Sequoia Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 3710 West Tulare Avenue, Visalia, California 93277
- CMS Provider Number
- 055916
- Inspections on file
- 51
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Sequoia Vista during CMS and state inspections, most recent first.
A resident with Type 1 DM and hyperglycemia had physician orders for twice-daily Insulin Degludec with instructions to notify the MD for BS readings greater than 250. Review of the MAR showed multiple BS values above 250 over the month, yet there was no documentation that the MD was notified of these elevated results. The care plan directed staff to administer insulin as ordered and report signs and symptoms of hyperglycemia, and facility policy required reporting critical test results to the physician, but the DON confirmed that documentation of MD notification for these high BS readings was not available.
The facility did not complete required annual performance evaluations for two CNAs in accordance with its policy. Both CNAs had their last evaluations documented more than a year earlier, and the HR manager acknowledged that new evaluations should have been completed around their employment anniversary dates. The Administrator confirmed that evaluations are expected yearly, and the written policy states that supervisors must conduct annual performance discussions at or around each employee’s anniversary date, but this was not done, resulting in overdue evaluations.
A resident with metabolic encephalopathy, mobility impairment, and cognitive communication deficit, but cognitively intact per BIMS, reported that an unknown CNA was rough and hurt her back while assisting her on and off the toilet during a p.m. shift when her usual CNA was at lunch. The resident and a family member relayed this allegation of physical abuse to a CNA, who immediately informed an LVN. The LVN admitted she did not report the allegation to the administrator/abuse coordinator or DON as required, stating she was overwhelmed and forgot. The SSD and administrator learned of the allegation only the next day from the family, despite facility policy requiring that all abuse allegations be reported to the administrator and appropriate agencies immediately, and no later than two hours after the allegation is made.
A resident with a history of elopement and moderate cognitive impairment was not monitored or documented every hour as required by her care plan. Staff failed to consistently check her whereabouts, leading to her unsupervised exit from the facility. She was found the next morning by police, suffering from hypothermia and other medical complications, and required hospitalization.
A resident involved in a peer altercation sustained visible facial injuries, but the RP and physician were not properly notified as required. Documentation indicated notification, but interviews and record review showed the RP was unaware until a visit. The facility also failed to assess, treat, or monitor the injuries according to policy, and staff were unclear about notification responsibilities.
A resident, assessed as cognitively intact, reported feeling intimidated and bullied by a social worker during a conversation in their room. An LVN present described the social worker's responses as snarky, which did not align with the facility's policy requiring respectful communication with residents.
A resident reported $600 missing, and although staff initiated an internal investigation and notified the resident's family, the facility did not report the alleged misappropriation to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by policy. The resident was cognitively intact, and staff interviews confirmed the delay in external reporting.
A resident's Inventory of Personal Effects (IPE) was not signed by the resident or their representative at admission, contrary to facility policy requiring all personal items to be inventoried and acknowledged. The Social Service Director confirmed the omission during a review.
A resident with major depressive disorder and social anxiety, who prefers to stay in her room, was forced to leave her room and remain in the hallway in her bed for about an hour during a scheduled deep cleaning, despite her refusal and documented preferences. Multiple staff members confirmed the resident's right to remain in her room was not honored, resulting in significant distress and a violation of her rights.
A resident was not given advance written notice before a new roommate, who exhibited frequent outbursts and confusion, was moved into his room. The facility did not monitor for compatibility as required, resulting in ongoing distress, sleep disruption, and a resident-to-resident altercation. Staff confirmed the lack of documentation and that the two residents were not compatible.
A resident's responsible party filed a grievance about the resident being found in a soiled gown, but did not receive a written decision as required by facility policy. The administrator confirmed the grievance was resolved but could not provide documentation that a written response was given, resulting in a violation of the resident's rights.
A resident with moderate cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unsupervised after staff failed to consistently report and intervene on her attempts to exit. The resident was later found by police outside the facility. Staff interviews and record reviews confirmed that the resident's behaviors were known but not always communicated or addressed according to facility policy.
A resident experienced repeated episodes of low blood pressure after dialysis, with multiple readings below normal limits. Despite the resident and family reporting these concerns and facility policy requiring physician notification and documentation for significant changes, staff did not document interventions or notify the physician. This failure to address and record the resident's change in condition did not meet professional standards of quality.
The facility failed to provide routine nail care for two residents, resulting in untrimmed nails and debris accumulation. Observations and interviews revealed that nail care, scheduled for Sundays, was not performed. One resident, a diabetic, did not receive the required care from a licensed nurse as per facility policy.
The facility did not ensure an RN was on duty for eight hours daily, seven days a week, as required by policy. On specific dates in November, no RN was present for the required duration, confirmed by the HR manager and staff schedules.
The facility did not complete Performance Evaluations for three CNAs, as identified during a review with HR. CNAs hired in 2021, 2022, and 2023 had no evaluations in their files, contrary to the facility's policy requiring HR to notify managers of upcoming evaluations. This oversight could impact staff awareness of areas needing improvement.
A facility failed to ensure proper communication between the Dietary Manager and Registered Dietitian regarding a malfunctioning refrigerator used to store TCS foods. The refrigerator was not maintaining the required temperature, leading to improper storage of foods like pudding cups and milk. The issue was identified but not communicated effectively, resulting in continued use of the faulty refrigerator, which posed a risk of bacterial growth.
The facility failed to maintain sanitary kitchen conditions, use pasteurized eggs, and ensure proper food storage temperatures. Observations revealed unsanitary utensils, non-pasteurized eggs served to residents, uncovered food delivery, and a malfunctioning refrigerator with temperatures above safe levels. Staff acknowledged these issues, which were contrary to the facility's policies.
The facility failed to conduct timely smoking assessments for two residents, resulting in a lack of safety evaluation for smoking. A resident admitted on an unspecified date and another admitted on May 1, 2022, did not receive required quarterly assessments after September 2023. The facility's policy mandated smoking assessments during admission and quarterly MDS assessments to determine supervision needs. This oversight posed a potential risk of burns while smoking.
A medication error rate of 11.63% was observed when an LVN administered medications orally instead of via G-tube as ordered for a resident. The medications, including aspirin, docusate sodium, metformin, Keppra, and Januvia, were crushed and mixed with pudding before being given. The LVN acknowledged the error and the facility's policy requires adherence to the prescribed route of administration.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices, as required by their policy. Observations showed a lack of signage and PPE carts, and staff interviews revealed a lack of awareness about the necessity of these precautions. Despite policy requirements, the facility did not ensure precautions were in place for residents with devices like Foley and dialysis catheters.
A facility failed to ensure accurate informed consent for a psychotropic medication for a resident with severe cognitive impairment. The resident, with a BIMS score of 2, signed their own consent for Zoloft, contrary to the facility's policy requiring a higher cognitive score for self-consent. The DON acknowledged the error, as the policy mandates assessing decision-making capacity.
A resident with schizophrenia and dementia was observed over several days with greasy hair, a strong smell of urine, and wearing the same dirty clothes, with no personal clothing available in her closet. Staff interviews revealed that the resident was often left to perform her own personal care, and her clothing was accidentally discarded. The facility failed to adhere to its policies on maintaining resident dignity and personal belongings.
A resident with lower extremity impairments was unable to participate in group activities due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities, the facility did not provide the necessary equipment consistently, resulting in no participation in group activities for two months. The facility had limited Geri-chairs and no schedule for their use among dependent residents.
A facility failed to notify a resident's family when the resident experienced a change in condition and was transferred to a hospital. The resident was unresponsive on two occasions and taken to the hospital by EMTs. Although the resident was their own Responsible Party (RP), the Director of Nursing (DON) acknowledged that the family should have been informed, as per the facility's policy on Notification of Changes.
The facility failed to provide an ABN to a resident who self-discharged from Medicare Part A and left another resident's ABN incomplete by not checking required option boxes. The Admissions Coordinator acknowledged these oversights, which could lead to the facility being held liable for care costs.
The facility failed to conduct PASRR Level II evaluations for two residents who tested positive for Serious Mental Illness (SMI) in their Level I screenings. Despite the facility's policy requiring a Level II evaluation prior to admission and within 40 days if the resident stays longer than 30 days, these evaluations were not performed, as confirmed by the DON.
A resident was admitted without a diet order, leading to potential unmet nutritional needs. The diet order was documented four days later, indicating a controlled carbohydrate diet. Interviews with the DON and ADON confirmed the absence of a physician-ordered diet upon admission, contrary to the facility's policies requiring immediate care orders, including dietary needs.
A resident experienced unmet communication needs due to the facility's failure to provide necessary hearing services and adaptive equipment. Despite the resident's expressed difficulty in hearing and desire for hearing aids, the Social Service Designee was unaware of any audiology services being used, and the resident had not received a hearing test. This was contrary to the facility's policy requiring access to hearing services.
A facility failed to document the quantity consumed of a nutritional supplement for a resident with significant weight loss. The resident did not consume the health shake due to disliking it, and the facility's documentation system did not itemize fluid intake, hindering accurate nutrition assessments. The MAR only indicated the shake was provided, not consumed, and the ADON acknowledged the lack of a system to document intake, preventing effective monitoring and timely intervention.
An LVN failed to secure and properly dispose of a controlled medication during a medication pass. The LVN left a cup containing Tramadol and other medications unattended on a cart and later disposed of them improperly in a hazardous waste container without using a solvent. The facility's policy requires controlled medications to be destroyed with a witness and in a manner that renders them unfit for consumption.
The facility did not follow the meal tray tickets and planned menus for two residents, potentially affecting their nutritional goals. A resident's lunch tray lacked the correct portion of garlic bread, and another resident's tray was missing the prescribed 4 oz of 2% milk. The facility's policy requires adherence to physician-prescribed diet orders, which was not followed in these instances.
A facility failed to serve a resident the correct therapeutic diet as per the physician's order. The resident, who required a pureed texture diet, was served a meal with regular texture food. The Registered Dietitian confirmed the discrepancy, noting two conflicting meal tray tickets on file. The facility's policy required diet orders to be communicated and provided accurately, which was not followed in this instance.
The facility did not follow its policy for labeling and dating food stored in the resident designated refrigerator (RDR). During an observation, undated and unlabeled food items were found in the RDR. A CNA and an LVN confirmed that all food should be dated and labeled with the resident's name, as per the facility's policy.
A CNA in an LTC facility used profanity while providing care to a resident with severe cognitive impairment, as confirmed by staff and the resident's roommate. The incident was documented as verbal abuse, violating the facility's policy on resident rights to respect and dignity.
The facility did not verify all employment references for a CNA before hiring, as required by its policy. Only one of two employment references and two personal references were verified, leaving one employment reference unchecked. This oversight was acknowledged by the Director of Staff Development and confirmed by the Assistant Administrator, who stated that both employment references should have been verified before personal references.
A facility failed to notify a resident's responsible party about redness to the resident's bilateral buttocks upon admission. The responsible party confirmed they were not informed, and both an LVN and the DON acknowledged the lack of documentation regarding the notification. The facility could not provide a policy for responsible party notification.
A resident's dignity was violated when a CNA made an inappropriate comment during care, referring to the resident's condition in a derogatory manner. The comment was overheard by the resident, who reported it to the DON. Interviews confirmed the incident, and the facility's Administrator acknowledged the comment was against policy.
A resident's family reported rushed care and a bad attitude from two CNAs. Despite instructions to provide in-service training, one CNA returned to work without receiving it. The DON assumed training was completed, but the DSD was unaware of the CNA's return. The facility lacked a policy on in-service training, leading to this oversight.
A resident in a long-term care facility did not receive prescribed doses of Lovenox and Depakote due to unavailability, and the physician was not notified of these missed medications. The facility's staff, including an LVN and the DON, acknowledged that the physician should have been informed, but there was no documentation to confirm this notification. The administrator could not provide a policy on notifying physicians about unavailable medications.
Failure to Notify Physician of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order and notify the physician when a resident’s blood sugar (BS) exceeded 250. The resident had Type 1 diabetes mellitus with hyperglycemia and physician orders for Insulin Degludec to be administered subcutaneously twice daily, with instructions to hold the insulin if BS was less than 90 and to notify the MD if BS was greater than 250. Review of the Medication Administration Record for the month showed multiple BS readings above 250, including values of 330, 342, 341, 301, 383, and 299 while the resident was on a 23-unit twice-daily dose, and subsequent readings of 335, 372, 252, 257, 325, and 324 after the dose was changed to 28 units twice daily. The resident’s care plan documented that the resident had diabetes mellitus and directed staff to administer Insulin Degludec as ordered and to monitor, document, and report signs and symptoms of hyperglycemia to the MD as needed. During an interview and concurrent record review with the DON, the facility was unable to provide documentation that the MD had been notified of any of the BS results above 250. The DON stated that the nurses should have notified the MD when the BS result was above 250, consistent with the physician’s order. The facility’s undated policy and procedure for Blood Glucose Monitoring stated that it is the policy of the facility to perform blood glucose monitoring for diabetic residents as per physician’s orders and to report critical test results to the physician in a timely manner. Despite these orders and policies, there was no documentation that the physician was notified of the elevated BS values identified in the resident’s record review.
Overdue Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to follow its policy and procedure for conducting annual performance evaluations (PEs) for two certified nursing assistants. Review of the employee roster showed both CNAs were hired on 5/1/19. Record review with the Human Resource/Payroll Manager on 3/9/26 showed that each CNA’s last PE was completed on 7/17/24, and the HRPM stated that both should have had PEs completed in July 2025. In an interview, the Administrator confirmed that PEs are supposed to be done yearly. Review of the facility’s undated Performance Evaluations policy indicated that supervisors are to complete, review, and conduct performance discussions annually at or around the employee’s anniversary date, but this was not done for the two CNAs, resulting in overdue performance evaluations. No resident-specific medical history or condition was mentioned in relation to this deficiency.
Failure to Timely Report Resident’s Allegation of Rough Handling During Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure an allegation of abuse was promptly reported to the abuse coordinator as required by policy. Resident 1 was admitted with metabolic encephalopathy, difficulty in walking, cognitive communication deficit, bilateral lower extremity range-of-motion impairment, and was wheelchair-bound and dependent for transfers. An MDS dated 1/30/26 documented that the resident was cognitively intact with a BIMS score of 13. On 1/28/26 during the p.m. shift, the resident reported that an unknown CNA who assisted her to and from the restroom while her regular CNA was on lunch had been rough and hurt her back while providing care, which the facility categorized as an allegation of physical abuse. A SOC 341 form dated 1/29/26 documented the resident’s report that an unknown staff member was rough while assisting her to the restroom on the 1/28/26 p.m. shift. Progress notes dated 1/30/26 at 1:57 p.m. indicated that the IDT met to discuss the staff-to-resident alleged abuse that occurred on 1/28/26, and that the resident’s granddaughter had found the resident crying and was told by the resident that a female staff member had been rough and hurt her back while helping her to the bathroom. The resident stated the staff member was not her usual CNA but was helping out during the CNA’s lunch break and was unable to identify the CNA involved. Multiple staff interviews confirmed that the allegation was reported by the resident and her family to CNA 3 during the 1/28/26 p.m. shift, and that CNA 3 relayed the allegation to LVN 1 that same evening. LVN 1 acknowledged that she did not report the allegation to the administrator (abuse coordinator) or the DON, stating she was overwhelmed and it slipped her mind, and further acknowledged it should have been reported right away. The SSD and administrator both stated they did not become aware of the allegation until the following day when the family reported it, and both indicated that staff should have reported the allegation to the abuse coordinator immediately. The facility’s abuse, neglect, and exploitation policy required reporting all alleged violations to the administrator and appropriate agencies immediately, but not later than two hours after the allegation is made when the events involve abuse or result in serious bodily injury, which did not occur in this case.
Failure to Monitor and Document Whereabouts of High-Risk Resident Resulting in Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document the hourly whereabouts of a resident identified as high risk for elopement, as required by the resident's care plan. The care plan specified that the resident, who had a history of elopement and impaired safety awareness, should be monitored every hour. However, documentation in the Point of Care Response History showed that staff did not consistently check or record the resident’s whereabouts every hour, with significant gaps between documented checks. Staff interviews confirmed that the resident was last seen in her room in the evening, but was later discovered missing, and staff were unable to determine when or how she exited the facility. The resident involved had diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, and was assessed as having moderate cognitive impairment and the ability to walk. She had a prior history of elopement from the facility. On the night of the incident, staff last observed her in her room, but she was later found to be missing. Despite a search of the facility and notification of the DON and police, the resident was not located until the following morning, when she was found by police approximately a mile away from the facility, exposed to cold weather conditions and without shoes. Medical evaluation after the incident revealed that the resident suffered from hypothermia, leukocytosis with left shift, and metabolic acidosis, requiring hospitalization. The facility’s policy required systematic monitoring and management of residents at risk for elopement, including regular assessment, care planning, and supervision, but these measures were not effectively implemented in this case. Staff interviews and documentation review confirmed that the required hourly monitoring was not performed or recorded as specified in the care plan, directly contributing to the resident’s unsupervised exit and subsequent medical complications.
Failure to Notify Responsible Party and Physician of Resident Altercation and Injuries
Penalty
Summary
The facility failed to notify the responsible party (RP) and the physician when a resident was involved in a resident-to-resident altercation and subsequently sustained visible injuries, including a cut under the left eye, bruising on the left cheek, and scabs to the left side of the nose and under the left eyebrow. Despite documentation indicating that the RP was notified, interviews with staff and the RP revealed that the notification did not occur as required. The RP only became aware of the injuries during a visit and was not informed about the altercation or the resulting wounds. Staff interviews further confirmed confusion and lack of clarity regarding who was responsible for notifying the RP, with documentation not matching actual communication events. Additionally, the facility did not assess, treat, or monitor the resident's injuries in accordance with its own policies. The ADON and Administrator were unaware of the full extent of the resident's injuries until they were observed during a visit, and there was no documentation of assessment, treatment, or physician notification regarding the wounds. The facility's policies required notification of changes in condition, accidents, and new treatments, but these procedures were not followed in this instance.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A deficiency occurred when a social worker (SW) failed to treat a resident with respect and dignity during a conversation in the resident's room. According to a Licensed Vocational Nurse (LVN) who was present, the SW responded to the resident's questions with a snarky attitude. The resident, who was assessed as cognitively intact with a BIMS score of 15, reported feeling intimidated and bullied by the SW during the interaction. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents, which was not followed in this instance.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to follow its policy and procedure regarding the timely reporting of an alleged misappropriation of resident property for one resident. On 8/10/25, a resident reported $600 missing, and this was documented in the Theft & Loss Form and in the resident's progress notes. The CNA notified the RN supervisor, who assisted in searching for the missing items, and the resident's daughter was informed. The resident, who was cognitively intact as indicated by a BIMS score of 15/15, completed a theft and loss form, which was submitted to Social Services. However, the incident was not reported to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by facility policy. Interviews with facility staff confirmed that the required notifications were not made within the specified timeframe. The Social Service Director acknowledged that the incident should have been reported to the appropriate authorities, regardless of the family's wishes. The Ombudsman confirmed that their office was not notified, and the Administrator admitted that the delay occurred because the amount of missing money was unclear during the investigation. Review of the facility's policy confirmed the requirement to notify authorities within 24 hours of any suspected misappropriation of resident property.
Failure to Obtain Resident Signature on Inventory of Personal Effects at Admission
Penalty
Summary
The facility failed to follow its policy and procedure regarding the inventory of personal effects for one resident at the time of admission. Specifically, the Inventory of Personal Effects (IPE) form for the resident, dated 4/10/25, was not signed by the resident or their representative, as required by facility policy. During an interview and record review, the Social Service Director confirmed that the IPE should have been signed to indicate that all belongings were properly inventoried upon admission. The facility's policy states that all resident personal items must be inventoried at admission and reviewed by the social services designee and the resident's representative, but this process was not completed as documented.
Resident's Right to Room Choice Not Respected During Deep Cleaning
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not allowing her to remain in her room during a scheduled deep cleaning. The resident, who has a history of major depressive disorder and social anxiety, prefers to stay in her room and avoid social situations, as documented in her care plan and confirmed by multiple staff interviews. Despite her clear preference and refusal to leave, she was removed from her room and placed in the hallway in her bed for approximately one hour while her room was cleaned. This action caused the resident significant distress, including anxiety and being nearly in tears. Interviews with facility staff, including the social service designee, LVN, CNA, housekeeper, DON, and administrator, all confirmed the resident's preference to remain in her room and acknowledged that she should not have been forced to leave. The facility's own policy on resident rights also states that residents have the right to make choices about aspects of their life in the facility that are significant to them, including remaining in their room. The failure to respect the resident's choice resulted in a violation of her rights and caused her emotional discomfort.
Failure to Provide Advance Notice and Monitor Roommate Compatibility
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to assigning a new roommate, as required by policy. The resident was not informed in writing before another resident, who was known to have frequent outbursts and confusion, was moved into his room. Multiple staff members, including the Social Service Assistant, Assistant Director of Nurses, and Licensed Vocational Nurse, confirmed that there was no documented evidence of written notification or monitoring for compatibility following the room change. The facility's policy requires advance notice and monitoring for 72 hours to ensure compatibility, but these steps were not followed or documented. As a result of this failure, the resident experienced significant distress, including inability to sleep due to the new roommate's constant yelling and outbursts. The resident reported the issue to several staff members but stated that nothing was done to address his concerns. Staff interviews confirmed that the two residents were not compatible as roommates, and no monitoring for compatibility was documented in the clinical records. This led to a resident-to-resident altercation and a violation of the resident's rights.
Failure to Provide Written Grievance Decision to Resident's Representative
Penalty
Summary
The facility failed to provide a written grievance decision to a resident's responsible party after a grievance was filed regarding the resident being found in a soiled gown. The responsible party reported submitting the grievance, and a review of the facility's Grievance/Concern Log confirmed the grievance was filed. During interviews and record reviews, the administrator acknowledged that although the grievance was resolved, there was no documented evidence that a written decision was issued to the responsible party. The facility's policy requires that a written decision be provided at the conclusion of the investigation, including specific details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. This omission resulted in a violation of the resident's rights.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a known history of attempting to leave the facility unsupervised. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was able to walk 50 feet with minimal assistance and had previously demonstrated exit-seeking behaviors, including leaving the facility and expressing a desire to go to Mexico. Staff interviews confirmed that the resident frequently attempted to leave, set off door alarms, and packed belongings in preparation to exit, with these behaviors occurring approximately every two weeks. Despite these known behaviors, staff did not consistently report the resident's actions to nursing staff as required. On the date of the incident, the resident was discovered missing during a staff lunch break, and after a search of the facility, the police were notified. The resident was subsequently found by police next to a neighboring church. Review of facility policy indicated that residents at risk for elopement should be assessed and have person-centered interventions implemented and communicated to staff, with ongoing monitoring by charge nurses and unit managers. However, the lack of timely reporting and intervention allowed the resident to elope without staff knowledge, resulting in a deficiency related to supervision and accident prevention.
Failure to Address and Document Low Blood Pressure in Resident
Penalty
Summary
Facility staff failed to address a resident's change in condition when the resident repeatedly presented with low blood pressure readings following dialysis treatments. The resident and a family member reported that after returning from dialysis, the resident often felt unwell and requested blood pressure checks, which consistently showed readings below the normal range. Despite these findings, there was no documentation of interventions or physician notification in the resident's medical record, as confirmed by the Director of Staff Development. The facility's grievance log also indicated the resident was dissatisfied with how blood pressure checks were conducted by a CNA. Review of the resident's orders showed no current medication for low blood pressure, and interviews with staff confirmed that the physician should have been notified for systolic blood pressure readings below 100 mm Hg. The facility's policy required nurses to notify the attending physician and document any significant changes in a resident's condition, but this was not done in this case. The lack of intervention and documentation for the resident's persistently low blood pressure constituted a failure to meet professional standards of quality.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, resulting in both having untrimmed fingernails and dark brown debris under their nails. During observations and interviews, it was noted that the nail care, which was supposed to be performed on Sundays, was not completed for these residents. Certified Nursing Assistants (CNAs) acknowledged the oversight, stating that the residents' nails should have been cleaned and trimmed the previous day. Further interviews revealed that one of the residents was diabetic, and according to the facility's policy, only licensed nurses are responsible for trimming or filing the fingernails of diabetic residents. A Licensed Vocational Nurse (LVN) admitted that nail care was not provided to the diabetic resident on the scheduled day. The facility's policy indicated that routine nail care should be part of the Activities of Daily Living (ADL) care and performed on a regular schedule, which was not adhered to in this instance.
Failure to Schedule RN 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. During an interview and record review with the Human Resource Payroll Manager, it was revealed that on specific dates in November 2024, namely the 9th, 23rd, and 24th, there was no RN present in the building for the required duration. This was confirmed by the facility's staff schedule and acknowledged by the HR manager. The facility's policy, titled 'Nursing Services-Registered Nurse (RN),' mandates the utilization of RN services for at least eight consecutive hours per day, seven days a week, which was not adhered to on the mentioned dates.
Failure to Conduct Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PEs) for three of eight sampled employees, specifically Certified Nursing Assistants (CNAs) 54, 88, and a terminated CNA. This deficiency was identified during interviews and record reviews conducted on December 5, 2024, with the Human Resources Payroll (HR) department. CNA 54, hired on June 22, 2021, and CNA 88, hired on April 5, 2022, both had no PEs in their files, as confirmed by HR. Similarly, the terminated CNA, hired on June 11, 2023, also lacked a PE in her file. The facility's policy and procedure for the evaluation process indicated that the HR department should notify department managers of upcoming evaluations, and managers or supervisors should inform employees of their evaluations at least one week prior to the due date. However, this process was not followed, leading to the absence of PEs for the mentioned CNAs.
Inadequate Communication Leads to Improper Food Storage
Penalty
Summary
The facility failed to ensure adequate communication between the Dietary Manager and the Registered Dietitian regarding the malfunction of a refrigerator used to store Time Temperature Control for Safety (TCS) foods. On observation, Refrigerator 1, located in the kitchen, was found to be not in good working condition, with an internal thermometer reading 38 degrees Fahrenheit, but the actual temperature of stored pudding cups was between 50.1 and 52 degrees Fahrenheit. The issue was first identified on 11/29/24, but the refrigerator continued to be used to store TCS foods, which were not maintained at the required temperature of 41 degrees Fahrenheit or less. The Lead Cook noted the problem with the refrigerator and reported it to the Plant Operations Manager on the same day. However, the Dietary Manager was not informed until 12/1/24, and the Registered Dietitian was not aware of the issue until 12/2/24. The Administrator received a text about the refrigerator needing a new compressor but did not communicate this to the Dietary Manager or the Registered Dietitian to ensure proper oversight of food safety. As a result, TCS foods continued to be stored in the malfunctioning refrigerator, posing a risk of bacterial growth due to improper temperature control. The facility's policy and procedure on sanitation require correct temperatures for food storage and handling, which was not adhered to in this case. The Food and Drug Administration (FDA) Food Code recommends that TCS foods be stored at a maximum temperature of 41 degrees Fahrenheit. Despite these guidelines, the facility failed to maintain the required standards, leading to the potential for residents' nutritional needs not being met safely.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was an extensive amount of dry old egg debris on the stove range area, and a #8 scooper with dry old food debris was stored inside the clean utensil drawer. The Dietary Manager acknowledged that the scooper should not have been stored with clean utensils, as it was unsanitary. The facility's policy indicated that all utensils should be kept clean, and all equipment used in food handling should be cleaned and sanitized to prevent contamination. The facility also failed to use pasteurized eggs as required by their policy. Observations revealed a case of shelled eggs in the refrigerator that were not labeled as pasteurized, and staff confirmed that the eggs were not pasteurized. The facility's Food and Service Invoice indicated that the supply of eggs was not pasteurized, and meal tray tickets showed that residents were served eggs over easy, which should have been made with pasteurized eggs according to the facility's policy. Additionally, a Certified Nursing Assistant was observed carrying an uncovered salad and dressing down the hallway to a resident's room, contrary to the facility's policy that required food to be covered during delivery. Furthermore, the facility failed to maintain the cold food storage refrigerator at the required temperature. The refrigerator's internal temperature was found to be above the safe range, with pudding cups measuring 50.1 and 52 degrees Fahrenheit. The Plant Operations Manager confirmed that the refrigerator's compressor needed replacement, and the facility's policy required monitoring of food temperature and refrigeration equipment to ensure safe storage conditions.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to ensure timely completion of smoking assessments for two residents, Resident 13 and Resident 22, which resulted in a lack of assessment for safety while smoking. Resident 13 was admitted on an unspecified date, and no quarterly smoking assessments were completed after September 13, 2023, despite the requirement for assessments on June 5, 2023, December 6, 2023, March 6, 2024, and September 6, 2024. Similarly, Resident 22, admitted on May 1, 2022, did not have quarterly smoking assessments completed after September 13, 2023, although assessments were due in December 2023, March 2024, and June 2024. The facility's policy required smoking assessments during the admission process and each quarterly or comprehensive MDS assessment process to determine the need for supervision or safety in smoking. The failure to conduct these assessments posed a potential risk of residents being burned while smoking.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, as evidenced by five medication errors observed out of 43 medication administration opportunities, resulting in an error rate of 11.63 percent. During an observation, a Licensed Vocational Nurse (LVN) administered medications to a resident orally, despite the resident's orders indicating that the medications should be given via a gastrostomy tube (G-tube). The medications involved included chewable aspirin, docusate sodium, metformin, Keppra, and Januvia, all of which were crushed and mixed with pudding before being administered orally. The LVN acknowledged during interviews that the medications should have been administered via G-tube as per the resident's Order Summary Report. The facility's policy and procedure for medication administration, dated January 2024, requires that medications be administered as ordered by the physician and in accordance with professional standards of practice, including verifying the right route of administration. The LVN admitted to not checking the order and failing to contact the physician to change the route of administration prior to giving the medications orally.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for five residents with indwelling devices, which are necessary to prevent the transmission of bacteria. Observations revealed that these residents did not have the required signage or Personal Protective Equipment (PPE) carts outside their rooms, indicating a lack of compliance with infection control protocols. Interviews with staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, highlighted a lack of awareness and understanding regarding the necessity of Enhanced Barrier Precautions for residents with indwelling devices. The facility's policy on Enhanced Barrier Precautions, dated January 2024, mandates that all staff receive training on these precautions and that orders for such precautions be obtained for residents with indwelling medical devices. Despite this policy, the facility did not ensure that the necessary precautions were in place for residents with devices such as Foley catheters and dialysis catheters. The Order Summary Reports for the affected residents indicated the need for regular checks for signs and symptoms of infection, yet the absence of Enhanced Barrier Precautions suggests a failure in policy implementation and staff training.
Failure to Ensure Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure accurate informed consent for a psychotropic medication for one resident. The resident, who had a severe cognitive impairment with a BIMS score of 2, signed their own informed consent for Zoloft medication. The facility's policy requires a higher cognitive score for a resident to sign their own consent. The Director of Nursing acknowledged that the resident should not have signed the consent due to their cognitive impairment. The facility's policy on informed consent for psychotherapeutic medications emphasizes the need to assess the resident's decision-making capacity, which was not adhered to in this case.
Failure to Maintain Resident Dignity and Personal Care
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 10, by not ensuring proper personal care and the availability of personal possessions. Resident 10, who was admitted with diagnoses of schizophrenia and dementia, exhibited moderate cognitive impairment and required partial assistance with personal care tasks. Observations revealed that Resident 10's room was cluttered, her hair was greasy and disheveled, and she emitted a strong smell of urine. Over several days, Resident 10 was observed wearing the same clothes, which were dirty, and she had no clothes or shoes in her closet. Staff interviews indicated that Resident 10 was often left to perform her own personal care, resulting in her unkempt appearance and odor. The facility's policy on resident personal belongings was not adhered to, as Resident 10's personal effects were not maintained in an orderly fashion, and her clothing was reportedly thrown out with the trash by accident. The facility's policy also stated that residents should have at least two sets of clothes, which was not the case for Resident 10. Staff members, including a CNA and the Administrator, acknowledged the lack of clothing and personal care for Resident 10, with the CNA attempting to provide clothing from her own resources. The facility's failure to support Resident 10's right to retain and use personal possessions and to provide necessary personal care compromised her dignity and respect, as outlined in the facility's policies on resident rights and personal belongings.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to accommodate a resident's choice to get out of bed daily, which impacted their ability to participate in group activities. The resident, who has impairments in both lower extremities and is dependent on care, expressed a desire to attend activities but was unable to do so due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities such as bingo, nails, and coloring, and their need for assistance to attend these activities, the facility did not provide the necessary equipment consistently. Interviews and record reviews revealed that the resident had not participated in any group activities for the months of November and December, as the facility only had three Geri-chairs, all of which were in use by other residents. The Interim Director of Activities confirmed the lack of participation and the absence of a schedule for Geri-chair use among dependent residents. Observations showed that a Geri-chair was not in use in one room, indicating a potential oversight in resource allocation. The facility's policies emphasize promoting resident self-determination and accommodating individual needs, but these were not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Responsible Party (RP) for a resident when there was a change in the resident's condition that required admission to an acute care hospital. During a review of the resident's Change in Condition Evaluation (COC) on two separate occasions, it was noted that the resident was unresponsive and transferred to the hospital by Emergency Medical Technicians (EMT). The COC indicated that the resident was their own RP, but the Director of Nursing (DON) confirmed that no family was notified, although they should have been. The facility's policy and procedure on Notification of Changes requires informing the resident, consulting with the resident's physician, and notifying the resident's family or legal representative when there is a significant change, such as a transfer or discharge from the facility.
Failure to Provide and Complete Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident and failed to accurately complete the ABN for another resident. In the first case, Resident 192 was not given the ABN after self-discharging from Medicare Part A before exhausting benefit days and remaining in the facility. The Admissions Coordinator (AC) acknowledged that the ABN should have been provided alongside the Notice of Medicare Non-Coverage (NOMNC), which was issued when the resident requested to be taken off occupational therapy. In the second case, Resident 195's ABN was left incomplete as none of the required option boxes were checked, although the resident had signed the form. The AC confirmed that one of the boxes needed to be checked for the form to be considered complete. The facility's instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) specify that the patient must select one option and sign the form to acknowledge understanding. Failure to complete the form correctly could result in the notice being invalidated and the facility being held liable for the care in question.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to accurately complete the annual pre-admission screening assessment and resident review (PASRR) for two residents, which is a federal requirement to ensure individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting. Resident 13's PASRR Level I Screening indicated a positive result for Serious Mental Illness (SMI) but negative for Intellectual Disability (ID), Developmental Disability (DD), and Related Condition (RC). However, there was no Level II PASRR performed on Resident 13, as confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident 42's PASRR Level I Screening also indicated a positive result for SMI and negative for ID/DD/RC, yet no Level II PASRR was conducted. The DON acknowledged that a Level II screening should have been performed for Resident 42. The facility's policy and procedure on Resident Assessment - Coordination with PASARR program, dated January 2024, states that a positive Level I screen necessitates a PASARR Level II evaluation prior to admission, and if a resident remains in the facility longer than 30 days, a Level II resident review must be completed within 40 calendar days of admission.
Failure to Obtain Diet Order Upon Admission
Penalty
Summary
The facility failed to obtain a diet order upon admission for a resident, which had the potential to result in unmet nutritional needs. Upon reviewing the resident's Admission Record, it was found that the resident was admitted without a diet order. The Order Summary Report, dated four days after admission, indicated a controlled carbohydrate diet with thin pureed texture and thin consistency was ordered by the facility's physician. This was the first diet order documented for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that there was no documentation of a physician-ordered diet upon the resident's admission. The ADON acknowledged that the nurse should have contacted the physician to obtain the diet order. The facility's policy and procedure on Admission Orders requires that a physician or other qualified healthcare professional provide written or verbal orders for residents' immediate care, including dietary needs. The facility's policy on Diet Orders specifies that diet orders prescribed by the physician should be communicated to the Food & Nutrition Services Department.
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, identified as Resident 10, to improve her hearing and communication needs. Upon review of Resident 10's Admission Record, it was noted that she was admitted on an unspecified date. During an observation and interview, it was evident that Resident 10 had difficulty hearing, requiring the surveyor to speak loudly and clearly near her ear. Resident 10 expressed a desire for hearing aids to improve her ability to hear. Further interviews revealed that the Social Service Designee (SSD) was unaware if audiology services had been utilized for Resident 10, despite acknowledging her hearing difficulties. It was confirmed that Resident 10 had never undergone a hearing test at the facility. The facility's policy and procedure on Hearing and Vision Services mandates that residents have access to necessary services and adaptive equipment, with the social worker or SSD responsible for assisting residents in obtaining these resources. However, this policy was not followed, resulting in Resident 10's communication needs not being met.
Failure to Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to document the quantity consumed of a nutritional beverage supplement for a resident who experienced significant weight loss. During an observation, it was noted that the resident had an unopened carton of a health shake on her meal tray, which she did not consume because she disliked it. The resident expressed concern about her rapid weight loss. Interviews with CNAs revealed that the facility's documentation system did not itemize fluid intake, making it unclear whether the health shake was consumed. The Registered Dietitian (RD) confirmed that the lack of documentation hindered accurate nutrition assessments and the ability to monitor the effectiveness of nutritional interventions. Further review of the resident's records showed that the Medication Administration Record (MAR) only indicated that the health shake was provided, without documenting the quantity consumed. The Assistant Director of Nursing (ADON) acknowledged the absence of a system to document the quantity consumed of nutritional supplements. The facility's policy stated that residents' nutritional needs should be assessed and reassessed periodically, but the lack of documentation prevented effective monitoring and timely intervention to address the resident's nutritional needs.
Improper Handling and Disposal of Controlled Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN 2) failed to ensure the security and proper disposal of a controlled medication during a medication pass. While administering medications to a resident, LVN 2 dropped a plastic medication cup containing multiple medications, including Tramadol, a controlled substance, onto the bed. LVN 2 acknowledged that the dropped medications needed to be wasted and required a witness to sign off on the wasted Tramadol. However, LVN 2 placed the medication cup on top of the medication cart and left it unattended while entering the resident's room, which was against the facility's policy that requires medications to be under direct observation or locked away. Additionally, LVN 2 improperly disposed of the controlled medication. After obtaining a witness, LVN 2 disposed of the Tramadol and other medications in a black plastic container labeled as a Hazardous Waste Container without crushing the tablets or using a solvent to destroy them. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the black bins were not appropriate for controlled medication disposal and that such medications should be destroyed using a drug buster liquid or brought to the DON's office for destruction with a pharmacist. The facility's policy requires that the destruction of drugs be witnessed by a consultant pharmacist and another designated individual, which was not followed in this instance.
Failure to Follow Meal Tray Tickets and Planned Menus
Penalty
Summary
The facility failed to adhere to the meal tray ticket and planned menu for two residents, potentially impacting their nutritional goals. During an observation and interview with the Registered Dietitian (RD), it was noted that Resident 62's lunch meal tray, which was supposed to include large portions, only had one slice of garlic bread instead of the two slices indicated on the meal tray ticket. This discrepancy was confirmed by the RD, who stated that two slices should have been served per the planned menu for a large portion diet. Additionally, Resident 83's meal tray was missing the 4 oz of 2% milk as indicated under standing orders on the meal tray ticket. The facility's policy and procedure for diet orders, dated 2023, requires that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department, with nursing responsible for sending a Diet Order Communication slip to the department.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served in accordance with the diet order for one resident, identified as Resident 22. During an observation and record review, it was noted that Resident 22 received a meal tray with regular texture food, including cornbread and chili, despite having a physician's diet order for a pureed texture diet. The meal ticket initially indicated a regular texture diet, but a handwritten notation had replaced 'thin liquid' with 'puree.' However, the resident was still served the incorrect diet. The Registered Dietitian confirmed that there were two meal tray tickets on file for Resident 22, one indicating a regular texture diet and the other a pureed diet, and acknowledged that the resident was not provided the correct physician-ordered therapeutic diet of pureed texture. The facility's policy and procedure required that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department, with nursing responsible for sending a Diet Order Communication slip to the department.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'FOOD FOR RESIDENTS FROM OUTSIDE SOURCES' concerning the storage of food brought in by family and visitors. During an observation and interview, it was noted that the resident designated refrigerator (RDR) contained undated and unlabeled foil-covered plated food items. Certified Nursing Assistant (CNA) 81 confirmed that all food stored in the RDR should have been dated and labeled with the resident's name. Licensed Vocational Nurse (LVN) 5 also stated that food stored in the RDR should include the resident's name and the date the food item was received. The facility's policy indicated that prepared foods requiring refrigeration should be sealed, dated, and disposed of within two days after opening, which was not followed in this instance.
CNA Uses Profanity During Resident Care
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) using profanity while providing care. The incident was documented in a Report of Suspected Dependent Adult/Elder Abuse, which indicated verbal aggression by CNA 1. The resident involved, who had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 05, was subjected to verbal abuse when CNA 1 used profanity during care. This was corroborated by an SBAR document noting that staff overheard CNA 1 yelling at the resident, and by interviews with other staff and the resident's roommate. CNA 2, who overheard the incident, confirmed that CNA 1 was shouting and using profanity towards the resident. The Assistant Administrator also confirmed that CNA 1 admitted to using profanity, acknowledging it as verbal abuse. The resident's roommate further described CNA 1's frustration and disrespectful behavior during care. CNA 1 admitted to becoming frustrated and using inappropriate language, recognizing it as verbal abuse. The facility's policy on Resident Rights, which emphasizes the right to be treated with respect and dignity, was not adhered to in this instance.
Failure to Verify Employment References for CNA
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding employment reference checks, which had the potential to put residents at risk for abuse. Specifically, the facility did not verify all employment references for a Certified Nursing Assistant (CNA 1) before hiring. CNA 1's Application for Employment listed two previous employers and three personal references. However, during the review of CNA 1's Pre-Employment Reference Check, it was found that only one of the employment references and two personal references were verified. The employment reference for the second previous employer, Facility 3, was not verified. The Director of Staff Development acknowledged this oversight, and the Assistant Administrator confirmed that both employment references should have been verified before personal references. The facility's policy, revised in January 2024, mandates that the human resources department must verify the certification status of applicants with the nurse aide registry of the state where they are certified or previously employed.
Failure to Notify Responsible Party of Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's condition, specifically redness to the bilateral buttocks, upon the resident's admission. The resident was admitted with this condition, but there was no evidence in the progress notes that the RP was informed. During an interview, the RP confirmed that they were not notified about the redness. Additionally, a Licensed Vocational Nurse (LVN) reviewed the medical record and confirmed the lack of notification. The Director of Nursing (DON) also reviewed the medical record and acknowledged the absence of documentation regarding the notification of the RP. The facility was unable to provide a policy and procedure for RP notification when requested.
Resident's Dignity Violated by Inappropriate Staff Comment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, resulting in a violation of the resident's rights. The incident involved a Certified Nursing Assistant (CNA) making an inappropriate comment while providing care to the resident. During the provision of care, the resident requested a pillow, and CNA 2 made a derogatory remark about the resident's condition, referring to it as a 'stinky butt.' This comment was overheard by the resident, who found it disrespectful and reported it to the Director of Nursing (DON). Interviews with the involved staff confirmed the incident. CNA 1 acknowledged that CNA 2 made the comment in a joking manner, but recognized it was inappropriate. CNA 2 admitted to making the comment and apologized, acknowledging it was not suitable. The facility's Administrator also confirmed that the comment was against the facility's policy on resident rights, which mandates treating residents with respect and dignity. The facility's policy review further supported that the resident has a right to be treated with respect and dignity.
Failure to Provide In-Service Training for CNA After Allegation
Penalty
Summary
The facility failed to provide in-service training for a Certified Nursing Assistant (CNA 1) before she returned to work, following an allegation of rushed care and a bad attitude towards a resident. The incident was reported by the resident's family, who noted that the care provided by CNA 1 and another CNA (CNA 2) was rushed. The Director of Nurses (DON) was informed of the resident's dissatisfaction on the same day the incident was reported. Despite instructions from the Administrator to provide in-service training to both CNAs, the Director of Staff Development (DSD) was unaware that CNA 1 had returned to work and did not provide the necessary training. CNA 1 returned to work on three separate days without receiving the in-service training, which she acknowledged she needed to understand and correct her actions. The DON assumed that the DSD had conducted the training, but it was confirmed that this had not occurred. Additionally, the facility lacked a policy on in-service training, which contributed to the oversight. This failure had the potential to allow CNA 1 to continue providing care with a bad attitude and in a rushed manner, as alleged by the resident.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident did not receive prescribed medications as ordered. Specifically, a resident was prescribed Lovenox, a blood thinner, to be administered daily for 30 days to prevent blood clots due to a fracture. However, the medication was not administered on multiple days throughout May 2024, as it was not available. Despite this, there was no documentation indicating that the physician was informed of the missed doses. Licensed Vocational Nurse (LVN) 1 confirmed the absence of such documentation and acknowledged that the physician should have been notified. Additionally, the same resident was prescribed Depakote for bipolar disorder, which was not administered on one occasion due to the medication being unavailable. Again, there was no documentation showing that the physician was notified of the missed dose. Both LVN 1 and the Director of Nursing (DON) confirmed that the physician should have been informed when medications were unavailable. The facility's administrator was unable to provide a policy regarding the notification of physicians in such situations.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
