Shasta View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Bluff, California.
- Location
- 1795 Walnut Street, Red Bluff, California 96080
- CMS Provider Number
- 055489
- Inspections on file
- 45
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Shasta View Care Center during CMS and state inspections, most recent first.
Two residents with mental health disorders and COPD were issued 30‑day discharge notices that did not comply with facility policy or regulatory requirements. The notices lacked key elements such as the date given, planned discharge date, specific discharge location, complete reasons for discharge, and contact information for the local Ombudsman and the state agency protecting the rights of individuals with mental illness. One resident’s records showed no safe or reasonable discharge location and ongoing need for staff assistance with medical needs, while the other resident reported being told by the ADON they were being discharged because they were "high functioning" without any discharge plan in place. The DON confirmed both notices were incomplete, and the Administrator acknowledged there was no firm discharge plan for either resident when the notices were issued.
A resident with borderline personality disorder and anxiety was prescribed PRN hydroxyzine for anxiety-related worry that their needs were not being met, and the care plan directed staff to monitor and track anxiety-related behaviors. The facility’s policy required medications to be monitored for effectiveness, but from admission through the survey period there was no behavioral monitoring in place to track signs or symptoms of anxiety. During an interview and record review, the DON confirmed the absence of behavioral monitoring, despite acknowledging its purpose to count episodes and assess medication effectiveness, resulting in failure to ensure the resident’s drug regimen was free from unnecessary medications.
The facility did not follow its Influenza Exposure Control policy when several residents with significant comorbidities, including COPD, pneumonia, dementia, diabetes, heart disease, chronic kidney disease, and cirrhosis, tested positive for Influenza A. After learning from a hospital that a resident was influenza-positive and while lacking influenza test kits on site, the IP tested only roommates of positive residents and those with flu-like symptoms, without reviewing the facility’s policy. A new consultant RN advised the IP on testing without first reviewing the policy and later acknowledged more residents should have been tested. The DON confirmed the facility was not prepared for an influenza outbreak, that the policy was not followed, and that all residents should have been tested due to shared dining, activities, and sick employees, and the report states this failure put residents, staff, and families at risk for Influenza A and potential serious negative clinical outcomes.
A resident with multiple complex conditions, including stroke-related paralysis, diabetes, COPD, chronic kidney disease, pressure ulcers, and moderate cognitive impairment, had a new physician order for a wound vac to a left hip pressure ulcer with specific dressing change and pressure settings. Despite a facility policy requiring care plan review and revision upon status change, the comprehensive care plan was not updated to include the new wound vac interventions or resident-specific considerations, such as the resident allowing only one nurse to perform wound care and possible involvement of a family member if treatments were refused. The DON confirmed during interview that the wound care plan had not been revised and needed to be more specific for wound care, and the report notes this failure had the potential to result in discomfort, further wound deterioration, and possible infection and hospitalization.
Two residents, both cognitively intact and with complex medical histories, were financially exploited by an Activity Assistant who solicited money, manipulated them into providing access to their bank cards, and failed to provide receipts for transactions. The staff member also made unauthorized purchases and discussed personal financial issues with residents, causing distress and violating facility policies regarding resident funds.
A resident with multiple medical and mental health conditions reported that an Activity Assistant received money from her for services that were not provided. The facility did not complete a thorough investigation, failed to interview all relevant parties, submitted the required abuse investigation report to CDPH late, and did not communicate findings or reimburse the resident as indicated. The DON and Regional Nurse Consultant confirmed the investigation was incomplete and not in accordance with facility policy.
Staff failed to follow infection control protocols for COVID-19, including improper use of PPE and lack of hand hygiene when entering and exiting a room with a COVID-19 positive resident. Both a CNA and an activity assistant did not comply with facility policy or posted precautions, resulting in lapses such as not wearing required PPE, not performing hand hygiene, and not changing PPE between residents.
A resident with bipolar and borderline personality disorder was prescribed Aripiprazole, but the informed consent form for this psychotropic medication was incomplete, lacking both the dosage and the diagnosis. Staff confirmed the consent was missing required information, resulting in the resident not being fully informed about her treatment.
A resident with severe cognitive impairment and multiple medical conditions was transferred to another facility without proper consent from the resident or his Responsible Party. The transfer was initiated without documentation of an IDT meeting or a 30-day discharge notice, and was only stopped after the Responsible Party intervened. The resident experienced distress due to the lack of communication and proper procedure.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that a resident received treatment and supports for daily living in a safe manner.
The facility did not have an RN on duty for at least 8 hours on multiple days, as confirmed by staffing records and the Interim DON, resulting in noncompliance with required RN coverage.
Surveyors found that kitchen staff failed to air dry a blender after cleaning, used two nonstick pans with excessively worn surfaces, and did not properly clean the stove exhaust hood, which had greasy, black debris. The CDM confirmed these issues, which affected food preparation for 52 residents with different diet requirements.
The facility did not maintain its walk-in freezer in safe operating condition, as evidenced by internal temperatures well above freezing, melted and thawed food items, and excessive ice build-up on the floor. Structural issues such as dry rot, exposed insulation, and missing exterior walls were also observed, with staff confirming the freezer was not functioning as required for safe food storage.
The facility did not provide the required minimum square footage per resident in 12 rooms, with multiple rooms set up to accommodate three residents each despite not meeting regulatory size standards. Residents in these rooms had reasonable privacy and adequate space for personal belongings, and no complaints about room size were reported.
Multiple residents did not receive care in accordance with physician orders and professional standards, including administration of oxygen without a physician's order, failure to administer prescribed medication due to pharmacy delays without a physician's hold order, improper wound care treatment, and failure to change and label oxygen tubing as required by care plans and facility policy.
A resident with chronic pain and syncope, who regularly used physician-ordered pain medication and oxygen, did not have care plans developed for pain management or oxygen use. Despite facility policy and staff confirmation of these needs, the care plans were missing, as verified by the DON.
A resident with significant physical and mental health needs did not receive timely PT services due to an unresolved insurance transfer after admission from another facility. The resident, who required substantial assistance and had a documented need for skilled PT, only received therapy once because staff did not help resolve the insurance issue, resulting in a violation of resident rights.
A resident who was cognitively intact and dependent on staff for daily living activities reported that an RN was rude during a disagreement about treatment timing, leading to feelings of disrespect. The incident was confirmed by the DON and administrator as a violation of the resident's dignity and rights, despite facility policies requiring respectful treatment of all residents.
A resident with quadriplegia and cognitive intactness was verbally abused by a CNA during a transfer with a Hoyer lift, causing the resident to feel scared and hurt. The CNA yelled at the resident and made derogatory remarks, which was witnessed and confirmed by other staff. The incident was documented in the resident's record and the CNA's employee file.
A resident with dementia, who was known to be resistive to care and preferred afternoon showers, became combative during a morning shower when a CNA did not follow the care plan intervention to leave and return later. The care plan also failed to include the resident's preference for afternoon showers, leading to an incident where the resident's wrist was injured during the shower. The DON confirmed that the care plan did not reflect the resident's needs and that staff did not follow established interventions.
A resident's care plan was not updated after a significant change in condition following hospitalization. Despite new orders for comfort care and medications, the care plan remained unchanged, leading to unrecognized care needs. The facility's administrator and DON confirmed the oversight.
A facility failed to conduct a required skin assessment for a re-admitted resident with complex medical needs, including pressure ulcers and new comfort care orders. The oversight was due to miscommunication and lack of follow-up among nursing staff, despite clear policy requirements for assessments upon re-admission.
The facility failed to thoroughly investigate an abuse allegation involving two residents and did not submit the required 5-day investigation results to CDPH. The incident involved one resident aggressively squeezing another's wrists and shouting threats. The facility's policy required interviews with all involved parties, but the 5-day follow-up report lacked statements from staff witnesses and was not submitted to CDPH, potentially leaving abuse allegations uninvestigated.
A facility failed to verify a staff member's nursing license before assigning her nursing duties. The staff member, previously a CNA, reported passing her LVN exam but had no online license verification due to a claimed spelling error. Despite this, she worked unsupervised on night shifts. The facility's policy required online verification, which was not followed, leading to the discovery that she had not passed her exam.
The facility failed to employ a full-time RD or qualified nutritional professional, resulting in unsafe food service practices for all residents. Observations revealed improper food safety protocols, such as inadequate freezer and dishwasher temperatures, and poor sanitation procedures. The RD, UDM, and CDM did not ensure dietary staff had required competencies, leading to unsafe food handling. Additionally, unresolved issues from kitchen audits further compromised food safety.
A resident experienced severe weight loss due to the facility's failure to maintain nutritional status. Despite recommendations for nutritional supplements, no orders were placed, and the care plan was not updated. The resident's weight was not consistently monitored, and significant changes were not communicated to the physician. The resident's ability to communicate deteriorated, and there was inadequate involvement of her Durable Power of Attorney in care planning.
The facility failed to maintain 24-hour licensed nursing coverage on multiple dates in the first and second quarters of 2024, as revealed by PBJ data. The administrator confirmed the reporting of these staffing deficiencies to CMS and did not contest the findings.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, during the first and second quarters of 2024. This was identified through a review of the Payroll-Based Journal (PBJ) data, which showed multiple dates without RN coverage. The facility administrator confirmed the issue during an interview.
The facility failed to ensure competent dietary staff, with eight out of ten lacking required training. Issues included improper dishwashing procedures and incorrect freezer temperatures, risking foodborne illness for 49 residents. The CDM and RD noted ongoing staffing and equipment challenges.
The facility failed to maintain proper food storage and sanitation practices, with freezer temperatures above required levels, improperly dated food items, and inadequate sanitation procedures. Kitchen staff were unable to demonstrate correct dishwashing techniques, and pests were observed in the kitchen. Management oversight was insufficient, with part-time CDM and infrequent RD visits, leading to unresolved issues.
The Administrator failed to ensure effective oversight and resources, leading to deficiencies in dietary services and resident care. The lack of a full-time RD or CDM resulted in unsanitary food practices, while dietary services did not follow national standards, risking infection and foodborne illness. Additionally, the Administrator did not ensure proper care for residents, leading to severe weight loss, unnecessary medical treatment, and inadequate fall care plans.
The facility's Governing Body failed to manage the dietary department, resulting in Immediate Jeopardy due to inadequate oversight and monitoring. The Registered Dietician identified numerous sanitation and operational issues, such as debris in kitchen drawers, mold in the ice machine, and malfunctioning equipment. Despite being informed, the Administrator did not implement a Performance Improvement Plan, and the issues persisted, with no structured plan to address the deficiencies.
The facility's ineffective QAPI committee resulted in several deficiencies, including lack of oversight in dietary services, failure to address insidious weight loss in a resident, unmet social service needs, and inadequate fall care plans. The administrator was aware of these issues but failed to implement corrective actions, and the QAPI meetings lacked proper documentation.
The facility's QAA program was ineffective, lacking a full-time RD or CDM for dietary oversight, leading to Immediate Jeopardy. Dietary services failed to meet cleanliness and safety standards, and staff did not address weight loss in a resident. Social Services did not meet care needs for several residents, and fall care plans were not timely initiated or revised. The facility had not started any PIPs, as shown by a blank document during a QAPI review.
The facility experienced multiple equipment failures, including non-functioning call light systems in two rooms, a walk-in freezer not maintaining the required temperature, and a broken dishwasher. These issues led to potential risks for residents, such as delayed assistance and food safety concerns. The Plant Operations Supervisor confirmed the call light issues, while the Certified Kitchen staff and administrators were unaware of the freezer's temperature problem.
The facility failed to maintain an effective pest control program, leading to flies and other pests throughout the building. Residents reported flies landing on them during meals, and observations confirmed the presence of pests in the kitchen and dining areas. Despite the installation of flytraps and weather stripping, the pest issue persisted, compromising residents' right to a pest-free environment.
The facility did not accommodate the needs and preferences of three residents in an overcrowded room, leading to safety hazards and restricted independence for a resident with mobility impairments. The room contained multiple obstacles, including fans and a portable air conditioner, which hindered access to personal items and the bathroom. Staff confirmed the presence of trip hazards and unsecured cords, but no alternative solutions were provided to ensure resident safety.
The facility failed to update care plans for three residents after significant incidents. A resident with multiple falls, including one with injury, did not have a fall care plan revised. Another resident experienced two Hoyer lift incidents without care plan updates. A third resident with severe cognitive impairment and high fall risk had two falls with injuries, yet no care plan was revised. The lack of timely care plan revisions left staff without updated guidance on necessary interventions.
A resident with a suprapubic catheter experienced a delay in care due to the facility's failure to assess and reevaluate the catheter's necessity. Despite symptoms of a UTI and pain, the facility did not conduct timely evaluations or communicate effectively with the physician. This led to the resident's hospitalization for treatment. The facility's lack of documentation and follow-up on a urology referral contributed to the deficiency.
The facility failed to provide adequate social services and care planning for four residents. A resident received unnecessary psychiatric evaluations, another missed a quarterly care conference, a third lacked a discharge care plan, and a fourth did not receive a required urology consult. These deficiencies were due to miscommunication and oversight by the social services director and staff.
The facility failed to maintain proper temperature controls in the medication storage room, with temperatures exceeding recommended levels, compromising medication efficacy. Additionally, a resident received potassium chloride with conflicting administration instructions, risking gastric irritation due to discrepancies between the MAR and pharmacy label. Staff interviews confirmed these deficiencies.
The facility did not provide the required 80 square feet per resident in multiple rooms, affecting 12 rooms with insufficient space. A resident reported difficulty accessing personal belongings and performing hygiene tasks due to cramped conditions and clutter, including a portable air conditioner and fans.
A facility failed to accurately document falls in the MDS assessments for a resident with Alzheimer's, diabetes, heart disease, and cancer. The resident experienced two falls, one witnessed and one unwitnessed, which were not recorded in the MDS assessments. This oversight was confirmed by the MDSLVN during a review.
The facility failed to develop baseline care plans for two residents at risk for falls within 48 hours of admission. One resident, with Alzheimer's and other conditions, was identified as at moderate fall risk, but no care plan was created. Another resident, readmitted with a leg fracture and on medications increasing fall risk, also lacked a fall prevention plan. These deficiencies were confirmed by facility staff.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident, at moderate risk for falls, experienced three falls due to the absence of a Fall Care Plan. Another resident, also at risk for falls and planning to return home, lacked both a Fall Care Plan and a Discharge Care Plan, leaving her uninformed about her discharge plans.
Two residents in the facility experienced inadequate fall risk management, leading to continued falls and potential injuries. One resident with Alzheimer's and other conditions had multiple falls without proper evaluations or care plans, while another resident with a fracture and on fall-risk medications was incorrectly assessed as low risk. Staff interviews confirmed the lack of necessary evaluations and care plans due to oversight and staffing issues.
A resident's pain medication was not administered as per the physician's order, leading to a potential risk for poor pain control. The LVN identified a discrepancy between the pharmacy label and the MAR instructions for gabapentin, which was supposed to be given every 8 hours but was scheduled every 4 hours in the facility's system. The resident had a history of a leg fracture, lung disease, and other conditions.
A facility failed to maintain a safe and comfortable environment for residents due to a malfunctioning air conditioning system. Six residents reported excessive heat, with room temperatures exceeding the facility's policy range. The Maintenance Supervisor acknowledged the inadequacy of portable AC units, and the facility did not report the issue to the California Department of Health as required. The Chiller System had been non-functional for over a month, and the facility did not seek professional repair services promptly.
A meal tray cart with a broken wheel was not repaired in a timely manner, leading to it falling over near a resident. The maintenance supervisor was aware of the issue but failed to log it in the TELS system or inspect the cart for safety. Despite receiving replacement wheels, the cart was not removed from use, posing a potential risk to residents.
The facility failed to maintain privacy and dignity for two residents during psychiatric telehealth visits conducted in a public hallway, where sensitive information could be overheard by others. The visits are usually conducted in private areas, but a lapse in judgment led to this deficiency.
Incomplete Discharge Notices and Lack of Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own transfer and discharge policy and federal requirements when issuing 30‑day discharge notices to two residents. The facility’s policy required that discharge notices be understandable to the resident and include the specific reason for discharge, the discharge date, the exact location (with address) to which the resident would be discharged, the name and address of the local Ombudsman, and information for the state agency responsible for protecting the rights of individuals with mental health illnesses. The policy also required that the notice be provided 30 days prior to discharge and that the Ombudsman’s office be notified when a 30‑day discharge notice was issued. Resident 1, who had borderline personality disorder, bipolar disorder, suicidal ideation, COPD, bowel and bladder incontinence, and functional limitations requiring assistance with ADLs, received a Notice of Involuntary Transfer or Discharge dated 2/20/26. The notice stated that the resident would be discharged to a home or apartment of their choice in another city but did not include a specific address. It listed reasons for discharge as improved health, no longer requiring skilled care, and the facility’s inability to meet the resident’s needs, but omitted information on how to contact the state agency responsible for protecting the rights of people with mental health illnesses. The DON confirmed that the IDT‑Notice of Transfer/Discharge for this resident was incomplete, missing the date the notice was provided, the planned discharge date, specific discharge location, the reason for discharge, Ombudsman and mental health rights contact information, and signatures from the resident and ADON. The record also showed that the resident’s discharge care plan and care conference summary documented that the resident did not have a safe or reasonable discharge location and required staff assistance for medical needs. Resident 2, who had bipolar disorder, schizoaffective disorder, COPD, and intact memory, was also issued an IDT‑Notice of Transfer/Discharge dated 2/20/26. The DON confirmed this notice was incomplete in the same ways: it lacked the date it was provided to the resident, the planned discharge date, specific discharge destination information, the reason for discharge, and contact information for the local Ombudsman and the state agency responsible for protecting the rights of people with mental health illnesses. Resident 2 reported being told by the ADON that they were being discharged in 30 days because they were “high functioning” and confirmed there was no discharge plan in place when the notice was given. The Administrator stated that there was no firm discharge plan in place for either resident at the time the 30‑day notices were issued and that the Administrator was not aware the notices had been provided, despite the expectation that a solid discharge plan should exist before issuing such notices.
Failure to Monitor PRN Anti-Anxiety Medication Use
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary medications when they did not implement behavioral monitoring for an as-needed anti-anxiety medication. The facility’s undated “Unnecessary Drugs” policy stated that medications would be monitored to ensure effectiveness. The resident was admitted with diagnoses of borderline personality disorder and anxiety and was her own responsible party. The resident’s anxiety care plan, dated 11/23/25, directed staff to monitor and track the resident’s behaviors. A physician’s order dated 11/22/25 prescribed hydroxyzine 50 mg every six hours as needed for anxiety, targeting symptoms of worry that needs were not being met due to anxiety. During an interview and concurrent record review on 2/26/26, the DON confirmed that from admission through 2/26/26 there was no behavioral monitoring in place to track signs or symptoms of anxiety, and stated that the purpose of such monitoring is to count the number of episodes and monitor the effectiveness of the medication. This lack of behavioral monitoring for the resident receiving PRN hydroxyzine for anxiety resulted in the facility not ensuring the resident’s medication regimen was monitored for effectiveness as required by facility policy and the resident’s care plan, and had the potential for the resident to not maintain their highest practicable mental, physical, and psychosocial well-being.
Failure to Follow Influenza Testing Policy During Outbreak
Penalty
Summary
The facility failed to implement its Influenza Exposure Control policy when multiple residents tested positive for Influenza A and timely, comprehensive testing of exposed residents was not conducted. The policy, revised in January 2026, required a multifaceted approach to preventing influenza transmission, including testing ill persons in both affected and previously unaffected units. Four residents with significant comorbidities, including respiratory failure, COPD, pneumonia, dementia with agitation, diabetes, heart disease, chronic kidney disease, and cirrhosis, were confirmed positive for Influenza A. The Infection Prevention Nurse (IP) reported that the facility first became aware of influenza in the building when notified by a local hospital that one resident was positive, and also stated that the facility initially had no influenza test kits on hand. The IP acknowledged that she only tested residents who shared rooms with influenza-positive residents and those with flu-like symptoms, and confirmed she did not review the facility’s influenza exposure policy before determining who to test. A consulting RN, who had been at the facility for about a week, confirmed she advised the IP without reviewing the facility’s policy and later acknowledged that more residents should have been tested. The DON confirmed that the facility was not prepared for an influenza outbreak, that the influenza policy was not followed for resident testing, and that all residents should have been tested because they dined and participated in activities together and there were sick employees. The report states that this failure to follow the infection control policy for testing put residents, staff, and families at risk for contracting Influenza A and had the potential to result in serious negative clinical outcomes.
Failure to Revise Wound Care Plan After New Wound Vac Order
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s wound care plan after a new physician order was issued for a wound vacuum-assisted closure (wound vac) to the left hip pressure ulcer. The facility’s policy titled “Care Plan Revisions Upon Status Change,” revised in 2025, requires that the comprehensive care plan be reviewed and revised as necessary when a resident experiences a status change, and that the care plan be updated with new or modified interventions. Record review showed that the resident had an order dated 1/20/26 for a wound vac to the left hip, with instructions to change the dressing every Monday, Wednesday, and Friday on the AM shift and as needed, and to ensure the wound vac dressing was sealed and intact with a setting of 125 mm/Hg every shift every day. However, the corresponding care plan was not updated to include these new wound vac interventions. The resident involved had multiple significant diagnoses, including paralytic syndrome following cerebral infarction affecting the right side, diabetes, COPD, dysphagia, pressure ulcers, chronic kidney disease, hypertension, a rare skin carcinoma, pulmonary embolism, and chronic pain. The most recent MDS indicated a moderate cognitive deficit with a BIMS score of 9/15 and total dependence on staff for all ADLs. During concurrent review of the care plans and interview on 2/5/26, the DON confirmed that the wound care plan needed revision to include specific interventions related to the new wound vac order and acknowledged that the care plan was not revised and needed to be more specific for wound care, including resident-specific considerations such as the resident allowing only one nurse to complete wound care and the potential involvement of a family member if the resident refused treatments. The report states that this failure had the potential for the resident’s wound care not to be managed appropriately, which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization.
Failure to Protect Residents from Financial Abuse and Exploitation by Staff
Penalty
Summary
The facility failed to protect two residents from financial abuse, manipulation, and exploitation by an Activity Assistant (AA J). The first resident, who was cognitively intact and had multiple medical conditions including osteomyelitis, diabetes, and bipolar disorder, was manipulated by AA J into giving her debit card and PIN. AA J withdrew money from the resident's account on multiple occasions, keeping a portion for herself and failing to provide receipts as required by facility policy. Additionally, AA J solicited money from the resident under the pretense of providing post-discharge services and for a going-away party, which she never delivered, causing the resident anxiety and embarrassment. The second resident, also cognitively intact and with diagnoses including lupus, chronic kidney disease, and schizoaffective disorder, gave her bank debit card to AA J to purchase coffee creamer. Despite the facility being able to provide the item, AA J uploaded the resident's card information to her personal online shopping account and had the item delivered to her own home. The resident was unsure if she received a receipt and later had to cancel her debit card after it went missing. Staff interviews confirmed that AA J violated the facility's policy by handling resident funds and making unauthorized purchases. Multiple staff members and witness statements indicated that AA J frequently discussed her personal financial problems with residents, complained about the activity budget, and implied that residents needed to contribute money for activities. These actions made residents uncomfortable and led to some giving money directly to AA J. The facility's policies clearly prohibit staff from handling resident funds or soliciting money, and require receipts for all transactions involving resident funds, but these policies were not followed in these instances.
Failure to Thoroughly Investigate and Report Financial Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of financial abuse involving a resident who was cognitively intact and responsible for her own healthcare decisions. The resident, who had multiple complex medical conditions including osteomyelitis, pressure ulcers, diabetes, and mental health diagnoses, reported that an Activity Assistant (AA) had received money from her under the pretense of providing services. The facility's policy required immediate and thorough investigation of abuse allegations, including identifying all involved parties, interviewing witnesses, and documenting findings. However, the investigation was not completed in a timely manner, and the required five-day report to the California Department of Public Health (CDPH) was submitted two days late. Interviews and record reviews revealed that the investigation was incomplete and did not follow facility policy. Key individuals, such as the resident's family member and other potential witnesses, were not interviewed. The Director of Nursing (DON) and the Regional Registered Nurse Consultant both confirmed that the investigation lacked thoroughness and proper documentation. Additionally, the facility failed to communicate the results of the investigation to the resident and did not reimburse the resident as indicated in their report to CDPH. Further, the staff member accused of financial abuse was not properly restricted from returning to work pending the outcome of the investigation, and there was no evidence that the required one-on-one abuse training was provided as reported. The facility's failure to follow its own abuse investigation procedures and to report findings within the required timeframe constituted a deficiency in responding to and documenting alleged violations.
Failure to Adhere to COVID-19 Infection Control Protocols
Penalty
Summary
The facility failed to properly implement its infection control program to prevent the spread of COVID-19, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and hand hygiene. Certified Nursing Assistant (CNA) A and Activity Assistant (AA) both entered a room with a resident confirmed positive for COVID-19 without following the required procedures. AA entered the room without wearing a gown, gloves, or eye protection, did not perform hand hygiene upon exit, and took a snack cart into the room, which was not permitted. AA also failed to remove his N95 mask after leaving the room and admitted to forgetting about the COVID-19 status of the resident, acknowledging non-compliance with posted signage and facility policy. CNA A entered the same room and put on a gown and gloves only after entering, did not tie the gown properly, and did not wear eye protection. She did not dispose of her N95 mask or perform hand hygiene upon exit and failed to change her gown and gloves between providing care to multiple residents in the room. CNA A stated she was unaware of the need to don PPE before entering and to change PPE between residents, despite having attended a recent in-service on these procedures. The Infection Preventionist and Administrator confirmed that both staff members did not follow facility policy regarding PPE and hand hygiene for contact and droplet precautions.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the treatment being provided, specifically regarding the use of a psychotropic medication. The facility's policy required that residents be fully informed prior to initiating or increasing a psychotropic medication. However, a review of the consent form for the use of Aripiprazole (Abilify), an antipsychotic medication prescribed for bipolar disorder, revealed that the form was incomplete. The consent form did not include the dosage or the diagnosis for which the medication was prescribed. The resident involved had diagnoses of bipolar disorder and borderline personality disorder and was responsible for making her own medical decisions. Interviews with facility staff, including a licensed nurse and the administrator, confirmed that the consent form was missing required information and was not properly completed. This omission meant the resident was not fully informed about her treatment as required by facility policy.
Resident Transferred Without Proper Consent or Notice
Penalty
Summary
The facility failed to protect a resident's rights by attempting to transfer him to another facility out of the area without obtaining his or his Responsible Party's (RP) permission. The resident, who had a severe cognitive deficit as indicated by a BIMS score of 6 out of 15, was admitted with multiple diagnoses including a right femur fracture, metabolic encephalopathy, dysphagia, cardiomegaly, pleural effusion, hypotension, anxiety, urinary tract infections, and Guillain-Barre Syndrome. The facility's own policy required support of resident self-determination and choice, but there was no documentation of an Interdisciplinary Team (IDT) meeting or a progress note for a planned and safe discharge. The admission coordinator admitted to not knowing about the requirement for a 30-day discharge notice. The social worker stated that both the resident and the RP had agreed to the transfer during a meeting, but the RP later intervened and stopped the transfer, stating she had never approved it and did not want the resident moved to a distant facility. The resident expressed distress about the attempted transfer, stating he was upset and unaware of where he was being taken. There was no documentation supporting that the required processes for transfer or discharge were followed, and the administrator confirmed that the attempted transfer was a violation of the resident's rights.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 hours per day, 7 days a week, as required. Review of the Payroll Based Journal (PBJ) for the specified quarter revealed that there was no RN coverage on several specific dates, including multiple Saturdays and Sundays. This was confirmed during an interview with the Interim Director of Nursing (IDON), who acknowledged the absence of RN coverage during these periods. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Unsanitary Kitchen Conditions and Improper Equipment Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility kitchen related to food safety and sanitation. A blender was found stored wet with the lid on, and the Certified Dietary Manager (CDM) confirmed it had not been air dried after cleaning. This practice does not comply with the USDA Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing. Additionally, two nonstick frying pans were observed to have excessively worn cooking surfaces, and the CDM acknowledged that these pans were no longer cleanable and would be discarded. The USDA Food Code specifies that multiuse food-contact surfaces must be smooth and free of imperfections such as cracks or pits. Further, the exhaust hood over the stove was found to have greasy, black debris on its interior surface, despite documentation indicating it had been cleaned the previous day. The CDM confirmed the hood was not clean at the time of inspection. The facility's own policy requires the kitchen hood exhaust system to be properly cleaned and maintained to support a safe and healthful environment. These deficiencies were identified during observations, interviews, and record reviews, and affected the kitchen that prepared food for 52 residents with various dietary needs.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the walk-in freezer used for food storage. Observations revealed that the internal temperature of the freezer was significantly above the required level for safe food storage, with thermometer readings ranging from 20 to 40 degrees Fahrenheit. Food items such as a five-gallon container of strawberry ice cream, cinnamon bread dough, and raspberry sorbet were found either melted or thawed, indicating the freezer was not keeping food frozen as required. Excessive ice build-up was also observed on the freezer floor, including a large ball of frozen ice and a black floor mat covered in ice. The Certified Dietary Manager (CDM) and Director of Maintenance (DM) confirmed these findings and acknowledged ongoing issues with the freezer's temperature and structure. Further inspection showed that the freezer's defrost cycle contributed to water accumulation and subsequent ice formation on the floor. Structural deficiencies were also noted, including dry rot in the wall and roof, exposed insulation, wood framing, and missing exterior wall sections, leaving hardware exposed to the outside. The Director of Nursing (DON) confirmed that the freezer should maintain temperatures at or below 0 degrees Fahrenheit and that all foods should be frozen solid, which was not the case during the observations.
Non-Compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms in 12 out of 22 resident rooms, as determined by observation, interview, and document review. During the survey, it was confirmed that rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, and 23 were set up to accommodate three residents each, despite not meeting the square footage requirements. A previous waiver for reduced bedroom sizes granted by CMS was reviewed, and there had been no physical expansion of the rooms since the last survey. Residents in these rooms were observed to have reasonable privacy, sufficient space for personal belongings, and no complaints regarding room size were reported.
Failure to Follow Physician Orders and Professional Standards in Medication and Oxygen Administration
Penalty
Summary
The facility failed to provide treatment and care to several residents in accordance with professional standards of practice and physician orders. One resident with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD) was observed receiving continuous oxygen therapy at 4 liters per minute without a physician's order. The resident's medication administration record (MAR) and order summary did not reflect an order for oxygen, although the care plan referenced oxygen therapy. The Director of Nursing (DON) confirmed that the resident was using oxygen without a physician's order, contrary to facility policy and professional standards. Another resident with osteomyelitis, a stage 4 pressure ulcer, polyneuropathy, and bipolar disorder did not receive their prescribed Lyrica medication for five consecutive days due to a pharmacy delivery issue. The MAR indicated the medication was held, but there was no physician order to hold it, and the care plan required administration per physician orders. The DON and a registered nurse confirmed that the pharmacy was notified but no follow-up occurred to obtain the medication, and the physician had not ordered the medication to be held. Additional deficiencies included failure to change and label oxygen tubing weekly as required by both care plans and facility policy for two residents, and failure to follow a physician's order for wound care for another resident. In one case, a nurse used table salt instead of Epsom salt for a prescribed soak, which was confirmed by the DON. In another case, oxygen tubing was not labeled or dated as required, and staff interviews confirmed inconsistent practices regarding tubing changes and labeling.
Failure to Develop Care Plans for Pain Management and Oxygen Use
Penalty
Summary
The facility failed to develop and implement care plans for pain management and oxygen use for one resident. Despite the facility's policy requiring a comprehensive, person-centered care plan for each resident, and revisions after each comprehensive and quarterly Minimum Data Set (MDS) assessment, no such care plans were created for this resident. The resident was admitted with diagnoses including chronic pain and syncope, and had a BIMS score indicating some memory and decision-making problems. Observations and interviews confirmed that the resident regularly used pain medication and oxygen, both of which were ordered by a physician. However, a review of the resident's care plans showed that neither pain management nor oxygen use was addressed. The Director of Nursing confirmed that these care plans were missing and acknowledged that they should have been developed.
Failure to Provide Timely Physical Therapy Due to Insurance Transfer Delays
Penalty
Summary
The facility failed to provide timely Physical Therapy (PT) services to a resident who required skilled PT following admission with multiple diagnoses, including hemiplegia and hemiparesis after a stroke, COVID-19, diabetes, hypertension, major depressive disorder, anxiety, muscle weakness, and chronic pain. The resident was cognitively intact and required substantial to maximum assistance with transfers, showers, and dressing, as documented in the Minimum Data Set. Despite a PT evaluation indicating the need for skilled therapy to assess functional abilities, enhance rehabilitation potential, and improve mobility and safety, the resident only received PT once since admission. The delay in therapy services was due to unresolved insurance transfer issues following the resident's move from another facility over 18 months prior. Staff interviews confirmed that the resident was not receiving therapy because her insurance had not been transferred to the local county, and no one had assisted her in resolving the issue. The Business Office Manager and facility leadership acknowledged that the insurance should have been changed months earlier, and the lack of assistance resulted in the resident not receiving needed PT services, which was confirmed as a violation of resident rights.
Resident Dignity Violated by RN's Rude Behavior During Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) was reported to have been rude to a resident during direct care, specifically during a disagreement about the timing of a treatment to the resident's left toe. The resident, who was cognitively intact with a BIMS score of 15 and required substantial assistance with activities of daily living due to multiple medical and mental health diagnoses, reported the incident to a licensed nurse and subsequently to the Director of Nursing (DON). The DON confirmed that the incident was discussed in a meeting with the resident and the Ombudsman present, and acknowledged that the RN's behavior constituted a violation of the resident's rights and dignity. The facility's policies on promoting and maintaining resident dignity, as well as resident rights, require all staff to treat residents with respect and dignity, regardless of their background or condition. Despite these policies, the RN's conduct during the care interaction failed to uphold these standards, resulting in the resident feeling disrespected and prompting her to report the incident. The administrator later confirmed that the RN's actions violated the resident's dignity and rights during the provision of care.
Verbal Abuse of Resident During Transfer
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) verbally abused a resident during a transfer using a Hoyer lift. The resident, who was cognitively intact and had significant physical disabilities including quadriplegia and contractures, reported feeling scared and hurt when the CNA stopped her mid-air during the transfer and began yelling at her. The CNA told the resident that no one liked to work with her or provide her care, which was confirmed by another CNA present in the room. A third CNA heard yelling from the hallway and entered the room to assist after being asked by the second CNA. The facility's policy defines abuse to include verbal abuse and intimidation that results in mental anguish. Documentation in the resident's clinical record and staff interviews corroborated the incident, with the resident expressing emotional distress and the CNA admitting to raising her voice and acting out of line. The incident was also documented in a Report of Suspected Dependent Adult/Elder Abuse and in the CNA's employee file, which noted misconduct and failure to maintain acceptable standards of respect for residents.
Failure to Develop and Implement Individualized Care Plan for Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to develop and implement an individualized, person-centered care plan for a resident with dementia and Alzheimer's disease. The resident had a documented history of being resistive to care, particularly with activities of daily living such as bathing. The care plan included an intervention for staff to reassure the resident, leave, and return 5-10 minutes later if the resident resisted care. However, during a morning shower, a CNA did not follow this intervention and instead proceeded with the shower despite the resident becoming combative. The CNA admitted to grabbing the resident's hands and continuing with the shower, resulting in the resident sustaining redness, swelling, and tenderness to her wrist, which required medical evaluation and treatment. Additionally, the care plan failed to address the resident's preference for afternoon showers, a preference known to regular staff and the resident's family. The resident was not a morning person and was more cooperative with showers in the afternoon. This information was not included in the care plan, and the CNA who provided care that day was unaware of this preference, leading to increased resistance and the subsequent incident. Observations and interviews confirmed that the care plan did not reflect the resident's specific needs and preferences regarding the timing of showers. The DON acknowledged that the care plan lacked this critical information and that the staff did not follow the existing intervention to leave and return later when the resident resisted care. These failures contributed to the resident's combative behavior and the injury sustained during the shower.
Failure to Update Care Plan After Resident's Hospitalization
Penalty
Summary
The facility failed to revise and update the care plan for a resident following a significant change in condition after hospitalization. The resident, who was admitted with multiple diagnoses including heart failure, COPD, pressure ulcers, and malnutrition, was readmitted to the facility with new orders for comfort care and new medications. Despite these changes, the care plan was not updated to reflect the resident's current needs, including the new comfort care measures and medications. Interviews with the facility's administrator and Director of Nursing confirmed that the care plan had not been revised since before the resident's hospitalization. The last update to the care plan was on 12/10/24, and it did not include the new comfort medications or address the resident's new problems. This oversight resulted in the resident's individualized care needs going unrecognized, with the potential for further decline in their physical, mental, and psychological status.
Failure to Complete Re-Admission Skin Assessment
Penalty
Summary
The facility failed to complete a skin assessment upon the re-admission of a resident, identified as Resident 2, which was a requirement according to the facility's policy. Resident 2 had been re-admitted to the facility with a history of heart failure, COPD, pressure ulcers, and other medical conditions, including new orders for comfort care. Despite these needs, the necessary skin assessment was not conducted, which was confirmed by the administrator, a licensed nurse, and the Director of Nursing. This oversight was attributed to a lack of communication and follow-up among the nursing staff, as one nurse assumed another had completed the re-admission process. The facility's policy required that admission orders provide essential care information and that new admissions undergo assessments every shift for three days. However, during interviews, it was revealed that the responsible nurse did not complete the skin assessment or verify the completion of the re-admission process. The Director of Nursing had instructed the staff to treat the re-admission as a new admission, but the assessment was still missed. This failure to adhere to the facility's policy had the potential for negative clinical outcomes for Resident 2, who had specific skin treatment needs.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents and did not provide the California Department of Public Health (CDPH) with the required 5-day investigation results. The facility's policy and procedure on abuse, neglect, and exploitation required the identification and interview of all individuals involved in the allegations, including victims, perpetrators, witnesses, and anyone with relevant information. However, the facility did not adhere to this policy. The report of suspected abuse, dated 10/10/24, indicated that facility staff witnessed resident-to-resident abuse, where one resident aggressively squeezed another resident's wrists and hands while shouting threats. Despite this, the facility did not include statements from the staff who witnessed the incident in the 5-day follow-up report. The facility's administrator confirmed that the 5-day follow-up report was incomplete and acknowledged that it was not submitted to CDPH as required. The residents involved had specific medical conditions; one was diagnosed with depression and chronic pain syndrome and was his own responsible party, while the other had age-related cognitive decline and chronic pain syndrome and was not his own responsible party. The failure to conduct a thorough investigation and report the findings to CDPH had the potential to leave abuse allegations uninvestigated, placing residents at risk for harm.
Unverified Nursing License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that only staff with a verified nursing license were assigned to care for patients. A staff member, who had been a Certified Nurse Assistant (CNA) for eight years, was assigned nursing duties after reporting that she had passed her licensing exam to become a Licensed Vocational Nurse (LVN). However, her employee file did not include online verification of her nursing license. The Director of Nurses (DON) and the Director of Staff Development (DSD) were informed by the staff member that there was a spelling error in her name, which delayed the online posting of her license. Despite this, the facility allowed her to work as a nurse without verifying her license through the Board of Vocational Nursing's website. The DSD confirmed that the staff member provided documents that appeared genuine, including photos of her successful exam results, but these were not verified online. The facility's policy required online verification of licenses, which was not followed in this case. The staff member worked unsupervised on the night shift, responsible for the care of all residents, without a verified nursing license. It was only during a recent internal review that the facility discovered the staff member had not passed her exam and did not have an LVN license, highlighting a significant oversight in the facility's verification process.
Lack of Qualified Dietary Oversight Leads to Unsafe Food Practices
Penalty
Summary
The facility failed to employ a full-time Registered Dietician (RD) or a clinically qualified nutritional professional to oversee the dietary staff, resulting in unsafe and unsanitary food service practices for all 49 residents. Observations revealed that dietary staff did not follow proper food safety protocols, such as maintaining appropriate temperatures in the freezer and dishwasher, and ensuring proper sanitation procedures. The lack of qualified oversight led to potential foodborne illness risks, as evidenced by the presence of flies in the kitchen, improper dishwashing techniques, and undated food items. The RD, Unqualified Dietary Manager (UDM), and Certified Dietary Manager (CDM) did not ensure that all dietary staff had the required state and federal competencies upon hire. Several staff members lacked necessary food handler certifications and competency verifications for kitchen duties and equipment. This lack of training and oversight contributed to the unsafe food handling practices observed during the survey. Additionally, the RD and dietary management team failed to address identified issues from kitchen and sanitation audits. Problems such as mold in the ice machine, debris in kitchen drawers, and malfunctioning equipment were not resolved, further compromising food safety. The RD's infrequent presence and the absence of a consistent CDM exacerbated these issues, leaving the facility's dietary department without adequate leadership and oversight.
Removal Plan
- Hiring a full-time qualified Certified Dietary Manager (CDM) to provide supervision to Food and Nutrition services staff
- Plans to repair the freezer/dishwasher
- Remove all food that had potential to cause foodborne illness
- Buy 2 freezers
- Train all dietary staff in dietary policies and procedures
Failure to Address Nutritional Needs Leads to Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident 22, who experienced severe weight loss over time. Initially admitted with a stable weight and a regular diet, Resident 22's intake decreased significantly, and her weight dropped from 153.4 pounds to 119.0 pounds over several months. Despite recommendations from the Registered Dietician to add nutritional supplements, no orders were placed, and the resident's care plan was not updated to address her declining nutritional status. Resident 22 had a history of medical conditions, including cerebral infarction, mild cognitive impairment, and difficulty swallowing, which contributed to her nutritional challenges. The facility's weight monitoring policy required weekly weight checks for residents with weight loss, but Resident 22 was not weighed consistently, and significant weight changes were not communicated to the physician. The interdisciplinary care team failed to hold regular weight meetings, and the resident's dietary orders were not consistently reviewed or modified to address her needs. Throughout the period of weight loss, Resident 22's ability to communicate her needs deteriorated, and she became nonverbal, requiring a picture book for communication. Despite these challenges, the facility did not adequately involve the resident or her Durable Power of Attorney in care planning, and there was a lack of communication regarding her transition to comfort-focused treatment. The facility's inaction and failure to implement timely interventions contributed to Resident 22's severe weight loss and health decline.
Insufficient Nursing Staff Coverage in 2024
Penalty
Summary
The facility failed to provide sufficient nursing staff during the first and second quarters of 2024, as evidenced by the Payroll-Based Journal (PBJ) data reviewed. Specifically, the facility did not maintain 24-hour licensed nursing coverage on multiple dates across these quarters. In the first quarter, the absence of licensed nursing coverage was noted on ten specific dates, while in the second quarter, it was noted on four dates. During an interview and record review with the administrator, it was confirmed that the facility had reported these staffing deficiencies to the Centers for Medicare & Medicaid Services (CMS). The administrator acknowledged the submission of the nursing staff data to CMS and did not dispute the findings.
RN Staffing Deficiency in 2024
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during the first and second quarters of 2024. This deficiency was identified through a review of the facility's mandatory submission of staffing information based on payroll data, known as the Payroll-Based Journal (PBJ), which is required by the Centers for Medicare & Medicaid Services (CMS). Specifically, the facility did not have RN coverage on multiple dates across both quarters, including several days in October, November, and December of 2023, as well as in January, February, and March of 2024. During an interview and record review with the facility administrator, it was confirmed that the staffing data had been reported to CMS, and the administrator acknowledged the issue without contesting the findings.
Deficiencies in Dietary Staff Competency and Kitchen Operations
Penalty
Summary
The facility failed to ensure that the kitchen had sufficient and competent dietary staff to perform their duties effectively. Eight out of ten kitchen staff lacked the required competencies and training to fulfill their job requirements. Two staff members were unable to demonstrate or verbalize how to test the sanitizing solution and set up an emergency 3-compartment sink according to guidelines. Additionally, one staff member did not know the correct temperature for the walk-in freezer and failed to report issues to administrative staff. These deficiencies had the potential to result in foodborne illnesses for the 49 residents consuming food prepared in the facility. The report highlights several specific instances of non-compliance with training and competency requirements. For example, a Certified Dietary Manager (CDM) was hired part-time and later full-time but did not complete the required training until four months after hire. Similarly, a Dietary Aide (DA) was hired without the necessary Food Handlers Certificate and did not have any verification of job competency until several months later. Other staff members also lacked proper certification and competency verification, which contributed to the overall deficiency in the dietary department. Observations during the survey revealed further issues, such as improper use of the 3-compartment sink for dishwashing and failure to test water temperature and sanitizer levels. The walk-in freezer was found to be at an incorrect temperature, with food items not properly frozen, posing a risk of foodborne illness. The CDM confirmed that the dishwasher had been malfunctioning, and there was a lack of consistent oversight in the kitchen. The Registered Dietician (RD) also noted ongoing challenges with staffing and equipment, which were not adequately addressed by the facility administration.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by several observations and interviews. The freezer temperature was found to be significantly above the required 0 degrees Fahrenheit, with items such as ice cream, cheese, and deli meat being soft to the touch. This issue was not reported by the kitchen staff, who were unaware of the temperature discrepancy. Additionally, food items in both the refrigerator and dry storage were improperly dated, with many lacking received or use-by dates, contrary to facility policy. Sanitation practices in the kitchen were also found to be lacking. Two kitchen staff members were unable to properly demonstrate or verbalize the correct procedure for using a 3-compartment sink for dishwashing, and there was no documentation of water temperature or sanitizer levels. The sanitizer solution was found to be above the recommended concentration, and the staff did not know how to test it correctly. Furthermore, flies and other pests were observed in the kitchen, and there were instances of dirty equipment and improper hand hygiene by staff. The facility's management and oversight of the kitchen were inadequate, with the Certified Dietary Manager (CDM) working part-time and the Registered Dietitian (RD) visiting infrequently. The RD's audits revealed ongoing issues such as gaps in logs, equipment malfunctions, and improper storage practices. Despite these findings, there was no evidence of a consistent plan to address these deficiencies, and the facility lacked a full-time qualified CDM to oversee kitchen operations.
Administrator's Oversight Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility's Administrator failed to ensure effective oversight and necessary resources to meet resident care services, resulting in several deficiencies. The Administrator did not ensure a full-time Registered Dietician (RD) or Certified Dietary Manager (CDM) was available to oversee dietary staff, leading to unsafe and unsanitary food service practices for all 49 residents. The RD and unqualified dietary manager failed to ensure dietary staff had the required competencies, and issues identified in kitchen audits were not resolved. This resulted in an Immediate Jeopardy situation due to the lack of qualified oversight and failure to maintain sanitary conditions in the kitchen. Dietary services did not adhere to national standards for kitchen cleanliness and food storage safety, increasing the risk of infection and foodborne illness among residents. The RD reported ongoing issues with the freezer and dishwasher, and the lack of consistent CDM oversight contributed to the kitchen's struggles. Observations revealed unsanitary conditions, such as flies in the kitchen, improper dishwashing procedures, and undated food items. The CDM was unable to locate logs for monitoring temperatures and sanitizer levels, further indicating a lack of proper oversight and documentation. The Administrator also failed to ensure proper care for individual residents. Resident 22 experienced severe weight loss due to the staff's failure to identify and address insidious weight loss. Social Services did not meet the needs of several residents, resulting in unnecessary medical treatment, missed care conferences, and lack of discharge planning. Additionally, fall care plans were not initiated or revised for residents at risk, leaving staff uninformed about residents' health status and necessary interventions. The Administrator admitted awareness of these issues but had not implemented a Performance Improvement Plan to address them.
Governing Body's Failure in Dietary Oversight Leads to Immediate Jeopardy
Penalty
Summary
The facility's Governing Body (GB) failed to effectively manage the dietary department, leading to an Immediate Jeopardy situation. The GB did not ensure adequate oversight and monitoring, resulting in numerous sanitation and operational issues in the kitchen. These issues were identified through various audits conducted by the Registered Dietician (RD), which highlighted problems such as debris in kitchen drawers, mold in the ice machine, and malfunctioning kitchen equipment like the oven and steam table. Additionally, there were gaps in sanitation logs, improper storage of supplies, and inadequate temperature regulation in storage areas. The RD communicated these findings to the facility's Administrator (ADMIN) and the GB, but there was a lack of effective response and corrective action. The RD noted that the Unqualified Dietary Manager (UDM) was not actively involved in kitchen operations and was still assisting with housekeeping duties. Despite the RD's recommendations for additional staffing and the presence of a Certified Dietary Manager (CDM) on weekends, the issues persisted. The ADMIN admitted awareness of the problems but failed to implement a Performance Improvement Plan (PIP) or track the issues effectively. Interviews with the ADMIN and the Regional Director of Operations (RDO) revealed acknowledgment of the deficiencies and the need for repairs and improvements. However, there was no evidence of a structured plan to address the deficiencies, and the facility had not started any specific PIP. The RDO confirmed that the RD, CDM, and ADMIN needed to work together to establish competencies and address the ongoing issues in the dietary department.
Ineffective QAPI Committee Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) committee, which resulted in several deficiencies. The facility did not have a full-time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to oversee dietary staff, leading to unsafe and unsanitary food service for all 49 residents. This lack of oversight resulted in an Immediate Jeopardy situation, as there was no qualified personnel to conduct daily kitchen inspections, provide feedback, or ensure staff competency. Additionally, the dietary services did not adhere to national standards for kitchen cleanliness and food storage safety. The staff also failed to identify and address insidious weight loss in a resident, which is a gradual, unintended, and progressive weight loss over time. Furthermore, the Social Services Department did not meet the needs of several residents, and fall care plans were not initiated or revised timely for some residents. The facility's QAPI program was not effectively implemented, as evidenced by the lack of tracking and measuring performance, establishing goals, and identifying quality deficiencies. The administrator was aware of the issues but failed to take corrective actions. The QAPI committee meetings lacked proper documentation, and no Performance Improvement Plan (PIP) was initiated to address the deficiencies. The Regional Director of Operations acknowledged the issues but noted that necessary repairs and competencies were not in place.
Ineffective QAA Program and Oversight in Dietary and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, as evidenced by several deficiencies. There was no full-time Registered Dietician (RD) or Certified Dietary Manager (CDM) to oversee dietary staff, resulting in an Immediate Jeopardy situation due to the lack of qualified oversight for daily kitchen inspections and staff competency. Additionally, dietary services did not adhere to national standards for kitchen cleanliness and food storage safety. The staff also failed to identify and address insidious weight loss in a resident, and the Social Services Department did not meet the care needs of multiple residents. Furthermore, fall care plans were not initiated or revised in a timely manner for several residents. During a review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes, it was revealed that the facility had not started any Performance Improvement Plans (PIPs), as evidenced by a blank document presented by the administrator. This lack of action and oversight contributed to the deficiencies identified during the survey.
Equipment Failures in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment, leading to several deficiencies. The communication call light systems in two rooms were not functioning properly, as observed during a facility tour. Residents in these rooms reported that their call lights were not working, causing delays in receiving assistance. The Plant Operations Supervisor confirmed that the call lights were intermittently turning on and off due to disconnected wires, which had been an issue for at least six weeks for one resident. Additionally, the walk-in freezer was not maintaining the required temperature of 0 degrees Fahrenheit or below. Service invoices indicated issues with the defrost timer and evaporator coil, leading to ice buildup and a freezer temperature of 35 degrees Fahrenheit. The Certified Kitchen staff and administrators were unaware of the temperature issue, which resulted in food items being improperly stored. Furthermore, the dishwasher in the kitchen was not operational due to a faulty electrical breaker, which had been an issue for over a week. The Registered Dietician expressed concerns about the sanitary conditions in the kitchen due to these equipment failures.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and other pests throughout the building. Observations and interviews revealed that flies were landing on residents during meals, compromising their right to a pest-free home environment. The facility's pest control policy, dated 2024, outlined measures to remove and contain common household pests, but these measures were not effectively implemented. A Registered Dietician's inspection of the kitchen noted a gap under the screen door, which was identified as a potential entry point for flies. Subsequent sanitation findings and interviews confirmed the presence of flies and other pests in the kitchen and dining areas. Residents expressed dissatisfaction with the pest situation, with 11 out of 14 residents reporting flies everywhere, and one resident specifically mentioning flies on their food. Observations also noted flies in resident rooms and on food trays. The Plant Operations Supervisor installed flytraps in various locations, including the entrance lobby, main dining hall, and kitchen, and applied weather stripping to the kitchen door to address the issue. However, these actions were insufficient to prevent the ongoing pest problem, as evidenced by continued resident complaints and observations of flies in the facility.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in a room with less than 80 square feet per resident, leading to safety hazards and a lack of dignity and independence for Resident 35. Resident 35, who uses a wheelchair due to heart failure and bilateral below-knee amputation, reported insufficient space to access personal belongings and perform oral hygiene tasks independently. The room was overcrowded with three beds, a portable air conditioner, and multiple fans, creating obstacles and trip hazards. Resident 35 expressed discomfort with a fan blowing on him and difficulty accessing the bathroom due to space constraints. Observations and interviews with staff confirmed the room's overcrowded conditions and the presence of unsecured cords and trip hazards. The Director of Nursing acknowledged the room's limitations and the residents' refusal to remove the fans, but no alternative solutions were offered to ensure safety. The facility's policy on accommodating resident needs emphasizes maintaining independence and dignity, which was not upheld in this situation, as evidenced by the residents' restricted mobility and access to personal items.
Failure to Revise Care Plans After Incidents
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) reviewed and revised the care plans for three residents following significant incidents. Resident 15 experienced multiple falls, including two without injury and one with injury, yet the care plan was not updated to address the risk of falls. Despite recommendations for a medication review, rehab referral, and care plan revision after the falls, no fall care plan was developed or reviewed. The Minimum Data Set Licensed Vocational Nurse (MDSLVN) confirmed the absence of a fall care plan for Resident 15, despite the falls occurring on three separate occasions. Resident 8, who was cognitively intact but physically dependent due to quadriplegia, experienced two incidents involving improper use of a Hoyer lift. In both cases, the care plan was not revised to address the issues with the Hoyer lift, despite the Director of Nursing (DON) acknowledging the incidents and the need for a short-term care plan. The lack of timely care plan revision left the staff without updated guidance on handling Resident 8's transfers safely. Resident 52, with severe cognitive impairment and a high fall risk, had two falls resulting in injuries, including a hip fracture. Despite these incidents, no care plan was created or revised to address the fall risk. The DON confirmed the absence of a care plan for these incidents, indicating that the shift nurse should have initiated a short-term fall care plan. The failure to update care plans for these residents potentially left staff uninformed about the residents' health status and the necessary interventions.
Failure to Assess and Reevaluate Suprapubic Catheter Needs
Penalty
Summary
The facility's nursing staff failed to assess and reevaluate the continued need for a suprapubic urinary catheter for Resident 12, leading to a significant delay in identifying a change in condition. Resident 12, who was admitted with a suprapubic catheter and other medical conditions such as type 2 diabetes and neuromuscular dysfunction of the bladder, experienced a urinary tract infection (UTI) and pain. Despite an active order for a urology evaluation, there was no documentation of a consult occurring. The resident was treated for a UTI with antibiotics, but the facility did not adequately monitor or address the resident's ongoing symptoms and pain. Interviews and record reviews revealed that Resident 12 reported kidney pain and cloudy urine, but the facility's response was inadequate. The Director of Nursing (DON) noted the resident's pain and cloudy urine but did not perform a urine assessment initially. When a urinalysis (UA) was eventually conducted, it showed bacteria and blood in the urine, indicating an infection. However, the results were not signed by the physician, and there was a lack of communication between the facility staff and the physician regarding the resident's symptoms and pain. The situation escalated when Resident 12 experienced increased back pain and vaginal bleeding, prompting a hospital visit where the UTI was confirmed, and antibiotics were prescribed. The DON and the physician had conflicting accounts regarding the UA results, with the physician stating he was not informed of the resident's symptoms and pain. The facility's failure to follow through with the urology referral and inadequate communication and documentation contributed to the resident's emergent hospitalization and treatment for the UTI.
Deficiencies in Social Services and Care Planning
Penalty
Summary
The facility failed to provide appropriate medically-related social services for four residents, leading to deficiencies in their care. For Resident 6, a weekly telehealth psychiatric assessment was ordered despite the resident not exhibiting any behavioral issues. This was confirmed by the family, a licensed vocational nurse, the medical director, and the social services director (SSD), who mistakenly believed the resident had anxiety. The unnecessary psychiatric evaluations continued without justification, as the resident had severe cognitive impairment and no behavioral symptoms. Resident 8 did not have a quarterly care conference arranged, which is a requirement for discussing and addressing care concerns. Although the resident was cognitively intact and capable of making her own healthcare decisions, she did not recall attending any care conferences. The SSD acknowledged that a care conference was not rescheduled after the resident initially refused to attend, and there was no communication among the interdisciplinary team to ensure the resident's care needs were met. Resident 303 did not have a discharge care plan developed, which is essential for preparing residents emotionally and practically for discharge. The SSD admitted that the discharge care plan should have been completed within the first 72 hours of admission but was not. Additionally, Resident 12 did not receive a urology consult as ordered, despite having a suprapubic catheter and a care plan indicating the need for such a consult. The SSD was unaware of the referral, and there was no documentation of a urology consult in the resident's records.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain proper temperature controls in the medication storage room, which compromised the integrity of the medications stored there. Observations revealed that the room's temperature exceeded the manufacturer's recommended range of 68 to 77 degrees Fahrenheit, with recorded temperatures ranging from 78 to 88 degrees Fahrenheit over a period of several weeks. Despite the presence of a portable air conditioner, the room's vent was blocked, contributing to the elevated temperatures. Interviews with staff, including the Clinical Resources Nurse Consultant, Pharmacist, and Maintenance Supervisor, confirmed that the temperature logs consistently showed non-compliance, and the efficacy of the medications could not be guaranteed. Additionally, the facility failed to ensure that medications were labeled and administered according to professional standards. A discrepancy was found in the administration instructions for potassium chloride prescribed to a resident. The Medication Administration Record (MAR) instructed administration with a full glass of water, while the pharmacy label indicated it should be taken with food. This inconsistency was not noticed by the Licensed Vocational Nurse (LVN) administering the medication, potentially leading to gastric irritation for the resident, who had a history of Gastro-Esophageal Reflux Disease. The Director of Nursing acknowledged that the system for inputting orders automatically populated instructions to administer potassium chloride with water but did not include the requirement to take it with food. This oversight resulted in conflicting instructions between the physician's orders and the pharmacy label, highlighting a failure in the facility's medication labeling and administration processes.
Inadequate Space in Resident Rooms
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in multiple occupancy rooms, as mandated by regulation. This deficiency was observed in 12 resident rooms, where the space was insufficient for the residents' needs. Despite a previously granted waiver for reduced bedroom sizes, the facility had not expanded since the last survey, and the current room arrangements did not meet the necessary space requirements. The resident roster indicated that several rooms housed three residents each, exacerbating the space limitations. During an observation and interview, a resident expressed difficulty accessing personal belongings due to the cramped conditions. The resident's wheelchair could not fit into the bathroom, preventing them from performing personal hygiene tasks independently. The room was cluttered with a portable air conditioner and fans, further restricting movement and access. These conditions highlighted the inadequate space and its impact on the residents' ability to function independently and maintain their dignity and well-being.
Inaccurate MDS Assessments for Resident Falls
Penalty
Summary
The facility failed to ensure accurate assessments in the Quarterly Minimum Data Set (MDS) for a resident, leading to an inaccurate reflection of care needs to prevent falls. Specifically, the MDS assessments for a resident did not document two falls that occurred within the assessment periods. The resident, who had diagnoses including Alzheimer's disease, diabetes, heart disease, and cancer, experienced a witnessed fall on January 1st, where they slid out of a walker in the main lobby. This incident was documented in the nursing progress notes but was not reflected in the MDS assessment dated February 16th. Additionally, the resident had an unwitnessed fall on April 1st, as documented in the Fall Interdisciplinary Team Post Event Note, where the resident was found sitting on the floor at the foot of the bed. This fall was also not recorded in the subsequent MDS assessment dated May 16th. During an interview and record review, the MDS Licensed Vocational Nurse confirmed that these falls were not identified in the MDS assessments, which should have been included to ensure an accurate assessment of the resident's health conditions.
Failure to Develop Baseline Care Plans for Fall Risk
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents, Resident 15 and Resident 303, within 48 hours of their admission, as required by the facility's policy. Resident 15, who was admitted with Alzheimer's disease, diabetes, heart disease, and cancer, was identified as being at moderate risk for falls based on a Fall Risk Evaluation conducted during the admission physical assessment. Despite this, no baseline care plan addressing fall prevention was developed for Resident 15. This oversight was confirmed during a review of Resident 15's care plans by the Minimum Data Set Licensed Vocational Nurse (MDSLVN). Similarly, Resident 303, who was readmitted after a hospital stay with diagnoses including a fracture of the right leg, lung disease, and muscle weakness, was also at risk for falls due to the use of medications such as Lasix, Metoprolol, and Prazosin, which can lower blood pressure and increase fall risk. Despite these risk factors, no baseline care plan for fall prevention was developed for Resident 303. This deficiency was confirmed during a review of Resident 303's records by the Director of Nursing (DON).
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident 15, who was at moderate risk for falls due to conditions such as Alzheimer's disease, diabetes, heart disease, and cancer, did not have a Fall Care Plan developed upon admission. This oversight resulted in Resident 15 experiencing three falls, one of which caused injuries. The Minimum Data Set Licensed Vocational Nurse (MDSLVN) confirmed that a comprehensive care plan to prevent falls should have been in place from the time of admission. Similarly, Resident 303, who had a history of a right leg fracture, lung disease, muscle weakness, anxiety disorder, and depression, was also at risk for falls. Despite being on medications that increased fall risk, no Fall Care Plan was developed for Resident 303. The Director of Nursing (DON) acknowledged that a comprehensive care plan with interventions to prevent falls should have been created upon admission. Additionally, Resident 303 was planning to return home, but there was no Discharge Care Plan developed. The Social Services Coordinator (SSC) admitted that a Discharge Care Plan should have been established within the first 72 hours of admission and discussed with the resident. The lack of a Discharge Care Plan left Resident 303 uninformed about her discharge plans, which was confirmed during an interview with the resident.
Inadequate Fall Risk Management for Two Residents
Penalty
Summary
The facility failed to ensure accurate and complete Fall Risk Evaluations and Fall Care Plans for two residents, leading to continued falls and potential risk for further injuries. Resident 15, who was admitted with Alzheimer's disease, diabetes, heart disease, and cancer, experienced multiple falls without appropriate interventions or care plans being developed. Despite having a severely impaired cognition and requiring assistance with mobility, Resident 15's fall risk was not accurately assessed, and no care plans were created on admission or after the falls on January 1 and April 1. It was only after a severe fall on July 2, which resulted in a laceration and emergency room visit, that a Fall Care Plan was developed. Resident 303, who was admitted with a fracture, lung disease, muscle weakness, and was on medications that increased fall risk, also did not have an accurate Fall Risk Evaluation or a Fall Care Plan. The evaluation failed to account for her fracture and medications, resulting in an incorrect low-risk score. Consequently, no interventions were planned to prevent falls, despite her medical conditions and medication regimen that heightened her fall risk. Interviews with facility staff, including the MDS Licensed Vocational Nurse, Infection Preventionist, and Director of Nursing, confirmed the absence of necessary evaluations and care plans for both residents. The staff acknowledged the oversight and the lack of follow-up on falls due to staffing changes and workload. The Director of Therapy and Physical Therapist also confirmed missed opportunities for therapy evaluations, which could have contributed to fall prevention strategies for Resident 15.
Medication Administration Discrepancy for Pain Management
Penalty
Summary
The facility failed to administer pain medication as per the physician's order for a resident, leading to a potential risk for poor pain control and a decrease in health and well-being. The discrepancy was identified during an observation and interview with an LVN who was dispensing medications to the resident. The LVN noted that the pharmacy label on the medication blister card indicated gabapentin should be given every 8 hours, while the Medication Administration Record (MAR) indicated it should be given every 4 hours. This inconsistency prompted the LVN to suggest that the gabapentin order should be clarified by the physician. The resident involved had a medical history that included a fracture of the right leg, lung disease, muscle weakness, anxiety disorder, dependence on oxygen, and depression. The resident's Interfacility Transfer Report from the hospital indicated a physician order for gabapentin to be administered every 8 hours. However, the transcribed physician order in the facility's system scheduled the medication to be given at intervals of 4 hours apart, specifically at 8:00 am, 12:00 pm, and 8:00 pm. This transcription error led to the administration of the medication not aligning with the physician's original order.
Facility Fails to Address Air Conditioning Malfunction
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for its residents by not addressing the malfunctioning air conditioning system promptly. Six residents complained about the excessive heat in their rooms and the dining area, with temperatures recorded above the facility's policy range of 71-81 degrees Fahrenheit. The facility's Maintenance Supervisor acknowledged that the portable AC units provided were insufficient for the room sizes, and some rooms lacked any cooling units. The facility's Administrator and Maintenance Supervisor were aware of the issue but did not take immediate corrective action, leading to uncomfortable and potentially unsafe conditions for the residents. The facility's policy on Loss of Heating or Cooling was not implemented effectively, as the air conditioning system, specifically the Chiller System, had been non-functional since June 3, 2024. Despite attempts to fix it internally, the facility did not seek professional repair services until July 16, 2024. The Maintenance Supervisor admitted to not regularly monitoring room temperatures and relied on portable AC units, which were inadequate for the facility's needs. The lack of timely action and proper monitoring resulted in several rooms and the dining area exceeding the acceptable temperature range. Additionally, the facility did not report the interruption of essential services to the California Department of Health as required by their Unusual Occurrence Reporting policy. The Administrator did not consider the malfunctioning Chiller System an unusual occurrence and believed the issue was resolved with temporary cooling solutions. This oversight contributed to the prolonged discomfort and potential health risks for the residents, as the facility failed to comply with its own policies and state regulations.
Failure to Maintain Safe Equipment
Penalty
Summary
The facility failed to maintain resident care equipment in a safe operating condition, specifically a large metal meal tray cart used to transport resident meal trays. The deficiency was observed when a housekeeper moved the tray cart, causing it to fall over approximately seven feet away from a resident, who was startled by the incident. The dietary aide reported that the wheel on the tray cart had been broken for some time, and a Post-it-Note indicating the need for repair was attached to the cart. The maintenance supervisor was aware of the broken wheel but did not log the issue in the TELS system or provide documentation of the repair order. The supervisor also failed to inspect the cart for safety after initially determining there was no safety concern. The maintenance supervisor acknowledged responsibility for inspecting the meal carts but admitted to not having done so in the past. Despite receiving replacement wheels in April, the supervisor did not perform further inspections or remove the cart from use. The facility's administrator confirmed the cart had fallen and stated that the expectation was for the wheel to be fixed the day it was reported. The lack of timely repair and proper documentation contributed to the unsafe condition of the tray cart, posing a potential risk to residents.
Failure to Maintain Privacy During Telehealth Visits
Penalty
Summary
The facility failed to ensure that dignity and privacy were maintained for two residents during psychiatric telehealth visits. Resident 3, who has aphasia and hemiplegia due to a stroke, was observed having a telehealth visit in the central hallway, a public area where other residents, staff, and visitors could overhear the conversation. Similarly, Resident 1, diagnosed with dementia and schizoaffective disorder, had a telehealth visit in the same public area, where sensitive information was discussed without any efforts to provide auditory or visual privacy. A visitor even questioned the appropriateness of conducting such visits in a public space. Certified Nurse Assistant (CNA) B, who facilitated the telehealth visits, acknowledged that these visits are usually conducted in private areas, such as resident rooms. However, on this occasion, the visits were conducted in the hallway due to a lapse in judgment. The facility's administrator confirmed that the expectation is for all telehealth visits to occur in private and acknowledged that privacy and dignity were not maintained during these incidents. The facility's policy on promoting and maintaining resident dignity was not followed, leading to this deficiency.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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