Sequoia Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 350 North Villa Street, Porterville, California 93257
- CMS Provider Number
- 055551
- Inspections on file
- 34
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sequoia Transitional Care during CMS and state inspections, most recent first.
A resident with a vascular/venous wound to the right lower leg had a revised wound care order documented by the wound physician, specifying cleansing with NS, patting dry, and applying Dakin’s flush with betadine to eschar QD and PRN. However, the active treatment orders in the record continued to reflect an older regimen using wound cleanser and betadine-soaked gauze with kerlex wrap. During interview and record review, the ADON could not show evidence that the new order was implemented and acknowledged the order was not updated, contrary to facility policy requiring a current and complete list of treatment orders. This failure resulted in the physician’s order being incorrect and created the potential for the wound to worsen.
A resident with dementia, muscle weakness, and a history of repeated falls, who was totally dependent on staff for toileting, was left waiting for about 30 minutes after requesting help. The resident attempted to use the bathroom without assistance, resulting in a fall that caused a head laceration and a T5 compression fracture. Staff and records confirmed the resident's high fall risk and need for total assistance, and the facility's failure to provide timely care led directly to the incident.
The facility failed to ensure an RN was on duty for eight hours a day, seven days a week, as required by policy. Interviews and record reviews with the DSD revealed multiple instances across several months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage.
The facility failed to notify the resident's representative and the state LTC ombudsman in writing when two residents were transferred to the hospital. One resident was transferred twice, once for gastrointestinal bleeding and once due to a fall, without notifying the family member listed as the Responsible Party. Another resident was transferred without notifying the ombudsman. The facility's policy requires such notifications, but they were not carried out.
The facility failed to develop and implement individualized care plans for three residents, potentially leading to unmet care needs. A resident with speech issues, another with gastrointestinal bleeding, and a third with incontinence did not have appropriate care plans in place, contrary to the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to use a communication tool for a resident with a speech impairment, leading to potential unmet needs. The resident was observed speaking in gibberish, and while a CNA familiar with the resident could understand her, the MDS assessment indicated unclear speech. The MDSC noted that without a communication tool, newer staff would struggle to meet the resident's needs, contrary to the facility's policy on effective communication.
The facility failed to follow its repositioning policy for two residents dependent on staff for mobility. Resident 71 was not repositioned consistently every two hours as required, and Resident 52, with hemiplegia, was not turned every hour while in a chair. Documentation showed irregular repositioning times, and discrepancies between care plans and actual needs were noted.
A facility failed to assess a resident for a Bowel and Bladder Training program, despite documentation indicating the resident was always incontinent. The Minimum Data Set Consultant and Coordinator found no care plan or documentation for such a program, and discrepancies in the resident's continence status were noted. Additionally, the facility could not provide a bowel and bladder training program policy.
The facility failed to monitor two residents on anticoagulation therapy as per their protocol. There was no documentation of monitoring for adverse effects of Eliquis and Xarelto for DVT prevention, as confirmed by the ADON and MDS Consultant. The facility's protocol requires monitoring for complications and consulting with a physician if signs of bleeding are observed.
The facility failed to remove expired medications from medication carts for two residents, risking administration of expired drugs. Additionally, a resident's medications were found unsecured in their room without a self-administration assessment. Licensed staff acknowledged responsibility for checking and removing expired medications, which was not done, and the facility's policies on medication storage and self-administration assessments were not followed.
A facility failed to follow a physician-prescribed therapeutic diet for a resident, potentially leading to adverse outcomes. The resident's diet required chopped meat due to multiple missing teeth, but the chicken fried steak served was not chopped, leaving it uneaten. An LVN confirmed the steak should have been chopped, as per the resident's dietary requirements.
The facility failed to ensure that arbitration agreements were clearly explained to residents in their primary language, resulting in several Spanish-speaking residents signing agreements in English without full understanding. The agreements were presented without certified interpreters, and staff members who were not certified to translate legal terms facilitated the process.
A resident received incorrect discharge appeal information, and the Ombudsman was notified late about the discharge. The NOPD contained wrong contact details for appeals, and the Ombudsman was informed three days after the notice, against the facility's policy.
A facility failed to notify a resident's responsible party before a room change, violating the resident's rights. The DON confirmed the room swap occurred without documented consent from the responsible party, contrary to facility protocol requiring notification and documentation in the clinical record.
A resident with Guillain-Barre syndrome was not referred to a neurologist as ordered, leading to a delay in care. The receptionist attempted to schedule the appointment but lacked documentation of these attempts. The DON confirmed the absence of documentation, contrary to the facility's policy requiring coordination and documentation of referrals.
The facility did not have a full-time licensed DON, as the previous DON left in March 2024. An interim DON, who completed the RN program but lacked an RN license, was assigned to the role. This situation did not comply with the facility's policy requiring a licensed RN as a full-time DON.
Failure to Update and Implement Revised Wound Care Orders
Penalty
Summary
The facility failed to ensure that a physician’s updated wound care order was implemented and reflected in the resident’s active treatment orders. A progress note completed by the wound physician on 12/4/25 documented that the resident’s right shin vascular wound (Wound #2) was not healed and included a specific treatment order: cleanse the wound with normal saline, pat dry, and apply Dakin’s flush with betadine to the eschar every day and as needed. However, the resident’s Order Summary Report continued to show an earlier treatment order for a venous wound to the right lower leg, directing staff to cleanse with wound cleanser, pat dry, apply betadine-soaked gauze to the wound bed, cover with a dry dressing, and wrap with kerlex every day or as needed. During an interview and concurrent record review with the ADON, the facility was unable to provide evidence that the 12/4/25 wound care order had been implemented or that the treatment order had been updated in the clinical record. The ADON acknowledged that the treatment order for the venous wound to the right lower leg was not updated with the new order and stated that it should have been. The facility’s own Medication Orders policy required that a current list of orders be maintained in each resident’s clinical record and that treatment orders specify the treatment, frequency, and duration, but this was not followed for this resident’s wound care. The report stated that this failure resulted in the physician’s order being incorrect and created the potential for the resident’s wound to worsen.
Failure to Provide Timely Toileting Assistance to High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, muscle weakness, and dementia, who was assessed as being at high risk for falls and totally dependent on staff for toileting, was left waiting for assistance for approximately 30 minutes after requesting help to use the bathroom. The resident's care plan and assessments clearly indicated the need for total assistance with toileting due to severe cognitive impairment and physical limitations. Despite these documented needs, the resident was not assisted in a timely manner after making the request to a CNA. During this period of waiting, the resident attempted to transfer herself to the bathroom without assistance. This resulted in an unwitnessed fall in the bathroom, where the resident was found on the floor with a laceration to the head and later diagnosed with a T5 compression fracture. Multiple staff interviews confirmed that the resident was known to be a high fall risk and required total assistance for toileting, and that the fall could have been prevented if the resident had been assisted promptly. Facility records, including the care plan, post-fall reviews, and staff interviews, consistently documented the resident's dependence and high risk for falls. The facility's own policy required appropriate support and assistance with activities of daily living, including toileting, for residents unable to perform these tasks independently. The failure to provide timely assistance directly led to the resident's fall and subsequent injuries.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews conducted with the Director of Staff Development (DSD) on January 8, 2025. The Nursing Staff Assignment and Sign-in Sheets (NSASS) for several months in 2024 and early 2025 revealed multiple instances where no RN was on duty for the required duration. Specifically, the absence of an RN for eight hours a day was noted on several days in July, August, September, October, November, and December 2024, as well as in January 2025. The facility's policy, titled 'Staffing, Sufficient and Competent Nursing,' dated August 2022, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the DSD confirmed during interviews that there were numerous days across the reviewed months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage. This failure had the potential to negatively impact resident care, although specific consequences or resident conditions were not detailed in the report.
Failure to Notify Representatives and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's representative and the state long-term care ombudsman in writing when two residents were transferred to the hospital. Resident 52, who had a history of diabetes and high blood pressure, was transferred to the hospital on two occasions: once for gastrointestinal bleeding and another time due to a fall. In both instances, the resident's family member, listed as the Responsible Party, was not notified. The first failure to notify was due to the nurse incorrectly listing the resident as his own representative, and the second was due to a full voicemail box. Resident 82 was transferred to the hospital, but the ombudsman was not notified. The facility's policy requires that when a resident is transferred or discharged, appropriate notice must be provided to the resident and/or legal representative, and a copy of the notice must be sent to the state long-term care ombudsman. However, the Social Services Designee admitted to not sending notifications to the ombudsman or the resident's representatives in these cases.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for three residents, which could potentially lead to unmet care needs. Resident 46 was observed in her wheelchair speaking in gibberish, and despite a CNA's ability to understand her needs, there was no care plan addressing her speech deficit. Resident 52 was transferred to the hospital for gastrointestinal bleeding and upon readmission, there was no care plan addressing this condition. Resident 79's records indicated incontinence, but there was no care plan to address this issue. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. These care plans should be updated when there is a significant change in condition, when outcomes are not met, or when a resident is readmitted from a hospital stay. However, the facility did not adhere to this policy, as evidenced by the lack of care plans for the identified issues in Residents 46, 52, and 79.
Failure to Use Communication Tool for Resident with Speech Impairment
Penalty
Summary
The facility failed to ensure the use of a communication tool for a resident with a speech impairment, identified as Resident 46. During an observation, the resident was noted to speak in short clips of gibberish with no discernable words. A Certified Nursing Assistant (CNA) who had cared for the resident for the past year stated she could understand the resident's needs. However, the Minimum Data Set (MDS) assessment indicated that the resident had unclear speech and was rarely or never understood. The Minimum Data Set Coordinator (MDSC) acknowledged that not using a communication tool would make it difficult for newer staff to understand and meet the resident's needs. The facility's policy on effective communication, dated February 2018, required staff to assist residents with language barriers to maintain effective communication, which was not adhered to in this case.
Failure to Follow Repositioning Policy for Dependent Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for repositioning residents, which was identified during interviews and record reviews. The policy required that residents in bed be repositioned at least every two hours, and those in a chair every hour, to prevent skin breakdown and promote circulation. However, the documentation for two residents, who were dependent on staff for mobility, showed inconsistent repositioning times that did not meet the policy's requirements. Resident 71, who was dependent on staff for all mobility tasks, was not repositioned consistently according to the facility's policy. The records indicated that the resident was turned at irregular intervals, often exceeding the two-hour requirement. This inconsistency was confirmed during an interview with the Assistant Director of Nursing, who reviewed the resident's medical records and noted the lack of adherence to the repositioning schedule. Similarly, Resident 52, who had a diagnosis of hemiplegia and was dependent on staff for mobility, was also not repositioned according to the policy. The documentation showed that the resident was turned at irregular intervals, failing to meet the one-hour requirement for residents in a chair. The Minimum Data Set Consultant acknowledged the discrepancy between the care plan and the actual needs of the resident, highlighting the potential for resident injury due to inaccurate care planning and documentation.
Failure to Assess Resident for Bowel and Bladder Training Program
Penalty
Summary
The facility failed to assess a resident, identified as Resident 79, for a Bowel and Bladder Training program, which is designed to help residents regain control over their bowel and bladder functions. During a review of Resident 79's medical records, it was found that the Bowel and Bladder Observation/Assessment indicated incontinence, with the resident always being incontinent of both bowel and bladder. However, there was no care plan for incontinence or documentation of the resident being placed on a bowel and bladder training program. The Minimum Data Set Consultant and Coordinator noted discrepancies in the documentation and acknowledged the absence of a bowel and bladder training program policy, which should have been in place given the resident's recent onset of incontinence.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to adhere to its policy and procedure for monitoring residents on anticoagulation therapy, specifically for two residents, Resident 10 and Resident 57. During a review of Resident 10's Medication Administration Record (MAR) for December and early January, it was found that there was no documentation of monitoring for adverse effects of the blood-thinning medication Eliquis, which was prescribed for deep vein thrombosis (DVT) prevention. The Assistant Director of Nursing confirmed the absence of such documentation, which was required by the facility's protocol. Similarly, for Resident 57, a review of the Order Summary Report revealed that there was no documentation of monitoring for adverse effects of the anticoagulant Xarelto, also prescribed for DVT. The Minimum Data Set Consultant acknowledged the lack of documentation. The facility's anticoagulation clinical protocol, dated November 2018, mandates that staff and physicians monitor for complications in individuals on anticoagulation therapy and manage related problems, including consulting with a physician if signs of bleeding are observed before administering the next dose.
Expired Medications and Insecure Storage Found in Facility
Penalty
Summary
The facility failed to implement its policy and procedure regarding expired medications for two residents, as expired medications were found in the medication administration carts. During an observation, three expired medications were found in the medication cart for one resident, including Hyosyne oral drops, Acetaminophen suppositories, and Bisacodyl suppositories, all with expiration dates of 9/19/24. Another resident had expired artificial tears lubricant eye drops with an expiration date of 8/2022 in the medication storage room. Licensed staff acknowledged that it was their responsibility to check and remove expired medications, which was not done, leading to the potential for expired medications to be administered. Additionally, the facility failed to ensure that a resident's medications were securely stored, as observed in the resident's room where five vials of Refresh Digital PF and a medication cup of unlabeled cream were found on the bedside table. The LVN confirmed that the cream was Voltaren gel, and there was no order for the resident to keep medication at the bedside. The resident had not been assessed for self-administration of medication, which should have been completed before allowing the resident to self-administer. The facility's policy required medications to be stored in locked compartments and for self-administration assessments to be conducted, which were not adhered to in this case.
Failure to Follow Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to adhere to the physician-prescribed therapeutic diet for a resident, identified as Resident 64, which could potentially lead to adverse outcomes. The Order Summary Report for Resident 64, dated March 12, 2024, specified a regular diet with chopped meat texture and thin liquids consistency. However, during an observation and interview on January 9, 2025, it was noted that the chicken fried steak on Resident 64's food tray was not chopped, rendering it uneaten. Resident 64, who had multiple missing teeth, expressed an inability to eat the unchopped steak. Licensed Vocational Nurse 1 confirmed that the steak should have been chopped according to the resident's dietary requirements. The facility's policy and procedure, dated October 2017, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care, taking into account the resident's informed choices, preferences, treatment goals, and wishes.
Failure to Explain Arbitration Agreements in Resident's Language
Penalty
Summary
The facility failed to ensure that the terms and conditions of its arbitration agreement were clearly explained to five residents, resulting in them signing the agreement without fully understanding that they were waiving their rights to a court proceeding in the event of a dispute. The residents involved primarily spoke Spanish, and the arbitration agreements were only available in English. The facility did not use certified interpreters to explain the agreements, relying instead on a staff member who was not certified to translate legal or medical terminology. Resident 26, with moderate cognitive impairment, and Resident 135, also with moderate impairment, both signed the English arbitration agreements without a certified interpreter present. Resident 57, Resident 70, and Resident 80, who were cognitively intact, also signed the agreements in English. Resident 80, who was very sick at the time of signing, stated he did not remember what he signed and was unsure if the documents were in English or Spanish. The Director of Marketing and a Certified Nursing Assistant (CNA) were involved in presenting and translating the arbitration agreements. The Director of Marketing admitted to encouraging residents to sign the agreements and acknowledged that the facility did not have agreements in Spanish. The CNA, who assisted with translations, was not certified to translate legal documents. The facility's policy required that arbitration agreements be explained in a manner that residents understand, considering their language and literacy, but this was not adhered to in these cases.
Failure to Provide Correct Discharge Information and Timely Ombudsman Notification
Penalty
Summary
The facility failed to provide proper discharge information to a resident, identified as Resident 1, as part of a 30-day notice. The Notice of Proposed Discharge (NOPD) given to the resident contained incorrect appeal information, directing the resident to contact the California Department of Public Health for complaints rather than the appropriate state agency for discharge appeals. This error was acknowledged by the Director of Nursing (DON) during an interview, who confirmed that the information provided was incorrect according to the facility's policy and procedure, which mandates that residents receive the correct contact details for appealing discharge notices. Additionally, the facility did not notify the Ombudsman in a timely manner regarding the facility-initiated discharge of Resident 1. The Ombudsman was informed three days after the notice was given to the resident, contrary to the facility's policy that requires notification within one day. The Social Service Director (SSD) admitted to the delay during an interview, and the DON confirmed that it was the SSD's responsibility to notify the Ombudsman. The facility's policy clearly outlines the responsibilities of the Social Services in preparing a resident for discharge, including informing relevant parties about the discharge.
Failure to Notify Responsible Party of Room Change
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a room change, resulting in a violation of the resident's rights. On August 15, 2024, a room change was conducted for two residents, where Resident 1 was moved to a different room to accommodate a request from Resident 2. The Director of Nurses (DON) confirmed that the room swap occurred on this date, but there was no documented evidence that Resident 1's responsible party was informed or consented to the change. During interviews and record reviews, it was revealed that the facility's protocol requires notification and consent from the resident and/or their responsible party before any room changes, with documentation in the clinical record. However, both the Licensed Vocational Nurse (LVN) and Social Service Designee (SSD) were unable to find any documentation indicating that Resident 1's responsible party was notified. The facility's policy and procedure also stipulate that all parties involved in a room change should be given advance notice, and the change should be documented in the resident's medical record, which was not adhered to in this case.
Failure to Schedule Neurology Appointment
Penalty
Summary
The facility failed to ensure that a resident was referred to a neurologist as ordered by the physician, resulting in a delay of care. The resident had a diagnosis of Guillain-Barre syndrome, a condition where the immune system attacks the nerves, and the physician had ordered a neurology consult. The receptionist, responsible for scheduling appointments, stated she attempted to schedule the neurology appointment but could not provide evidence of these attempts. The Director of Nursing confirmed the absence of documentation regarding the scheduling attempts in the resident's medical record. The facility's policy required social services or a designee to coordinate referrals and document them in the medical record, which was not adhered to in this case.
Lack of Full-Time Licensed DON
Penalty
Summary
The facility failed to ensure there was a full-time licensed Director of Nursing (DON), which had the potential to affect the needs of all 94 residents. Interviews and record reviews revealed that the previous DON had not worked at the facility since March 2024. An interim DON, who had completed the Registered Nursing (RN) program but was awaiting a testing date, was currently assigned to the position. However, this interim DON did not possess an RN license. The facility's policy and procedure indicated that the DON should be a licensed RN employed full-time, which was not the case at the time of the survey.
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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