Santa Fe Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 5053 Peck Rd., El Monte, California 91732
- CMS Provider Number
- 555106
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Santa Fe Lodge during CMS and state inspections, most recent first.
A resident with dementia, impaired cognition, gait and mobility issues, and a known fall risk experienced a fall that triggered an alarm, after which an LVN found the resident on the floor with an abrasion and notified the primary nurse. Despite facility policy requiring prompt assessment, documentation of a change of condition (COC), and physician notification for injuries and falls, no post-fall assessment, COC documentation, or MD notification was found in the record. The DON and nursing staff later confirmed that a fall is considered a change of condition and that the charge nurse was responsible for completing the COC, but this was not done.
A resident with severe cognitive impairment was placed on bed and wheelchair alarms and started on Lexapro and Remeron without documented informed consent from the resident or their representative. Staff confirmed that required consents were not obtained prior to implementing these interventions, contrary to facility policy.
The facility did not ensure that executed advance directives were obtained and maintained in the medical records for three residents, despite documentation indicating that these legal documents existed. For two residents with severe cognitive impairment and one with intact cognition, the actual ADs were missing from their files, and the Social Services Assistant confirmed the documents could not be found. Facility policy required that ADs be readily retrievable, but this was not followed.
Three residents with significant medical conditions did not have weekly weights obtained or documented as required by physician orders and facility policy. Staff responsible for weighing residents lacked access to the electronic record system and relied on others to enter data, resulting in missing documentation for required weekly weights. This failure occurred despite clear orders and care plans indicating the need for close monitoring due to recent weight loss.
Surveyors found that food items in the kitchen walk-in refrigerator, including sliced cheese, a jar of pickles, and whipping cream, were not labeled with required open or received dates. Both the Certified Dietary Manager and Registered Dietitian confirmed that labeling is necessary to track food quality and freshness, and facility policy requires all items to be properly dated and labeled.
Two residents with significant medical and mental health conditions signed binding arbitration agreements that did not include a provision allowing them or their representatives to communicate with federal, state, or local officials. The Admission Coordinator confirmed the omission during interviews and record reviews.
Multiple infection control lapses were observed, including unlabeled and improperly stored personal care items in a shared restroom, a resident with severe cognitive impairment independently accessing communal drink pitchers, uncleaned dryer lint traps, soiled bed linens with suspected fecal matter, and a used cup left on a hallway handrail. Staff interviews confirmed these practices did not follow facility policy and posed risks for cross-contamination.
A resident with severe cognitive impairment and mental health conditions was left exposed while sitting in a shower chair, with privacy curtains only partially drawn and the room door open as a CNA prepared for care. This exposure was visible to others in the hallway, and both the CNA and RN Supervisor acknowledged the lapse in maintaining the resident's privacy and dignity, contrary to the care plan and facility policy.
A resident with severe cognitive impairment and multiple mental health diagnoses was observed sitting in a wheelchair with the call light secured to the bed's grab bar, out of reach. Staff confirmed the call light was not accessible, despite facility policy requiring call lights to be within reach for all residents.
A resident was readmitted with multiple diagnoses and a new order for Depakote to treat bipolar disorder, but the facility failed to update the MDS and admission records to reflect the new diagnosis. Despite documentation in physician orders and progress notes, the bipolar disorder was not included in the resident's official records, contrary to facility policy requiring current and detailed health records.
A resident with a history of traumatic subdural hemorrhage, seizures, and hypertension was admitted and had a positive PASARR Level I screening for SMI, but the facility did not complete or document the required Level II evaluation, as confirmed by interviews and record review.
A resident was readmitted with a new diagnosis of bipolar disorder, but the facility did not update the MDS or develop a care plan to address this condition. Interviews confirmed that staff were aware a care plan was needed for the new diagnosis, but it was not completed, contrary to facility policy requiring care plan updates after significant changes or hospital readmissions.
The facility did not meet the required minimum of 80 square feet per resident in multiple-occupancy rooms, as shown by facility records and room measurements. Despite a waiver request and staff reporting no issues providing care in the available space, the documented room sizes for 20 rooms were below regulatory standards.
A resident with dementia and major depressive disorder eloped from an LTC facility due to inadequate supervision. The resident left through an exit door that was not properly monitored or secured during mealtime, as staff were occupied with feeding other residents. The resident was found with a skin tear upon return. Facility policy emphasized continuous supervision to prevent such incidents, which was not followed.
The facility failed to maintain an acceptable temperature range, affecting several resident rooms, a dining room, and a hallway. The air conditioning unit malfunctioned, leading to temperatures exceeding the facility's acceptable range. The Director of Nursing acknowledged the issue, and the Maintenance Director confirmed the malfunction, stating that the HVAC technician was working on repairs. The facility's policy emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition policy after a fall experienced by Resident 1. Resident 1 had multiple diagnoses including abnormalities of gait and mobility, unspecified dementia, and a history of falling, and had been assessed as a fall risk on a Fall Risk Evaluation that directed staff to alert the physician if a fall occurred. An MDS assessment indicated Resident 1 had moderately impaired cognition and was dependent for ADLs, requiring supervision or touching assistance. Despite these identified risks, when Resident 1 fell, the required assessments and notifications were not completed. On 1/9/2026 at approximately 3 AM, LVN 2 heard an alarm from the back hallway, entered Resident 1’s room, and found Resident 1 sitting on the floor in front of the roommate’s bed. Resident 1 stated, “I do not know, I just fell.” LVN 2 noted an abrasion on Resident 1’s mid-back on the right side and notified Resident 1’s primary nurse, LVN 3, who stated LVN 2 would resume follow-up. There was no documented evidence that a post-fall assessment was completed, that the physician was notified, or that a Change of Condition (COC) form was initiated for this event, despite the facility’s policy requiring prompt handling, documentation, and physician notification for changes such as bruises, lacerations, and other injuries. During subsequent interviews and record reviews, the DON confirmed that the progress note from 1/9/2026 indicated a fall and that LVN 2, as charge nurse, was responsible for completing the COC, which was not found in the record. The DON also confirmed there was no documentation that the physician was notified or that an assessment was completed after the fall. LVN 1 and LVN 3 both acknowledged that a fall constitutes a change of condition and that it is important to assess the resident and notify the physician and family, yet LVN 3 stated they did not assess Resident 1 after the fall and relied on LVN 2 to “take care of the incident.” The facility’s Change of Condition policy required proper assessment, prompt handling, licensed nurse documentation, completion of a COC, and prompt physician notification with daily assessments, which were not carried out in this case.
Failure to Obtain Informed Consent for Alarms and Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of bed and wheelchair alarms, as well as for the administration of two anti-depressant medications, Lexapro and Remeron, for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia, and muscle weakness, was assessed as having severely impaired cognition. Despite facility policy requiring informed consent prior to the use of safety devices and psychotherapeutic medications, there was no documentation of consent being obtained from the resident or their responsible party before implementing these interventions. Observations confirmed that the resident was using bed and wheelchair pad alarms, and physician orders for both the alarms and the medications specified that informed consent should be obtained. Interviews with facility staff, including a CNA, LVN, and RN Supervisor, confirmed that the required consents were not present in the resident's records. Facility policies reviewed also indicated that informed consent must be obtained and documented prior to the use of such interventions, but this process was not followed for the resident in question.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were obtained and maintained in the medical records for three of five sampled residents. For each of these residents, documentation indicated that an AD had been executed, as shown by their Advance Healthcare Directive Acknowledgement (AHDA) forms. However, during record review, the Social Services Assistant (SSA) was unable to locate copies of the actual ADs in the residents' medical records, despite facility policy requiring that such documents be readily retrievable. Resident 14 and Resident 145 both had severe cognitive impairment and lacked capacity to make decisions, as documented in their History and Physicals and Minimum Data Sets. Their care plans referenced respecting the wishes specified in their ADs, but the actual AD documents were not present in their records. Resident 38, who had intact cognition and capacity, also had an AHDA indicating an executed AD, but the AD itself was missing from the file. In all three cases, the POLST forms on file noted that the POLST was not a substitute for an AD and should complement, not replace, the AD. The SSA confirmed responsibility for obtaining and filing ADs upon admission and acknowledged that the facility had not followed through in securing and maintaining these documents in the residents' records. Facility policy required that executed ADs be obtained and kept in a specific section of the medical record, but this was not done for the three residents in question.
Failure to Obtain and Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to obtain and document weekly weights for three residents as required by physician orders and the facility's own policy. For one resident with heart failure and dementia, the weight was not taken upon readmission or on the date specified by the physician order. The Restorative Nurse Assistant (RNA) reported weighing the resident upon return but did not have access to the electronic documentation system and provided the weight to the Infection Preventionist (IP) on paper. The IP did not enter the weight into the system and had no documentation to confirm the weight was taken. Another resident with dysphagia, hypertension, and acute kidney failure experienced significant weight loss, and a physician order was in place for weekly weights. However, the medical record showed no weights were recorded on two consecutive weeks as required. Both the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that weights were missing and acknowledged the importance of monitoring weight for residents experiencing weight loss. A third resident with multiple diagnoses, including dementia and anxiety disorder, also had a physician order for weekly weights due to recent weight loss. The care plan and nutritional assessment indicated the need for close monitoring, but the weekly weight for one of the required weeks was not documented. The RNA, responsible for weighing residents, stated that weights were sometimes taken on different days depending on workload and that the Director of Nursing (DON) was responsible for entering weights into the electronic record. The facility's policy required weekly weights for all residents for four weeks after admission or readmission, but this was not consistently followed or documented.
Failure to Label and Date Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in the kitchen's walk-in refrigerator. Specifically, a transparent container with sliced cheese was not labeled with an open date, a halfway-filled jar of hamburger pickles was not labeled with an open date, and two unopened plastics of whipping cream were not labeled with a received date. These observations were made during a walkthrough with the Certified Dietary Manager, who confirmed that food items should be labeled with open and receive dates to monitor quality and freshness. Further interview with the Registered Dietitian confirmed that all items in the refrigerator should be labeled with open and receive dates to track when food items arrived, determine when to discard them, and ensure the highest quality of food served to residents. Review of the facility's policy and procedure on Refrigerator/Freezer Storage indicated that leftover food or unused portions of packaged foods should be covered, dated, and labeled, and that all items should have appropriate delivery, open, and thaw dates. The facility's failure to follow these procedures led to the cited deficiency.
Arbitration Agreements Lacked Required Communication Provision
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included a provision allowing residents or their representatives to communicate with federal, state, or local officials. This deficiency was identified during interviews and record reviews for two residents. In both cases, the Admission Coordinator confirmed that the arbitration agreements signed by the residents' responsible parties did not contain a selection or statement affirming the right to communicate with authorities such as surveyors or the Ombudsman. One resident had a history of schizophrenia, bipolar disorder, and anxiety, while the other had chronic obstructive pulmonary disease, major depressive disorder, and psychosis, with documented intact cognition and partial assistance needs for daily activities. The omission in the arbitration agreements was acknowledged by the Admission Coordinator, who stated the importance of allowing such communication to honor residents' rights.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for six sampled residents, as evidenced by multiple observations and staff interviews. Personal toiletries and resident care items belonging to four residents were found unlabeled and improperly stored in a shared restroom, with items such as an opened cleanser, uncapped shaving cream, and a wash basin left accessible. Staff confirmed these items should have been labeled and secured in residents' closets to prevent cross-contamination, especially since some residents were ambulatory and could access items not belonging to them. Additionally, a resident with severe cognitive impairment was observed independently pouring water from a communal pitcher on a medication cart in the hallway, with no staff intervention. Staff interviews confirmed that residents should not be allowed to serve themselves from communal drink pitchers due to infection control concerns, as residents could contaminate the pitchers with dirty hands or by returning unwanted liquid. Facility policy also required measures to prevent the transmission of communicable diseases, which were not followed in this instance. Further deficiencies included a heavy accumulation of lint in two out of three dryer lint traps in the shared laundry room, contrary to the facility's schedule requiring frequent cleaning. Staff acknowledged the risk and admitted to not cleaning the lint traps as often as required. In another instance, a resident's bed sheets and room wall were observed with brown streaks suspected to be stool, and staff confirmed the resident had a history of handling feces and was unable to clean their own hands. Lastly, a used cup with leftover liquid was found on a hallway handrail, and staff stated that such items should not be left unattended as they could be used by other residents, posing an infection risk.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple mental health diagnoses was not provided adequate privacy and dignity during personal care. The resident was observed sitting in a shower chair at the bedside with the right flank and thigh exposed. The privacy curtains were only partially drawn, and the room door was propped open while a CNA was outside the room donning PPE. During this time, several male residents were walking in the hallway, making the resident's exposure visible to others. The resident's care plan specifically included interventions to maintain privacy and respect the resident's rights. Facility policy and procedures also required staff to close the room entrance door and ensure bodily privacy during personal care. Both the CNA and the RN Supervisor acknowledged that the resident's body was exposed and should have been covered for dignity and privacy. The failure to follow these protocols resulted in the resident being exposed in a manner inconsistent with facility policy and the resident's care plan.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. The resident, who had a history of unspecified dementia, psychotic and mood disturbances, and anxiety, was assessed as having severely impaired cognition and required varying levels of assistance with activities of daily living. During the observation, the resident was seated in a wheelchair in the middle of the room, facing away from the bed, while the call light was secured around the right-side grab bar of the bed, making it inaccessible to the resident. A Certified Nursing Assistant confirmed that the call light was not within the resident's reach and acknowledged that it should have been accessible in case the resident needed help. The Registered Nurse Supervisor also stated that call lights must be within reach for all residents, including those who are confused, to allow them to call for assistance. The facility's policy and procedure on call lights required staff to ensure that call lights are within reach when residents are in their rooms or on the toilet.
Failure to Update Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a required assessment following a significant change in condition for a resident who was readmitted with multiple diagnoses, including dementia and major depressive disorder. Upon review, it was found that the resident's Minimum Data Set (MDS) did not reflect a new diagnosis of bipolar disorder, despite the presence of a physician's order for Depakote to treat this condition. The MDS Coordinator confirmed that the resident's hospital records, which should have been reviewed upon readmission, indicated treatment for bipolar disorder, and that this diagnosis should have been documented in both the Admission Record and the MDS. Further review of the resident's active orders and physician progress notes confirmed ongoing treatment for bipolar disorder, yet the diagnosis was not included in the facility's official records. The facility's policy requires that health records be current and detailed, consistent with good medical and professional practice. The omission of the bipolar disorder diagnosis in the resident's records and assessment tools represented a failure to update documentation after a significant change in the resident's condition.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a required Level II Pre-Admission Screening and Resident Review (PASARR) evaluation for a resident who had a positive Level I PASARR screening for serious mental illness (SMI). The resident was initially admitted with diagnoses including traumatic subdural hemorrhage, seizures, and hypertension. The Level I PASARR screening, conducted after admission, indicated the need for a Level II evaluation, but there was no documentation that this evaluation was ever completed. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that there were no records of a Level II PASARR evaluation for the resident, despite facility policy requiring such an evaluation for residents with a positive Level I result. The facility's policy also required staff to review PASARR information regularly, follow up with the appropriate contractors, and maintain documentation, none of which was evidenced in this case.
Failure to Develop Care Plan for New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to develop a care plan addressing bipolar disorder for a resident who was readmitted following a hospital stay. The resident's admission record indicated multiple diagnoses, including dementia and major depressive disorder, and hospital records obtained during the recent hospitalization included a new diagnosis of bipolar disorder. However, the Minimum Data Set (MDS) completed after readmission did not list bipolar disorder as an active diagnosis, and no care plan was created to address this new condition. Interviews with the Minimum Data Set Coordinator (MDSC) revealed that the resident's medical record should have reflected the new bipolar disorder diagnosis and that a care plan should have been developed upon admission to ensure staff awareness and appropriate interventions. The facility's policy required the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition or upon readmission from a hospital stay, but this was not done for the resident in question.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 20 out of 23 resident rooms met the minimum required space of 80 square feet per resident in rooms with more than one occupant. Documentation from the Resident Listing Report and Client Accommodation Analysis showed that multiple rooms, each housing two residents, measured only 140 square feet, resulting in less than the required space per resident. Additionally, one room with four residents measured 308 square feet, also falling short of the standard. These findings were based on a review of facility records and room measurements. A waiver request letter from the facility stated that reasonable privacy, closet, and storage space were provided, and that there was sufficient room for nursing care and resident equipment. During an observation and interview, a CNA was able to move freely and provide care in a room with two wheelchairs present, and reported no issues with space when attending to residents. However, the documented room sizes did not meet the regulatory requirements for square footage per resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident at risk for elopement, leading to the resident leaving the facility unnoticed. The resident, who had diagnoses of dementia and major depressive disorder, was identified as having moderately impaired cognition and required supervision for daily activities. Despite these needs, the resident was able to elope from the facility without staff noticing, as staff were occupied with assisting other residents during mealtime. The incident occurred when a CNA and a Dietary Aide entered the hallway from the exit door and failed to ensure the door was closed or locked. The resident was seen on surveillance video holding the door open and subsequently leaving the facility. Interviews with staff revealed that during mealtimes, there was no one monitoring the exit door, as staff were busy feeding residents. This lack of supervision allowed the resident to leave the facility unnoticed. Upon the resident's return, it was noted that the resident had sustained a skin tear on the left arm. The facility's policy and procedure emphasized the importance of continuous supervision and redirection to prevent accidents and elopements, which was not adhered to in this case. Staff interviews confirmed that there was a lapse in monitoring and that the exit door was not properly checked, contributing to the resident's elopement.
Facility Fails to Maintain Acceptable Temperature Range
Penalty
Summary
The facility failed to maintain an acceptable temperature range as per its policy, affecting six resident rooms, one dining room, and one hallway. The air conditioning unit for the middle part of the nursing unit malfunctioned, leading to temperatures ranging from 84.4 to 97 degrees Fahrenheit, which exceeded the facility's acceptable range of 71 to 81 degrees Fahrenheit. The Director of Nursing acknowledged the issue, stating that the air conditioner had been broken since the previous day, and fans were being provided to residents as a temporary measure. The Maintenance Director confirmed the malfunction and stated that the HVAC technician was working on replacing the condenser. The air conditioning unit was reportedly fixed later that day. The facility's policy, titled 'Homelike Environment,' emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction. The Maintenance Supervisor's job description highlighted the responsibility for maintaining the facility in good repair, including mechanical systems, which was not fulfilled in this instance.
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.
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