Shields Richmond Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, California.
- Location
- 1919 Cutting Blvd, Richmond, California 94804
- CMS Provider Number
- 055292
- Inspections on file
- 18
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shields Richmond Nursing Center during CMS and state inspections, most recent first.
A resident with traumatic brain injury, hemiplegia/hemiparesis, and moderately impaired cognition (BIMS 9) was discharged for reported clinical improvement and transferred to another SNF at the request of the responsible party, who did not want the resident to remain and sought more rehab therapy. Social services and the Admin acknowledged that, although an admission agreement letter was sent, the facility did not obtain or document confirmation that the receiving facility had accepted the resident before discharge. As a result, the resident was not admitted by the receiving facility and was instead sent to a GACH ED, contrary to facility policy requiring specific criteria, notification, orientation, and documentation for facility-initiated transfers/discharges.
A resident with moderately impaired cognition, traumatic brain injury, and hemiplegia who required maximal assistance for bathing did not receive scheduled twice-weekly showers on multiple occasions, according to facility documentation. The shower schedule required showers on specific days, and facility policy required staff to offer showers as scheduled, document any refusals with reasons and interventions, and notify the supervisor and physician as appropriate. CNA and DON interviews confirmed these expectations, but the DON could not provide documentation that showers were offered as scheduled or that refusals and required notifications were recorded.
The facility failed to consistently prepare palatable, flavorful meals, as evidenced by a resident reporting that facility food was sometimes inedible, including hard French fries and meat too tough to cut, leading the resident to keep personal food at bedside. The recently hired Dietary Supervisor stated she was unaware of food concerns, while the RD acknowledged prior complaints about overly salty food. During a test tray review, the brussels sprouts were bland, the turkey was salty, and the mashed potatoes were not creamy, which the Dietary Supervisor attributed to the use of bagged frozen potatoes.
Four residents did not receive necessary assistance with ADLs, including nail care and scheduled repositioning. Two residents with cognitive impairment and one with visual impairment had long, dirty fingernails, and staff confirmed that nail care was not provided as required. Another dependent resident was not turned and repositioned every two hours as outlined in the care plan, with staff interviews revealing this task was omitted from daily routines and documentation.
Three residents did not receive prescribed medications or appropriate care as ordered, including anti-hypertensives and other essential treatments. Staff held medications without physician orders, failed to notify physicians of elevated blood pressure or repeated medication refusals, and did not inform responsible parties when a resident with cognitive impairment refused medications. These actions were not in accordance with professional standards or facility policy.
Three residents experienced medication administration errors, including receiving the wrong type of multi-vitamin, missing a prescribed oral care medication during the scheduled pass, and delayed blood sugar monitoring with subsequent insulin administration. Nursing staff acknowledged the errors, which resulted in the facility's medication error rate exceeding 5 percent.
Two expired medications, Rocklatan eye drops and Humalog insulin, were discovered in a medication cart during an audit with an RN, who confirmed their expired status while assisting with medication administration. Facility policy requires outdated medications to be returned or destroyed, but these remained accessible in the cart.
The facility did not employ a qualified Dietary Services Manager when the Registered Dietitian was not present, resulting in unqualified staff overseeing dietary services and improper food preparation and storage for 64 residents. The Dietary Service Supervisor lacked required certification, and the Nutrition Support Specialist, who covered in the RD's absence, was not a qualified RD.
Surveyors found that food was prepared in a three-compartment sink, open pasta was not stored in airtight containers, and spoiled produce was kept unlabeled or undated. A dented can was stored with usable canned goods, and a can opener had visible rust. These actions did not comply with facility policies for food safety and sanitation.
A CNA transferred a resident with severe cognitive impairment and physical limitations from bed to wheelchair using a Hoyer lift without the required second staff member, contrary to the resident's care plan and facility policy. The DON confirmed that this action increased the risk of falls.
A resident with severe cognitive impairment, malnutrition, and pressure injuries consistently refused or consumed minimal food and fluids over several days, with intake records showing amounts far below recommended levels. Despite clear signs of inadequate nutrition and hydration, staff did not promptly notify the RD or physician, nor did they document interventions or inform the responsible party in a timely manner. Laboratory results later confirmed severe dehydration, and facility policies requiring prompt reporting and assessment were not followed.
Nursing staff failed to complete required annual competency evaluations, resulting in improper infection control practices and inadequate response to changes in residents' conditions. For example, a resident with C. diff infection did not have proper contact precautions implemented, and another resident experiencing multiple episodes of diarrhea did not receive appropriate assessment or testing. The DON confirmed that the RN had not completed the annual skills check, which could lead to significant errors.
Housekeeping and nursing staff did not use the required bleach-based disinfectants for cleaning a contact precaution room and medical devices used by a resident with C. diff infection. Instead, non-bleach cleaning agents and bleach-free wipes were used, contrary to facility policy and manufacturer recommendations for effective C. diff spore elimination.
A resident was given antibiotics for a history of urinary tract infections without proper diagnostic evidence, and staff failed to monitor for side effects such as diarrhea. Documentation showed repeated episodes of diarrhea, but there was no consistent follow-up or testing, and staff were not always aware of the resident's symptoms. The facility did not adhere to its own antibiotic stewardship policy or established clinical criteria before prescribing antibiotics.
The facility did not provide the required 80 square feet per resident in 12 multi-bed rooms, with measurements showing each resident had less than the minimum space. Although one resident noted the room felt small, others reported no issues, and care provision was not impacted during observations.
A facility failed to maintain proper infection control when a nurse did not perform hand hygiene between glove changes during a wound dressing change for a resident with a Stage III pressure ulcer. The nurse cleansed the wound and applied Santyl without washing hands between glove changes, contrary to the facility's hand hygiene policy. The DON acknowledged that this practice increases infection risk.
The facility failed to provide timely dental services for two residents, leading to potential health risks. One resident with a chipped tooth did not receive a dental referral within the required three days, while another resident experienced a significant delay in obtaining replacement dentures. The facility's policy requires referrals for damaged or lost dentures within three days, but this was not followed, contributing to the delay in addressing the residents' dental needs.
The facility failed to protect a resident from physical abuse when another resident repeatedly hit them on the legs. The abused resident, with Alzheimer's dementia and impaired vision, reported feeling unsafe. The aggressive resident had a history of similar behavior, and staff witnessed the incident, leading to the separation of the two residents.
Unsafe Discharge Without Confirmed Acceptance by Receiving Facility
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was transferred to another skilled nursing facility without confirmed acceptance from the receiving facility. The resident had a history of traumatic brain injury, hemiplegia/hemiparesis, and a BIMS score of 9, indicating moderately impaired cognition, though they were able to make themselves understood and understand others. The resident’s admission MDS documented difficulty recalling the correct year, month, and day of the week. A Notice of Proposed Transfer/Discharge dated 1/2/26 stated the transfer or discharge was appropriate because the resident’s health had improved sufficiently so that they no longer required the services provided by the facility. Interviews revealed that the resident’s responsible party requested transfer to another nursing home because they did not want the resident to remain at the current facility and wanted more rehabilitation therapy. The SS staff member stated the responsible party did not like the facility and confirmed that the facility did not receive confirmation from the receiving facility of the resident’s admission before discharge and transfer occurred. The DON stated the facility had provided physical, occupational, and speech therapy as ordered and that a referral for more therapy had been denied. The Administrator reported that a letter of admission agreement was sent to the receiving facility but could not provide documentation that admission had been confirmed prior to discharge. As a result, the resident was not accepted for admission at the receiving facility and was sent to a GACH emergency department. The facility’s policy on facility-initiated transfer or discharge stated that residents have the right to remain in the facility and that such transfers must meet specific criteria and require notification, orientation, and documentation.
Failure to Provide and Document Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to provide scheduled shower services and to maintain grooming and personal hygiene for one of three sampled residents. The resident had an admission MDS dated 12/2/25 showing a BIMS score of 09, indicating moderately impaired mental status, and required maximal assistance for showers, with the helper performing more than half of the effort, including lifting and holding the trunk or limbs. The resident’s diagnoses included traumatic brain injury and hemiplegia/hemiparesis related to stroke. The facility’s AM Shift Shower Schedule, dated 5/2020, indicated the resident was to receive showers twice weekly on Wednesdays and Saturdays. A review of the Documentation Survey Report for December 2025 showed the resident did not receive showers on 12/6/25, 12/13/25, 12/17/25, and 12/24/25, despite being scheduled. CNA 1 stated that the facility process was to provide showers as scheduled, complete shower sheets, document refusals, and notify the charge nurse. The DON confirmed that staff were expected to offer showers twice weekly and, if refused, to notify the charge nurse and document the refusal in the resident’s record. The DON was unable to provide documentation that showers were offered as scheduled or that refusals and notifications were recorded. The facility’s policy on Bath, Shower/Tub, revised February 2018, required documentation of refusals, reasons, interventions taken, the signature and title of the person recording, and notification of the supervisor and physician as appropriate.
Failure to Prepare Palatable and Flavorful Meals
Penalty
Summary
The facility failed to ensure food was prepared by methods that conserved flavor and maintained palatability, attractiveness, and safe, appetizing temperatures, placing residents at risk of unplanned weight loss due to poor food intake. During an interview, one resident, who was awake and verbally responsive while lying in bed, reported keeping his own stack of food at his bedside because the food served by the facility was sometimes not edible. He stated that French fries were hard and could not be eaten, and that meat served for dinner was very tough and could not be cut with a knife. He reported having informed nursing staff and the Dietary Supervisor of these concerns. The Dietary Supervisor, who stated she was recently hired, reported she was not aware of any food concerns, while the Consultant Dietician, also recently hired, stated she was aware of complaints about food being salty and had discussed this with the former Dietary Supervisor. During a test tray observation with the Dietary Supervisor, the brussels sprouts were found to be bland, the turkey was salty, and the mashed potatoes were not creamy; the Dietary Supervisor acknowledged the brussels sprouts were bland and explained the mashed potatoes were not creamy because they were made from bagged frozen potatoes. These observations, interviews, and record reviews demonstrate that the facility did not consistently prepare food in a manner that conserved flavor and ensured palatability, contributing to resident dissatisfaction with meals and concerns about food quality.
Failure to Provide Required ADL Care: Nail Hygiene and Repositioning
Penalty
Summary
Four residents did not receive appropriate assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene and mobility. Two residents with cognitive impairment and one with visual impairment were observed to have long fingernails with black matter underneath, and one had overgrown fingernails. These residents required at least partial assistance with personal hygiene, as documented in their assessments. Staff interviews confirmed that nail care was not provided as required, and in one case, a CNA incorrectly stated that a resident refused care, which the resident denied. Nursing staff acknowledged the importance of nail care, especially for residents with conditions such as diabetes and a history of scratching wounds, but confirmed that care was not provided. Another resident, who was dependent on staff for all ADLs due to severe cognitive impairment and physical limitations, was not turned and repositioned every two hours as indicated in the care plan. Observations showed the resident remained in the same position for several hours. Staff interviews revealed that the repositioning task was not included in the daily task list or electronic health record for this resident, resulting in the omission of this essential care activity. Both CNAs and RNs acknowledged the importance of regular repositioning for this resident. Facility policy and procedure documents reviewed by surveyors indicated that daily cleaning and regular trimming of fingernails, as well as scheduled repositioning for dependent residents, are required to prevent infection and skin breakdown. The Director of Nursing confirmed that the lack of nail care and repositioning placed residents at risk for infection and skin injury, and that the required care was not provided according to facility policy.
Failure to Administer and Manage Medications According to Orders and Resident Needs
Penalty
Summary
Three residents experienced deficiencies in the administration and management of their prescribed treatments and medications. One resident with a history of hypertensive emergency, end-stage renal disease, and other significant comorbidities did not receive multiple prescribed medications, including anti-hypertensives, stool softeners, and phosphate binders, on numerous occasions. The medication administration records showed repeated omissions of these medications, with staff documenting the reason as "Other/See Progress Notes." Interviews with nursing staff revealed that medications were routinely held on dialysis days without a physician's order to do so, and there was no documentation supporting this practice. Blood pressure readings before and after dialysis were consistently elevated, and the Director of Nursing confirmed that medications should have been administered as ordered or the timing adjusted appropriately. Another resident with end-stage renal disease, a history of stroke, and hypertension had multiple episodes of elevated blood pressure that were not addressed according to facility policy. The care plan required monitoring and reporting of malignant hypertension and medication side effects, but the medical record showed no documentation that the physician was notified when the resident's blood pressure exceeded the facility's threshold for notification. The resident reported not receiving blood pressure medication on one occasion and was told by a nurse to request it directly. The nurse admitted to not notifying the physician of repeated refusals, and the DON confirmed that no documentation existed of physician notification during periods of significantly elevated blood pressure. A third resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and neuromuscular bladder dysfunction, refused oral medications multiple times, including tamsulosin, zinc sulfate, and melatonin. The resident's medical record indicated that staff explained the risks and benefits of the medication, but the resident was not capable of understanding due to cognitive impairment. There was no documentation that the physician or responsible family members were notified of the repeated refusals, despite facility policy requiring notification after two or more consecutive refusals. The resident's responsible party was unaware of the refusals and stated this was not typical behavior for the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by three separate incidents involving medication administration errors. In one instance, a registered nurse administered a multi-vitamin tablet without minerals to a resident, despite the physician's order specifying a multi-vitamin with minerals. The nurse later discovered the correct medication in the medication cart but had not noticed it earlier due to similar packaging. In another case, a licensed vocational nurse did not administer a prescribed chlorhexidine gluconate solution for oral care to a resident during the morning medication pass, only preparing it after the omission was identified during review. Additionally, a licensed vocational nurse failed to obtain a resident's blood sugar at the ordered time of 7 a.m., instead performing the test later in the morning and administering insulin based on the delayed reading. The nurse acknowledged missing the scheduled time and was unaware of the resident's insulin order for that morning. The facility's policy requires medications to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Expired Medications Found in Medication Cart
Penalty
Summary
Surveyors observed that two expired medications, a bottle of Rocklatan eye drops and a vial of Humalog insulin, were found stored in a medication cart during an audit conducted with a registered nurse. The medications had expiration dates of 4/7/25 and 4/8/25, respectively, and were still accessible for use. The registered nurse confirmed the medications were expired and explained that she was not the regular nurse for that medication cart, but was assisting with medication administration at the time. Review of the facility's policy indicated that outdated medications should be returned or destroyed per pharmacy instructions, but these expired medications remained in the cart.
Failure to Employ Qualified Dietary Services Manager in Absence of Full-Time RD
Penalty
Summary
The facility failed to employ a qualified Dietary Services Manager (DSM) in the absence of a full-time Registered Dietitian (RD) for 64 residents who received food from the kitchen. During a kitchen tour, surveyors observed improper food preparation, improper storage of food items, and unmaintained kitchen equipment. The Dietary Service Supervisor (DSS) confirmed she was not a certified Dietary Manager, having taken but not completed the required course. The RD, who was only present part-time, also confirmed the absence of a qualified Dietary Manager. The Nutrition Support Specialist (NSS), who covered the kitchen when the RD was not present, had not passed the exam to be a qualified RD. Interviews with facility staff, including the Administrator, confirmed that the RD worked only two to three days per week, and the NSS, who was not qualified as a RD, was responsible for overseeing the kitchen and staff during the RD's absence. Review of the facility's contract showed the RD was contracted for only 16 hours per week. The facility did not have a full-time qualified DSM as required by state regulations when the RD was not present, and the DSS did not meet the necessary certification or training requirements to supervise dietary services.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices. A staff member was seen preparing food in the emergency three-compartment sink, which is not permitted for food preparation due to the risk of cross-contamination. Open packages of pasta were not stored in airtight containers, and several produce items, including cherry tomatoes, bell peppers, and strawberries, were found to be spoiled, mushy, or showing signs of mold and discoloration. Some of these items were not labeled or dated, making it unclear when they should be used or discarded. Additionally, a dented can of sweet potatoes was stored alongside ready-to-use canned goods, contrary to facility policy requiring damaged cans to be set aside for return or disposal. The mounted can opener was found to have a reddish and brown flaky coating near the blade, which was identified as rust. This equipment was not properly cleaned and sanitized, posing a risk of contamination to food prepared with it. Interviews with the Dietary Service Supervisor and Registered Dietician confirmed that staff were accustomed to using the three-compartment sink for food preparation and that there was a need for retraining. Facility policies and procedures reviewed by surveyors clearly stated that food preparation should not occur in these sinks, that opened dry goods should be stored in airtight containers, and that equipment must be cleaned and sanitized to prevent foodborne illness. The observed practices were not in compliance with these policies.
Improper Use of Hoyer Lift Without Required Staff Assistance
Penalty
Summary
A certified nursing assistant (CNA) transferred a resident from bed to wheelchair using a Hoyer lift without the required assistance of a second staff member. The resident had a history of muscle weakness, traumatic brain injury, and severely impaired cognition, and was documented as dependent on two or more helpers for transfers. The CNA acknowledged operating the Hoyer lift alone, stating it was a mistake and recognizing the risk of dropping the resident without support from another staff member. The resident's care plan indicated a self-care performance deficit, impaired balance, and dependence on staff for transfers. The facility's policy and procedure, as confirmed by the Director of Nursing (DON), required at least two nursing assistants to safely transfer a resident using a mechanical lift. The DON also confirmed that transferring the resident alone increased the risk for falls. The deficiency was identified through observation, interview, and record review.
Failure to Address Poor Food and Fluid Intake Resulting in Resident Dehydration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's disease, severe protein-calorie malnutrition, and pressure injuries, was admitted to the facility and assessed as having severely impaired cognitive skills. The resident's care plan included a goal to consume more than 75% of meals to promote wound healing and prevent further skin breakdown. However, meal intake records over several days showed the resident consistently refused meals or consumed only 0–50% of food offered, with several instances of complete refusal. Fluid intake records also indicated the resident was consuming significantly less than the recommended daily amount, with daily totals ranging from 180 ml to 920 ml, well below the dietician's recommendation of 1,830–2,140 ml per day. Despite these ongoing issues, there was no timely intervention or escalation by staff. Certified Nurse Assistants (CNAs) observed and reported the resident's poor intake, but licensed nurses did not notify the Registered Dietician (RD) or the physician as required by facility policy. The RD confirmed she was not informed of the resident's recent poor intake and was unaware of the refusals to eat or drink. The Director of Nursing (DON) also acknowledged that no interventions were documented by licensed nurses to address the resident's poor intake, and the responsible party was not notified until several days after the issue began. Laboratory results revealed the resident was severely dehydrated, with elevated blood urea nitrogen, creatinine, and sodium levels. The facility's policies required prompt reporting and multidisciplinary assessment of poor intake and changes in condition, but these procedures were not followed. The lack of timely notification and intervention resulted in the resident developing dehydration and placed the resident at risk for malnutrition and further health decline.
Failure to Ensure Nursing Staff Competency and Infection Control Practices
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a registered nurse (RN), had the appropriate competencies and skills to provide safe and effective care for residents, as evidenced by the lack of completion of an annual competency and skills evaluation for the RN. This deficiency was observed in the context of infection control practices and the management of residents with complex medical needs. For example, one resident was admitted with enterocolitis due to a Clostridium difficile (C. diff) infection, requiring contact precautions. Observations revealed that the contact precaution signage was not properly displayed, and the RN used Clorox wipes with a white top, which were bleach-free, to disinfect medical devices, despite the need for sporicidal agents effective against C. diff. The Director of Nursing (DON) was unsure about the disinfectant's contents, and the Infection Preventionist (IP) clarified that only certain wipes were effective against C. diff spores. Additionally, another resident with a history of urinary tract infections experienced multiple episodes of diarrhea, which were not appropriately communicated or acted upon by the RN, despite being informed by a certified nursing assistant (CNA). The RN minimized the significance of the diarrhea, and there was no evidence of appropriate diagnostic testing or escalation. Review of facility policies indicated that staff should receive ongoing training in infection control and antibiotic stewardship, but the RN in question had not completed the required annual skills check. The DON acknowledged that failure to evaluate licensed nurses' skills could lead to significant errors.
Failure to Use Appropriate Disinfectants for C. diff Infection Control
Penalty
Summary
The facility failed to follow proper infection prevention and control procedures for a resident admitted with enterocolitis due to Clostridium difficile (C. diff) infection. Housekeeping staff did not use the appropriate disinfectant for cleaning the resident's contact precaution room. Instead of using the Sani-Cloth Germicidal Disposable Wipe/Bleach, which is effective against C. diff spores, the Housekeeping Aide used pink Ecolab Smartpower Sink and Surface sanitizer and purple Oasis 499 Disinfectant Cleaner, neither of which are indicated as effective against C. diff. The Sani-Cloth disinfecting wipes were not available on the housekeeping cart, and the Housekeeping Aide confirmed she only used the spray solutions and not the recommended wipes. Additionally, a Registered Nurse did not consistently use the appropriate disinfectant for medical devices between resident use. The nurse reported using Clorox wipes with a white top, which were found to be bleach-free, rather than a bleach-based disinfectant as required for C. diff precautions. The facility's policy specifies that environmental cleaning in rooms of residents with C. diff should be done with an EPA-registered germicidal agent effective against C. diff spores, such as bleach-based products. Observations and interviews confirmed that the recommended disinfecting agents were not used as per policy.
Failure to Implement Effective Antibiotic Stewardship and Monitor for Side Effects
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, specifically lacking an adequate antibiotic stewardship program. A resident was administered Cephalexin for a personal history of urinary tract infections without documented evidence of a current infection, such as a urinalysis or urine culture. The clinical record did not indicate that appropriate diagnostic criteria, such as those outlined in the McGeer Criteria, were met prior to initiating antibiotic therapy. The resident experienced multiple episodes of diarrhea over several days, as documented by both certified nursing assistants and bowel and bladder elimination records. Despite these symptoms, there was no evidence that the resident was monitored for possible antibiotic side effects, nor was there documentation of appropriate follow-up or testing, such as sending a stool specimen for evaluation. Nursing staff were not consistently aware of the resident's symptoms, and discrepancies existed between CNA documentation and skilled nursing evaluations regarding the presence of diarrhea. Interviews with facility staff, including the Infection Preventionist, revealed concerns about the use of antibiotics as prophylaxis and the lack of adherence to established criteria for diagnosing urinary tract infections. The facility's policy required education on the relationship between antibiotic use and gastrointestinal disorders, but there was no indication that this was effectively implemented. The failure to monitor for side effects and to ensure antibiotics were prescribed only when clinically indicated contributed to the identified deficiency.
Insufficient Square Footage Provided in Multi-Bed Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 12 multi-bed rooms occupied by 31 residents. Measurements of the rooms showed that each resident had between approximately 70 and 73 square feet, which is below the regulatory standard. Multiple rooms were observed to have either two or three residents, and the square footage per resident was consistently less than required. These findings were based on direct measurements and observations conducted over several days. During the survey, residents and staff were interviewed and observed. One resident expressed that the room felt small and preferred a two-bed room, while another resident reported no complaints and was able to move around the room with a walker without difficulty. Observations of care provision indicated that there was sufficient space for routine care, and no negative consequences or safety concerns were identified as a result of the decreased space. The facility administrator requested a continuous room waiver for the affected rooms.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Treatment Nurse 1 (TN 1) during a wound dressing change for a resident with a Stage III pressure ulcer. TN 1 did not perform hand hygiene between glove changes while attending to the resident's wound care. Specifically, after cleansing the wound with normal saline and removing the soiled gloves, TN 1 donned a new pair of gloves to apply Santyl without washing hands. This process was repeated when TN 1 covered the wound with Mepilex dressing, again changing gloves without performing hand hygiene. The resident involved had been readmitted to the facility with a diagnosis of diabetes mellitus and had a treatment order for a sacral region pressure ulcer. The Director of Nursing confirmed that the failure to perform hand hygiene between glove changes increases the risk of infection. The facility's policy on hand hygiene, revised in August 2019, emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, stating that handwashing should occur after removing gloves and before handling clean or soiled dressings.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for two residents, leading to potential health risks. Resident 2, who was admitted with moderate protein-calorie malnutrition, had a chipped tooth that was not promptly referred for dental services within the required three days. Despite a physician's order for a dental consult dated 5/11/23, the referral was delayed until 6/6/24, 16 days after the issue was known. The resident reported difficulty eating due to the chipped tooth, which was part of their lower dentures, and expressed that the situation should have been treated as an emergency. Resident 3, admitted with dysphagia following a stroke and major depressive disorder, experienced a significant delay in obtaining replacement dentures after losing their full set. Although a dental consult was ordered on 10/19/23, the process to replace the dentures did not begin until 2/6/24, when dental impressions were taken. The delay in receiving the new dentures, which were ready by 7/9/24 but not fitted due to COVID, was attributed to the dentist's infrequent visits to the facility. The resident expressed feelings of depression and frustration due to the slow process. The facility's policy and procedure for dental services, last revised in December 2016, requires referrals for damaged or lost dentures to be made within three days, with documentation provided if there is a delay. However, this policy was not followed in the cases of Residents 2 and 3, leading to potential decreased food intake and significant weight loss. The Social Services Assistant was unaware of the three-day referral requirement, contributing to the delay in addressing the residents' dental needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from physical abuse when Resident 2 repeatedly hit Resident 1 on the left lower extremity. Resident 1, who has Alzheimer's dementia, severe open-angle glaucoma, and type 2 diabetes mellitus, was admitted to the facility in March 2021. Resident 1's Minimum Data Set (MDS) indicated impaired vision and a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognitive response. On 2/14/24, Certified Nursing Assistant (CNA) 1 witnessed Resident 2 hitting Resident 1 on both legs. Resident 2, who has an intact cognitive response with a BIMS score of 15, stated that he was bothered by Resident 1's constant calls. Resident 1 reported feeling unsafe in the same room with Resident 2 unless staff was present. Resident 2's clinical record revealed a history of aggressive behavior, including an incident on 11/20/23 where Resident 2 was witnessed hitting another roommate and causing skin tears. On 2/14/24, CNA 1 responded to a call light in Resident 1 and Resident 2's room and found Resident 2 hitting Resident 1's legs with a closed fist. Resident 2 was separated from Resident 1, but this was not the first incident involving Resident 2's aggressive behavior. The facility's failure to protect Resident 1 from physical abuse by Resident 2 had the potential to result in physical injury and psychosocial harm.
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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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