essential equipment in safe operating condition, but this was not adhered to in this instance.
Deficiency in Resident Room Sizes
Penalty
Summary
The facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 27 out of 50 rooms. Specifically, rooms 101 to 110, 201, and 203 to 218 had three occupied resident beds in each room with a total square footage of 216, providing each resident only 72 square feet of space. This deficiency was identified during a concurrent interview and record review with the Administrator, who confirmed the room sizes did not meet the required standards. Despite this, staff and residents interviewed did not express concerns about the room sizes affecting their ability to provide or receive care safely. During observations and interviews, staff members, including a Licensed Vocational Nurse and a Certified Nursing Assistant, indicated that while the room sizes were tight, they were still able to perform their tasks effectively and safely. Residents also reported having enough space to move around and did not express concerns about the room sizes. The facility had submitted a variance request, indicating that the current room sizes did not adversely affect residents' health and safety or impede their ability to achieve their highest level of well-being.
Failure to Follow Transfer Policy Results in Resident Injury
Penalty
Summary
The facility failed to follow its policy and procedure on Resident lifting/Assisting Transfer Policy for a dependent resident, resulting in a left shoulder fracture and hospitalization. Certified Nurse Assistants (CNAs) 1 and 2 did not use the mechanical lift transfer for a resident who was totally dependent on staff for transfers. Instead, they held the resident's armpits to stand up from the wheelchair, which led to the injury. The resident had a history of sclerosis, hemiplegia, osteoporosis, and a left-hand contracture, making them particularly vulnerable to fractures. The incident occurred when the CNAs were changing the resident's diaper, and the resident complained of pain immediately after being returned to the wheelchair. Interviews with the Occupational Therapist and the Director of Staff Development confirmed that the appropriate procedure for transferring dependent residents involved using a mechanical lift or a gait belt, neither of which were used in this case. The facility's policy also mandated the use of transfer belts or appropriate lifting devices for resident transfers. The resident's family confirmed that the resident was still hospitalized and experiencing pain from the shoulder fracture. The facility's policy and procedure documents were reviewed and indicated the requirement for mechanical lifts or transfer belts for resident transfers, which were not adhered to by the CNAs involved.
Failure to Follow Fall Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that Resident 1 was free from injury after sustaining a fall. Certified Nurse Assistant (CNA) 1 found Resident 1 on the floor by the foot of the bed but did not report this to the licensed nurses. Instead, CNA 1 transferred Resident 1 back to bed alone, without any assessment from licensed nurses. This action was against the facility's fall protocol, which requires immediate reporting and assessment by licensed nurses to prevent further injury. Registered Nurse (RN) 1 was not informed of the fall and did not conduct an immediate assessment, leading to a delay in care. Resident 1, who had a history of dementia and was at high risk for falls, complained of pain in the left leg and had a purplish discoloration on the right forearm the morning after the fall. The facility did not initiate the 72-hour neurological assessment until 10 hours after the fall. An x-ray conducted two days later revealed that Resident 1 had sustained an acute left femoral neck fracture, requiring surgical intervention. The delay in reporting and assessing the fall resulted in a delay in diagnosing and treating the fracture. Interviews with staff revealed that CNA 1 did not receive regular in-service training and was unaware of the proper protocol for handling falls. The Director of Nursing (DON) confirmed that the facility's fall protocol was not followed, leading to a delay in treatment. The DON stated that the licensed nurse should have immediately conducted a post-fall assessment, including a neurological check, and notified the physician to provide appropriate interventions. The failure to follow these protocols resulted in Resident 1 experiencing significant pain and requiring hospitalization for a hip fracture.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
