Sierra Valley Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 301 West Putnam, Porterville, California 93257
- CMS Provider Number
- 055568
- Inspections on file
- 32
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sierra Valley Rehab Center during CMS and state inspections, most recent first.
A resident with a chronic indwelling catheter and history of UTIs did not receive a physician-ordered urinalysis because an LVN failed to enter the order, resulting in a delay of care. Facility policy requires nurses to promptly and accurately enter new physician orders into the MAR/eMAR.
The facility failed to provide binding Arbitration Agreements in a form and manner that three Spanish-speaking residents could understand, leading them to sign without comprehending the implications. The agreements were presented in English, contrary to the facility's policy requiring translation for populations with limited English proficiency exceeding 5%.
The facility failed to follow infection control protocols, including not placing a symptomatic resident on Droplet Isolation Precautions, not dating or timing oxygen and nebulizer tubing, improperly managing a suction machine, and neglecting hand hygiene before meals.
The facility failed to provide adequate dining room accessibility and space for its 132 residents. Observations revealed that the dining room door was locked, limiting access, and the space could only accommodate a small number of residents at a time. Residents were observed waiting in the hallway for their turn to dine, as the dining room could not accommodate more than eight residents simultaneously. The Administrator acknowledged the issue, and no policy addressing dining room space was provided.
A facility failed to accurately complete the MDS for a resident by incorrectly coding Aspirin as an anticoagulant. The MDS consultant confirmed the error, and the MDS nurse acknowledged the mistake. This inaccuracy could potentially affect the resident's care, as the MDS is crucial for establishing person-centered care needs.
A facility failed to implement communication interventions for a Spanish-speaking resident, who was at risk for impaired communication. The resident's care plan lacked interventions despite goals for communication being set. The resident expressed difficulty in communicating with English-speaking staff and preferred communication in her language. A Registered Nurse Consultant confirmed the requirement for interventions in care plans, which was not met.
A resident was administered Potassium Chloride ER tablets inappropriately when an LVN crushed the tablets and mixed them with applesauce, contrary to guidelines that specify extended-release tablets should not be crushed. The DON confirmed the error, and a pharmacist reiterated that Potassium ER should not be crushed, aligning with the facility's policy against crushing such medications.
A facility failed to implement a physician's wound treatment orders for a resident's right heel blister. The physician ordered cleansing with normal saline and Betadine application twice daily, but the order was not recorded or carried out. The facility's policy requires immediate recording and implementation of such orders, which was not followed in this case.
A resident with documented hearing loss was not provided with hearing aids as recommended by an audiogram. Facility staff were unaware of the recommendation, and the facility's policy to ensure access to necessary adaptive equipment was not followed.
A facility failed to follow its policy for labeling IV tubing, as observed during an interview with an LVN. The IV tubing for a resident was not labeled with the date, time, and initials of the person who hung it, contrary to the facility's policy. This policy aims to prevent infections associated with contaminated IV therapy equipment, and it requires that any unlabeled tubing be changed and labeled.
The facility failed to complete the required annual competency for a CNA. The CNA was hired and completed their initial orientation and competency checklist shortly after hiring. However, the Director of Staff Development could not provide documentation of the CNA's 2024 annual competency, indicating it was not completed as required.
A cook in the facility failed to follow the standardized recipe for Zesty Spinach by adding unmeasured amounts of ingredients, contrary to the facility's food preparation policy. The cook admitted to not using the recipe and relying on taste, which was confirmed as incorrect by the Certified Dietary Manager.
A resident with hemiplegia did not receive necessary adaptive feeding devices as specified on their meal ticket, despite facility policies requiring such provisions. The oversight was confirmed by both the Registered Dietician and Certified Dietary Manager, highlighting a deficiency in care.
A facility failed to follow its smoking policy for a resident, as tobacco was found at the bedside without a completed smoking care plan or assessment. Staff confirmed that tobacco should be locked up, and the DON acknowledged the absence of necessary evaluations. The facility's policy requires smoking evaluations and care plans, which were not adhered to in this case.
The facility did not meet the required minimum square footage for resident rooms, affecting 20 out of 48 bedrooms. Rooms intended for multiple residents were below the 80 square feet per resident requirement, with measurements showing insufficient space. The Administrator acknowledged the deficiency but noted that residents had adequate privacy and storage. No previous room waiver was available.
A resident with severe cognitive impairment was verbally abused by his roommate, who had intact cognition, for over a year. The abuse included derogatory remarks and racial slurs, which were known to staff but not reported to the Administrator or DON as required by facility policy. The resident's condition improved after being moved to a different room.
A resident with severe cognitive impairment was subjected to persistent verbal abuse by a roommate with intact cognition. Despite staff awareness, the abuse was not reported to the Administrator as required by facility policy. The resident, who suffers from quadriplegia and dysphasia, showed signs of distress during the period of abuse but improved after being moved to a different room. Staff interviews confirmed the failure to report the abuse, which violated the facility's procedures.
The facility did not follow its policy for timely reporting a resident-to-resident abuse incident to the CDPH. An altercation occurred where a moderately cognitively impaired resident kicked a severely cognitively impaired resident. The incident was not reported within the required two-hour timeframe, leading to a 48-hour delay. The Administrator was unaware of the incident until two days later, and the Social Services Director confirmed the reporting lapse.
A facility failed to follow a resident's care plan by not using a mesh stop sign intended to prevent wandering residents from entering the room. This oversight was confirmed by a CNA and the SSD, despite the care plan's directive following an incident of inappropriate touching. The facility's policy emphasizes maintaining residents' well-being, which was not upheld in this case.
A facility failed to implement a physician's order to increase a resident's Xanax dosage to 1 mg three times a day. Instead, the resident continued to receive 1 mg twice daily due to a communication lapse by the Social Service Director, who did not relay the updated order to nursing staff. This oversight was contrary to the facility's medication administration policy.
A facility failed to complete competency evaluations for an LVN before allowing independent medication administration. The LVN's skills checklist was incomplete, yet they worked across all stations providing care. The facility's policy requires competency validation during onboarding, which was not adhered to, as confirmed by the DSD and Administrator.
A facility failed to document medication administration timely for a resident, leading to potential inaccuracies in medical records. A resident reported not receiving medications on time, and a review showed Levothyroxine Sodium was documented 10 days late by an ADON, contrary to policy requiring immediate documentation.
A resident with mobility issues and a care plan requiring a Hoyer lift for transfers experienced multiple falls and injuries due to staff not adhering to the care plan. Despite being assessed as dependent on assistance, staff used inappropriate transfer methods, leading to significant injuries, including broken bones and the need for surgery.
A facility failed to implement nutritional interventions for a resident as recommended in a Nutritional Risk Assessment. The assessment suggested adding a nutritional supplement, protein supplement, zinc, and vitamin C. During a review, the DON could not provide evidence of these recommendations being carried out, acknowledging they should have been addressed within 72 hours. The facility's policy required the FNS Director or Dietitian to complete dietary recommendations within three days.
A facility failed to implement a care plan for a resident at high risk for falls. The care plan required a bed alarm, but during an observation, the resident did not have one. Interviews with the ADON and MDSC confirmed the resident's fall risk and attempts to get out of bed. The resident's fall risk assessment showed a high score, and the ADON acknowledged the care plan was not followed.
A facility failed to ensure a resident's call light was within reach, as it was found hanging on the wall behind the bedside drawer. The resident, who had severe cognitive impairment and bilateral above-the-knee amputation, was unable to locate the call light. A CNA confirmed the call light was not accessible, contrary to the facility's policy requiring call lights to be within reach.
Failure to Enter and Implement Physician Order for Urinalysis
Penalty
Summary
A deficiency occurred when a physician ordered a urinalysis (UA) for a resident with a chronic indwelling catheter and a history of urinary tract infections (UTIs) due to the presence of spasms. The order was discussed with nursing staff on the date of service, but the Licensed Vocational Nurse (LVN) assigned to the resident did not enter the physician's order into the system. As a result, the urinalysis was not ordered or collected as required. Review of facility policy confirmed that nurses are responsible for promptly and accurately entering new physician orders into the Medication Administration Record (MAR/eMAR). This failure led to a delay in care for the resident.
Failure to Provide Arbitration Agreements in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement (AA) was presented in a form and manner that residents could understand, specifically for three residents who primarily spoke Spanish. The AAs were provided in English, which the residents could not read or understand. This led to the residents signing the agreements without comprehending their implications. Interviews with the residents revealed that they did not know what an arbitration agreement was and did not remember signing it. The facility's policy required that vital information be translated if the limited English proficiency population exceeded 5%, which was the case here. The Admission Coordinator acknowledged that the AAs were written in English, which hindered Spanish-speaking residents from reviewing the agreements to decide if they wanted to rescind them within the 30-day period allowed. The facility's policy on Binding Arbitration Agreements emphasized the importance of explaining the terms and conditions in a manner that residents understand, considering their language and literacy. Despite this, the facility did not provide the AAs in Spanish, failing to adhere to their own policy and procedures, and potentially compromising the residents' ability to make informed decisions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards in several instances. One resident, who exhibited flu-like symptoms and was treated with influenza medication, was not placed under Droplet Isolation Precautions. Despite being symptomatic and receiving medications like Tamiflu and Xofluza, there was no documentation or evidence that isolation precautions were implemented to protect staff and visitors, as confirmed by the Director of Nursing and the Infection Preventionist. Additionally, two residents requiring oxygen therapy had issues with their equipment. The oxygen and nebulizer tubing for these residents were not dated or timed, and in one case, the oxygen tubing was found on the floor uncovered. The facility's policy required these items to be changed weekly and labeled, but this was not followed, as noted by the Licensed Vocational Nurse during observations. Another resident using a portable suction machine had the suction canister and tip improperly managed. The canister was not labeled or dated, and the suction tip was left uncovered on the bedside table. The facility's policy required the canister to be changed twice a week and the tip to be covered, but these procedures were not adhered to. Furthermore, a resident was not provided hand hygiene before being served lunch, contrary to the facility's hand hygiene policy.
Inadequate Dining Room Accessibility and Space
Penalty
Summary
The facility failed to ensure that the dining room was accessible and had adequate space to accommodate the 132 residents residing at the facility. During observations and interviews, it was noted that the dining room door was closed and had a coded lock, restricting resident access. The dining room contained seven round tables with a seating chart for 15 residents, but typically only accommodated around eight residents at a time. Residents were observed waiting in the hallway for their turn to enter the dining room, as the space could not accommodate more than eight residents at once. The Assistant Director of Nursing (ADON) confirmed that the facility lacked the space to accommodate more residents in the dining room simultaneously. Further observations revealed that the dining room door remained closed and locked, preventing residents from freely accessing the space. The Certified Dietary Manager (CDM) was unsure why the door was locked and confirmed that the dining room could not accommodate the additional residents waiting in the hallway. The Administrator acknowledged that the dining room should not have a closed, locked door and should be a common space allowing residents to come and go. A policy and procedure addressing dining room space was requested but not provided, indicating a lack of formal guidelines to ensure adequate dining accommodations for all residents.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one of the residents, identified as Resident 47. During an interview and record review, it was discovered that the MDS-Section N-Medications for Resident 47, dated January 6, 2025, incorrectly coded Aspirin as an anticoagulant. The Medication Administration Record (MAR) for February 2025 did not provide documentation that Resident 47 was on anticoagulant medications. The MDS consultant confirmed that Aspirin, which was prescribed to Resident 47, should not have been coded as an anticoagulant on the MDS. The MDS nurse acknowledged the mistake in coding Aspirin as an anticoagulant. The CMS Resident Assessment Instructions Manual specifies that anticoagulant medications such as warfarin, heparin, or low-molecular weight heparin should be coded if taken by the resident during the 7-day look-back period. However, antiplatelet medications like Aspirin should not be coded as anticoagulants. The failure to accurately code the medication could potentially lead to Resident 47 not receiving care based on his specific needs, as the MDS is a tool used to collect data to establish person-centered care needs.
Failure to Implement Communication Interventions for Spanish-Speaking Resident
Penalty
Summary
The facility failed to develop and implement communication interventions for Resident 329, who is at risk for impaired communication due to her primary language being Spanish. The care plan report for Resident 329 indicated goals for communication, such as being able to make needs known and having no declines in communication, but did not list any interventions to achieve these goals. This omission was identified during a review of the care plan report. During an interview, Resident 329, who only speaks Spanish, expressed that English-speaking staff sometimes did not understand her, and she did not understand them. Although staff used an interpreter to communicate with her, Resident 329 preferred to have someone who could speak her language directly. The Registered Nurse Consultant confirmed that care plans are required to have interventions listed, which was not the case for Resident 329. The facility's policy and procedure for comprehensive person-centered care plans also emphasized the need for interventions to address the underlying sources of problem areas, which was not adhered to in this instance.
Improper Administration of Potassium Chloride ER Tablets
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident. During an observation, an LVN was seen preparing to administer Potassium Chloride ER tablets to a resident by crushing them and mixing them with applesauce. This action was contrary to the medication's administration guidelines, which specify that extended-release tablets should not be crushed, as it can alter the medication's intended release and effectiveness. The LVN did not verify the medication's form against the resident's Medication Administration Record (MAR) and Order Listing Report (OLR), which did not specify the extended-release form. The Director of Nursing (DON) confirmed that the LVN should have clarified the discrepancy between the medication package and the MAR/OLR and should not have crushed the extended-release tablets. A pharmacist also confirmed that Potassium ER tablets should not be crushed. The facility's policy and procedure documents further supported that medications like extended-release tablets should not be crushed, and alternative forms should be sought if necessary. This failure had the potential to impact the resident's treatment for hypokalemia by not delivering the medication as intended.
Failure to Implement Physician's Wound Treatment Orders
Penalty
Summary
The facility failed to implement its policy and procedure for handling physician orders, specifically for a resident identified as Resident 126. The deficiency occurred when the wound treatment orders for Resident 126's right heel blister were not implemented. During an interview and record review, it was found that the physician had ordered a specific wound treatment on 2/19/25, which included cleansing the blister with normal saline, patting it dry, and applying Betadine twice a day. However, this order was not recorded in the resident's medical record, and the treatment was not carried out. The facility's policy requires that telephone and verbal orders be recorded and implemented immediately, with the nurse taking the order signing it with a full signature. The policy also mandates that all physician orders be complete and clearly defined to ensure accurate implementation. In this case, the registered nurse consultant confirmed that the physician's order for the wound treatment was not documented or implemented, leading to a failure in providing necessary wound care for Resident 126.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to provide hearing aids for Resident 22, which was identified as a deficiency. The resident had an initial ENT consultation on June 11, 2024, where difficulty hearing and stuffy ears were noted, and an audiogram was recommended. The audiogram, conducted on July 10, 2024, confirmed that Resident 22 had a significant hearing loss that qualified them for hearing aids, particularly noting greater difficulty in the right ear. Despite these findings, Resident 22 reported not having hearing aids and not being seen by a hearing doctor recently. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's need for hearing aids. The Social Service Director Case Manager and Social Services staff both stated they were unaware of the audiogram's recommendation for hearing aids. The facility's policy on hearing and vision services mandates that residents receive necessary adaptive equipment, and the social worker is responsible for assisting residents in accessing these services. However, this policy was not followed, resulting in the deficiency.
Failure to Label IV Tubing as per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the administration of intravenous (IV) fluids, specifically in the case of one resident. During an observation and interview with a Licensed Vocational Nurse (LVN), it was noted that the IV tubing for a resident was not labeled as required. The LVN acknowledged that the tubing should have been labeled with the date, time, and initials of the person who hung the IV tubing. A review of the facility's policy, dated February 2023, confirmed that the tubing should be labeled to prevent infections associated with contaminated IV therapy equipment. The policy also stated that any unlabeled tubing must be changed and labeled accordingly.
Failure to Complete Annual Competency for CNA
Penalty
Summary
The facility failed to ensure that annual competencies were completed for one of the five sampled Certified Nursing Assistants (CNA). During an interview and record review with the Director of Staff Development (DSD), it was found that CNA 1, who was hired on December 26, 2023, had completed their new employee orientation and competency checklist by December 27, 2023. However, the DSD was unable to provide documentation of a 2024 annual competency for CNA 1, indicating that it had not been completed as required. The facility was also unable to provide the requested policy related to this requirement.
Failure to Follow Recipe in Food Preparation
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preparation' when a cook did not measure recipe ingredients as required. During an observation and interview, it was noted that the cook, while preparing spinach to be pureed, added unmeasured amounts of garlic powder, iodized salt, chili powder, and melted butter, instead of following the specified recipe for Zesty Spinach. The cook admitted to not using the recipe and relying on taste instead. The Certified Dietary Manager confirmed that the cook should have followed the recipe and measured the spices as indicated. The facility's policy requires food to be prepared using approved recipes that are standardized to meet the resident census, with specific instructions on portion yield, preparation methods, ingredient quantities, and time and temperature guidelines.
Failure to Provide Assistive Feeding Devices
Penalty
Summary
The facility failed to provide necessary assistive feeding devices for a resident, identified as Resident 72, who required them due to hemiplegia following a stroke. During an observation, it was noted that Resident 72's lunch tray lacked the adaptive equipment specified on the meal ticket, such as a two-handle sip cup and special spoons. The resident confirmed not having received these items for some time. The Registered Dietician and Certified Dietary Manager acknowledged that the adaptive devices listed on the meal ticket were not provided, despite being responsible for ensuring the correct equipment was included with meals. Further review of Resident 72's records revealed that occupational therapy had recommended specific adaptive equipment to aid in self-feeding, including a universal cuff, built-up utensils, and a plate guard. These recommendations were documented in the resident's treatment notes and order listing report. The facility's policy on assistive devices emphasized the provision of specialized eating utensils to support resident independence, yet this policy was not followed in Resident 72's case, leading to a deficiency in care.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) titled 'Smoking' for one of the residents, identified as Resident 4. During an observation, it was noted that Resident 4 had a can of tobacco at the bedside, which was against the facility's policy that requires tobacco to be locked up. Licensed Vocational Nurse (LVN) 4 confirmed that the tobacco should not have been left at the bedside. Additionally, the facility did not complete a smoking care plan or smoking assessment for Resident 4, which are necessary to ensure safe smoking practices. Interviews with staff and family members further highlighted the oversight. The Activities Assistant mentioned that Resident 4 should not have full access to his chewing tobacco as it could lead to excessive use. The Director of Nursing (DON) confirmed that there was no tobacco use care plan or safe smoking evaluation for Resident 4, which should have been in place. A family member also noted that Resident 4's tobacco pouches were usually at the bedside, indicating a lack of adherence to the facility's smoking policy. The facility's P&P requires a smoking evaluation upon admission and regular reevaluations, with any smoking-related privileges or restrictions noted in the care plan, none of which were completed for Resident 4.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation in 20 out of 48 facility bedrooms. During an observation and interview with the Environmental Services Director (ESD), it was noted that multiple occupancy rooms did not meet the required 80 square feet per resident. Measurements of these rooms revealed that they were significantly below the required space, with rooms housing three residents each but only providing between 208 and 219 square feet in total. The Administrator confirmed that there had been no changes to the room sizes or the facility floor plan since the previous survey. Despite the deficiency in room size, the Administrator stated that residents had a reasonable amount of privacy, adequate storage, and sufficient space for ambulation or wheelchair use. However, the facility was unable to provide a copy of a previous room waiver, indicating a lack of documentation to justify the current room sizes.
Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from verbal abuse inflicted by his roommate. The resident, who had severe cognitive impairment and was unable to speak, was subjected to verbal aggression and derogatory remarks by his roommate, who had intact cognition. The abuse included being called a pedophile, racial slurs, and other derogatory terms. This situation persisted for approximately one year and seven months while the two residents shared a room. Interviews with staff members, including CNAs, LVNs, and the Director of Staff Development, revealed that the abusive behavior was known among the staff. Despite this, the verbal abuse was not reported to the Administrator or the Director of Nursing as required by the facility's policy. Staff members noted that the resident's condition improved after being moved to a different room, indicating the negative impact of the abuse on his well-being. The facility's policies on abuse reporting and behavioral assessment were not followed, as the staff failed to report the abuse immediately. The facility's policy required that any suspicion of abuse be reported to the Administrator and other officials according to state law. The failure to report and address the verbal abuse in a timely manner resulted in the resident experiencing agitation, restlessness, and difficulty sleeping, with the potential for psychosocial harm.
Failure to Report Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting of verbal abuse, resulting in a deficiency. Resident 1, who has severe cognitive impairment and is unable to speak, was subjected to persistent verbal abuse by his roommate, Resident 2, who has intact cognition. Despite multiple staff members being aware of the verbal abuse, it was not reported to the Administrator as required by the facility's policy. Resident 1, who suffers from quadriplegia and dysphasia following a cerebral infarction, shared a room with Resident 2 for approximately one year and seven months. During this time, Resident 2 frequently directed verbal abuse towards Resident 1, including calling him derogatory names and using racial slurs. Staff members, including CNAs and LVNs, observed these interactions and noted that Resident 1 appeared more comfortable and rested after being moved to a different room. Interviews with various staff members, including CNAs, LVNs, the Social Service Director, and the Director of Staff Development, revealed that the verbal abuse was known but not reported to the Administrator or the Director of Nursing. The facility's policy requires that any suspicion of abuse be reported immediately to the Administrator, but this protocol was not followed. The failure to report the abuse allowed the situation to persist, impacting Resident 1's well-being.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely reporting of a resident-to-resident abuse allegation to the California Department of Public Health (CDPH). An incident occurred involving two residents, where one resident, who was moderately cognitively impaired, kicked another resident with severe cognitive impairment during an argument. This incident was not reported to the CDPH within the required timeframe as outlined in the facility's policy, which mandates immediate reporting within two hours for allegations involving abuse or resulting in serious bodily injury. The deficiency was identified during interviews and record reviews. The Administrator was unaware of the incident until two days after it occurred, indicating a lapse in communication and reporting procedures. The Social Services Director confirmed that the staff should have notified the abuse coordinator immediately, and the incident should have been reported to the CDPH as per the facility's policy. This oversight resulted in a delay of approximately 48 hours before the incident was reported to the appropriate authorities.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to ensure that the care plan for a resident was followed, specifically regarding the use of a mesh stop sign intended to deter wandering residents from entering the resident's room. The care plan, which was undated, included an intervention to place a bright-colored stop sign at the entrance of the resident's room due to an incident on 12/3/24 where the resident was allegedly inappropriately touched by another resident. During an observation and interview on 12/30/24, it was noted that the mesh stop sign was not in use, which was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the sign should have been in place. The Social Service Director (SSD) also confirmed that the stop sign should always be used to prevent wandering residents from entering the room. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of services that maintain the resident's highest practicable well-being, which was not adhered to in this instance.
Failure to Implement Physician Orders for Medication Dosage
Penalty
Summary
The facility failed to ensure that physician orders were implemented correctly for a resident, resulting in the resident not receiving the prescribed medication dosage. The physician's order, dated December 11, 2024, indicated that the resident's Xanax dosage should be increased to 1 mg three times a day. However, the Order Summary Report from December 30, 2024, showed that the resident was still receiving Xanax 1 mg twice a day, as per an earlier order from October 24, 2024. The Medication Administration Record for December 2024 confirmed that the resident was administered Xanax 1 mg twice daily. During an interview, the Social Service Director admitted to receiving the updated physician order but failing to communicate it to the nursing staff, which led to the resident not receiving the correct dosage as per the updated order. The facility's policy on administering medications requires that medications be administered according to prescriber orders, which was not followed in this case.
Incomplete Competency Evaluation for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had completed the necessary competency evaluations before independently providing care to residents. The LVN Competency Skills Checklist for LVN 1 was found to be incomplete, lacking validation in several critical areas such as effective communication, nursing process utilization, emergency procedures, medication administration, and pain management. Despite these incomplete competencies, LVN 1 was assigned to work across all three stations in the facility, administering medications to residents without direct supervision. Interviews with the Director of Staff Development and the facility Administrator confirmed that LVN 1's competencies were not completed as required by the facility's policy. The policy, dated December 31, 2015, mandates that all competencies must be validated during the onboarding period, which is the first 90 days of employment, before a nurse can perform skills independently. The Administrator acknowledged that LVN 1 should not have been passing medications independently without completed competencies, indicating a lapse in adherence to the facility's procedures for ensuring staff competency.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one resident, leading to potential inaccuracies in the resident's medical record. During an interview, a resident reported not receiving her scheduled 6 a.m. medications on time. A review of the Administration History (AH) for another resident revealed that Levothyroxine Sodium, a thyroid medication, scheduled for administration on December 9th, was not documented until December 19th by the Assistant Director of Nursing (ADON). The ADON admitted to administering the medication on the scheduled date but failed to document it immediately, as required by the facility's policy and procedure for administering medications. The policy mandates that the individual administering the medication must initial the resident's Medication Administration Record (MAR) immediately after giving each medication and before administering the next ones. This lapse in documentation could lead to inaccuracies in the resident's medical records, as the medication was documented 10 days after it was administered.
Failure to Implement Care Plan Leads to Resident Injuries
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident requiring assistance with activities of daily living (ADL), specifically in the use of a Hoyer lift for transfers. Despite the care plan indicating the necessity of a Hoyer lift, the resident was transferred using alternative methods, such as a sliding board and standing pivot, which were not appropriate for their condition. This led to multiple falls, resulting in significant injuries, including two broken bones in each lower leg, necessitating surgical intervention. The resident, who was readmitted with diagnoses including difficulty in walking, muscle wasting, and generalized muscle weakness, was assessed as being dependent on assistance for transfers. The care plan specified the use of a Hoyer lift, yet staff members, including a CNA, reported using a gait belt and other methods for transfers. The resident experienced falls during these transfers, with one incident involving the resident being asked to stand and use a walker, leading to a fall when the resident expressed feeling tired and weak. Interviews with staff revealed a lack of adherence to the care plan, with conflicting instructions from therapy and nursing staff regarding transfer methods. The resident, who was cognitively intact, reported that the Hoyer lift was never used, and staff continued to use inappropriate transfer techniques, resulting in further falls and injuries. The facility's failure to follow the established care plan and ensure the use of the Hoyer lift as required contributed directly to the resident's injuries.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement nutritional interventions for a resident, as identified in a Nutritional Risk Assessment (NRA) dated September 6, 2024. The NRA recommended the addition of a nutritional supplement (Boost) 4oz daily, a protein supplement (Prostat) 30ml, zinc, and vitamin C. During an interview and record review on October 1, 2024, the Director of Nursing (DON) was unable to provide evidence that these nutritional recommendations were implemented. The DON acknowledged that the recommendations should have been addressed within 72 hours. The facility's policy and procedure for Nutritional Screening/Assessments/Resident Care Plan, dated 2023, stated that the Food and Nutrition Services (FNS) Director and/or Facility Registered Dietitian should complete dietary recommendations within three days.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for one of the residents, identified as Resident 1, who was at high risk for falls. The care plan, dated May 16, 2017, specified the use of a bed alarm to alert staff when the resident attempted to get out of bed. However, during an observation on July 19, 2024, it was noted that Resident 1 did not have a bed alarm on his bed. Interviews with the Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) confirmed that Resident 1 was at risk for falls and occasionally attempted to get out of bed. The Fall Risk Observation/Assessment conducted on July 5, 2024, indicated that Resident 1 had a high fall risk score of 24. The ADON acknowledged that the care plan was not followed, as Resident 1 was expected to have a bed alarm in place. The facility's policy and procedure on comprehensive person-centered care plans, dated December 2016, required the development and implementation of care plans with measurable objectives and timetables to meet residents' needs. The failure to provide a bed alarm as per the care plan had the potential to place Resident 1 at risk for falls resulting in injuries.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 5. During an observation and interview, it was noted that Resident 5 was lying in bed and unable to locate his call light, which was hanging on the wall behind his bedside drawer. Resident 5 expressed his inability to find the call light, and a Certified Nursing Assistant (CNA) confirmed that the call light was not within reach, acknowledging that it should have been accessible to the resident. Resident 5's Minimum Data Set (MDS) assessment indicated a severe cognitive impairment with a BIMS score of 7 and limitations in both lower extremities that interfered with daily functions. The resident's care plan highlighted a self-care performance deficit related to general weakness, impaired balance, and bilateral above-the-knee amputation, necessitating assistance for personal care activities. The facility's policy on call light usage, dated 2018, required that call lights be placed within reach of each resident, which was not adhered to in this instance.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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