Sierra View Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 465 W Putnam Ave, Porterville, California 93257
- CMS Provider Number
- 555766
- Inspections on file
- 18
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sierra View Medical Center during CMS and state inspections, most recent first.
A resident with a persistent vegetative state, chronic respiratory failure, and ventilator dependence had head lice first observed by a family member, who reported it to staff, but no timely action was taken to follow the facility’s head lice infection control policy. A CNA acknowledged being informed and shown a picture of the lice but could not recall reporting it to a nurse, and the LVN caring for the resident that day stated he was unaware of any lice. The Infection Control Nurse was not notified, the resident was not placed on contact isolation, and the physician was not notified for treatment until a later date when an RN assessed the resident after another family complaint and then initiated isolation, contrary to the facility’s written lice management protocol.
Surveyors found that empty and full oxygen cylinders were intermingled in the designated storage area, with three empty tanks stored alongside four full tanks. The Administrator confirmed the improper storage and was unsure of the cause. This deficiency was observed in one smoke compartment and affected 11 residents.
Surveyors identified that the facility's memorandum of understanding with partner facilities and providers, required for emergency preparedness, was expired at the time of review. The Administrator confirmed the agreement was not current and renewal was pending, resulting in noncompliance with emergency preparedness regulations.
Several residents receiving G-tube feedings were observed with their head of bed (HOB) elevated below the required 35 degrees, despite physician orders, care plans, and facility policy specifying this standard. Nursing staff acknowledged the HOB should have been higher during feedings, but did not maintain the required elevation, resulting in noncompliance with established protocols.
The facility did not consistently follow its policy requiring two licensed nurses to verify and sign narcotic count check sheets at each shift change, resulting in multiple instances of missing or incomplete documentation over several months. Interviews with the RN Supervisor and DON confirmed that this process was not properly followed, as required for controlled medication accountability.
Surveyors found that pre-made and opened food items, including sliced strawberries, strawberry puree, mixed fruit, brown rice, and breadcrumbs, were not labeled with use-by or opened dates and some were not covered as required. Staff confirmed these items should have been labeled and covered according to facility policy.
The facility did not perform required quarterly legionella testing of its water system, as confirmed by the absence of testing on several occasions and staff interviews. Additionally, an LVN failed to wear an isolation gown while providing suctioning care to a resident on contact and enhanced barrier precautions, contrary to facility policy.
The facility failed to ensure the Crash Cart was inspected daily, as required by policy. An RN confirmed that the Crash Cart Integrity Check List was not completed on multiple dates, potentially resulting in necessary supplies and medications being unavailable during an emergency.
The facility failed to ensure that two residents in a persistent vegetative state had appropriate surrogate decision-makers, relying instead on the Interdisciplinary Team (IDT) for advocacy. Despite attempts to contact a public conservatorship agency, no conservatorship was obtained, and the residents' rights to have a surrogate decision-maker were not honored.
The facility failed to ensure that two Respiratory Care Practitioners were competent in managing respiratory care equipment, leading to potential contamination and risk of respiratory infections for three residents. Observations revealed improper handling of tubing, and interviews confirmed that infection control policies were not followed.
The facility failed to follow infection control practices, including not changing suction canisters and Yaunker catheters per policy, not discarding contaminated T-pieces, improper storage of aerosol tubing, and inadequate hand hygiene by staff, leading to potential respiratory infection risks among residents.
The facility failed to re-evaluate the need for a left-hand mitten restraint for a resident after 90 days as per the physician's order. The restraint was found in the resident's room, and there was no current physician's order for its use, as the charge nurse did not re-evaluate the need for it.
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving g-tube feedings. An LVN confirmed the head of bed was at 25 degrees, contrary to the physician's order and facility policy, increasing the risk of aspiration.
A facility failed to ensure a physician-ordered medication, Pantoprazole, was available for a resident requiring it to reduce stomach acid. Despite being ordered from the pharmacy, the medication was not received in time for administration, contrary to the facility's policy on timely drug administration.
The facility failed to include required language in arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with officials. Despite the Admin/DON stating that the facility does not offer arbitration agreements, signed agreements were found for two residents, lacking the necessary language. The facility could not provide a policy for arbitration agreements when requested.
Failure to Implement Head Lice Infection Control Policy and Timely Isolation
Penalty
Summary
The facility failed to implement its infection control guideline for head lice for one resident. On 11/6/25, the resident’s family member observed lice on the resident’s pillow at approximately 8:13 p.m. and reported this to staff, though the family member could not later identify which staff were notified. The resident, who had been admitted on 10/30/25 with a persistent vegetative state, chronic respiratory failure, and ventilator dependence, was under the care of CNA 1 and LVN 1 on that date. CNA 1 stated the complainant told her about the lice and showed her a picture on 11/6/25, but she could not remember if she reported this to a nurse or who the nurse was. LVN 1, who also worked with the resident on 11/6/25, stated he was not made aware of any lice by family or staff. The Infection Control Nurse (ICN) confirmed that she was not notified of the lice infestation on 11/6/25 and that the resident was not placed on isolation until 11/16/25, ten days after lice were initially observed. The ICN stated that facility interventions for lice include immediately placing the resident on contact isolation and notifying the physician, and there was no physician notification documented on 11/6/25. On 11/16/25, RN 1, who was working with the resident, received a complaint from the family about lice, assessed the resident, and noted lice, at which point the resident was placed on isolation. RN 1 reported he had not received any prior report indicating the resident had lice, although the complainant told him she had reported the issue to other staff previously. Review of the facility’s undated policy "INFECTION CONTROL GUIDELINE FOR PEOPLE WITH HEAD LICE" showed that patients with lice are to be placed in contact isolation, with gown and glove use, bagging of linens, and physician notification for treatment, measures that were not implemented when lice were first reported on 11/6/25.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to properly maintain the storage of medical gas cylinders, specifically oxygen tanks, as required by NFPA 101 and NFPA 99 standards. During a tour of the facility, surveyors observed that empty and full oxygen cylinders were intermingled within the designated storage area. Specifically, three empty oxygen tanks were found stored in the section intended for full tanks, alongside four full tanks. This observation was made in one of three smoke compartments and affected 11 of 33 residents. Upon interview, the Administrator confirmed the finding and indicated uncertainty regarding why the tanks were misplaced. The report notes that the storage closet did not comply with the requirement to segregate empty cylinders from full ones, as outlined in the relevant fire and safety codes. No additional information about the medical history or condition of the affected residents was provided in the report.
Plan Of Correction
Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During the building tour it was discovered that 3 empty oxygen tanks were being stored in the full section. The facility had Engineering remove the tanks. Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/ Safety & Security Manager had an additional 6 tank holder ordered so that there is available storage capacity for empty tanks, this will reduce the risk of comingling tanks. (see attachment C) PI Monitoring: The Facility will utilize its Environment of Care (EOC) rounds to ensure that proper tank storage is being adhered to.
Expired Emergency Operations Agreement
Penalty
Summary
The facility failed to maintain an up-to-date Emergency Operations Plan (EOP) as required by federal regulations. During a record review and interview with the Administrator, surveyors found that the memorandum of understanding with partner facilities and providers, which is necessary to ensure the continuity of services to residents in the event of limitations or cessation of operations, was expired. The agreement provided by the facility had an expiration date in February 2025, and at the time of the survey, it was no longer valid. The Administrator confirmed during the interview that the agreement was expired and stated that renewal was in process. This lapse in maintaining a current arrangement with other facilities could affect the facility's ability to properly respond during an emergency, as required by the emergency preparedness regulations. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Sierra View Medical Center Distinct Part Skilled Nursing Unit submits this plan of correction as part of the requirement under the State and Federal regulations. The plan of correction is submitted and shall not be construed as admission to the alleged deficiency cited or any liability. The plan of correction shall constitute a credible allegation of compliance. Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During document review, it was noted that the Hospital's Memorandum of Understanding (MOU) with its regional partners had expired on February 26, 2025. The MOU is normally updated by the EMS Coordinator-Disaster Services Fresno County MHOAC and sent out for all parties to agree upon. The Environment of Care/Safety & Security Manager from Sierra View notified the coalition of the need for an updated MOU. The EMS Coordinator from Fresno County then submitted an addendum to the coalition for an extension of the MOU until December 31, 2025. All parties agreed and the amendment to the MOU was officially updated. (Please see attachments A & B highlighted areas) Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/Safety & Security Manager will attend regular meetings with the coalition to ensure the MOU does not lapse. PI Monitoring: The MOU will be presented no less than annually to the organization’s Safety Committee for tracking purposes.
Failure to Maintain Required Head of Bed Elevation During G-Tube Feedings
Penalty
Summary
The facility failed to ensure that the head of bed (HOB) was properly elevated for five residents receiving gastrostomy tube (G-tube) feedings. During multiple observations, residents were found lying in bed with the HOB elevated to levels ranging from 18 to 27 degrees, which was below the required 35 degrees as specified in their physician orders and care plans. Nursing staff, including registered nurses, a licensed vocational nurse, and the director of nursing, acknowledged during interviews that the HOB should have been elevated to at least 30 or 35 degrees during tube feedings, in accordance with both physician orders and facility policy. Record reviews for each resident confirmed active orders and care plans specifying the required HOB elevation during tube feedings. The facility's policy also directed staff to elevate the HOB to 35-45 degrees during and for at least one hour after feedings. Despite these clear instructions, staff did not maintain the required HOB elevation during observations, resulting in noncompliance with physician orders, care plans, and facility policy for the care of residents with feeding tubes.
Failure to Consistently Complete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its policy and procedure for medication storage, specifically regarding the completion of Narcotic Count Check Sheets (NCCS), was consistently followed. Record review revealed that, across several months, there were multiple instances where either one or no licensed nurses signed the NCCS at required times, despite the policy mandating that two licensed nurses verify and sign the count at each shift change. Specific dates were identified where signatures were missing or incomplete, indicating that the required physical inventory of controlled medications was not properly documented. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that two nurses are responsible for counting narcotics and signing the NCCS at the beginning and end of each shift. The facility's policy also requires this process to be documented for all controlled substances in accordance with federal and state regulations. The observed lapses in documentation and missing signatures on the NCCS represent a failure to adhere to these established procedures.
Failure to Label and Store Food Items According to Standards
Penalty
Summary
Surveyors observed multiple instances in which food items in the facility's kitchen were not properly labeled or stored according to professional standards and facility policy. Specifically, twelve individual containers of sliced strawberries were found in the refrigerator without labels or dates, and the Nutritional Lead confirmed that these should have been labeled with the prepared and use-by dates. Additionally, two containers of strawberry puree and one container of mixed fruit were found uncovered and undated in the tray line refrigerator, and the Nutritional Lead acknowledged that these items should have been covered and dated. Further observations revealed that a 25-pound bag of brown rice and a 25-pound bag of Panko dry breadcrumbs, both stored in plastic bins, were open but not labeled with the date they were opened. Staff confirmed that these items should have been dated upon opening. Review of the facility's policy indicated that all foods in process must be covered, labeled, and dated with the expiration or opened date, but these procedures were not followed for the items observed.
Failure to Conduct Legionella Testing and Adhere to Contact Precaution Protocols
Penalty
Summary
The facility failed to follow standard infection prevention and control practices in two key areas. First, the facility did not conduct required quarterly testing of its water system for legionella bacteria, as indicated by the absence of testing on several documented dates. The Safety and Security Manager confirmed that the facility's water was not tested for legionella on multiple occasions, despite a previous request to begin such testing and a water management program recommending quarterly sampling. The Director of Nursing was unaware that the testing had not occurred, and the facility's water management plan outlined the need for routine monitoring and sampling. Second, a Licensed Vocational Nurse did not adhere to contact precaution protocols while providing respiratory care to a resident on contact and enhanced barrier precautions. During a suctioning procedure for a resident who was coughing, the nurse failed to wear an isolation gown as required by the facility's policy for contact precautions. The nurse acknowledged the omission and stated an attempt was made to avoid close contact, despite the policy specifying the use of gloves and gowns when entering the room of a resident on contact precautions, especially when substantial contact with the resident or their environment is anticipated.
Failure to Inspect Crash Cart Daily
Penalty
Summary
The facility failed to ensure that the Crash Cart, used for 30 sampled residents, was inspected daily. During an interview and record review with a Registered Nurse (RN), it was found that the Crash Cart Integrity Check List (CCICL) was not completed on multiple dates. The RN confirmed that the crash cart is supposed to be checked every night shift and acknowledged that if the checklist is blank, it means the cart was not checked. The RN also stated that the cart needed to be checked to ensure that the supplies and medications were functioning and available in case of an emergency. A review of the facility's policy and procedure for Crash Carts indicated that daily inspections should include checking the defibrillator, the contents on top of the crash cart, the oxygen cylinder, and verifying tamper-evident seals. The policy also required the staff nurse to sign the CCICL to document the completion of these checks. The failure to complete these daily inspections had the potential to result in necessary supplies and medications being unavailable during an emergency.
Failure to Ensure Surrogate Decision-Makers for Residents
Penalty
Summary
The facility failed to ensure that two residents, who were in a persistent vegetative state and lacked family or conservators, had appropriate surrogate decision-makers. Instead, the facility's Interdisciplinary Team (IDT) was used as the sole source of advocacy for these residents. The facility's policy required the appointment of a surrogate decision-maker when a resident lacked decision-making capacity and had no written advance directive or court-appointed conservator. However, the facility did not follow this policy, resulting in the residents' rights to have a surrogate decision-maker not being honored. Interviews and record reviews revealed that the Next of Kin sections for both residents were blank, and the Person to Notify was listed as the facility's medical director. The Ombudsman, who previously attended care planning sessions, no longer participated due to a recommendation from the state ombudsman. Social Services attempted to reach out to a public conservatorship agency for guidance but did not obtain conservatorship, leaving the IDT to continue representing the residents. This failure was documented in the facility's policy and procedure and an All Facilities Letter from the state health care agency, which indicated the need for public patient representatives in such cases.
Failure to Ensure Competency in Respiratory Care Practices
Penalty
Summary
The facility failed to ensure that two Respiratory Care Practitioners (RCP 1 and RCP 2) were competent in setting up and managing respiratory care equipment according to facility policy. This was observed in the cases of three residents (Resident 8, Resident 6, and Resident 10). During observations, corrugated tubing with oxygen was found laying on the floor, on empty beds, and touching the headboard, which is against the facility's infection control policy. Interviews with the RCPs and the Infection Preventionist (IP) confirmed that the tubing should have been placed in a clear plastic bag when disconnected from the resident to prevent contamination. Additionally, the tubing and water traps were not changed as required when contamination was identified, and PRN tubing changes were not documented, only weekly changes were recorded. Further review revealed that the annual competency assessments for RCP 1 and RCP 2 did not include evaluation of their ability to maintain infection control practices during the setup and changing of the tubing. The Manager of Respiratory Care Services (MRCS) acknowledged that these practices should have been part of the competency assessment and need to be incorporated. The failure to follow proper infection control procedures and the lack of comprehensive competency assessments had the potential to result in contaminated respiratory equipment being used, posing a risk of respiratory infections to residents with compromised respiratory systems.
Infection Control Deficiencies in Respiratory Care and Hand Hygiene
Penalty
Summary
The facility failed to follow standard infection control practices in several instances, leading to potential risks of respiratory infections among residents. In one case, a suction canister liner containing respiratory secretions was not changed when it was over three-quarters full for a resident with a tracheostomy. The resident was observed coughing with sputum filling his tracheostomy tubing, and the Registered Nurse acknowledged that the canister should have been changed at 750 ml. The Administrator/Director of Nursing confirmed that the canister should have been changed at that level. In another instance, a Yaunker suction catheter was not replaced per policy for a resident. The catheter was found open and dated as opened five days prior, but it should have been replaced three days after opening. Additionally, a T-piece used in oxygen delivery was found unlabeled, undated, and contaminated with dried mucus in another resident's room. The Respiratory Care Practitioner confirmed that the T-piece should have been discarded and replaced due to the lack of labeling and dating. Further observations revealed that aerosol tubing was not stored and secured properly, leading to potential contamination. Tubing was found laying on the floor, on empty beds, and touching the headboard in multiple residents' rooms. The Infection Preventionist and Respiratory Care Practitioner both stated that the tubing should have been placed in a clear plastic bag when disconnected to prevent contamination. Additionally, hand hygiene was not performed by a Licensed Vocational Nurse before and after glove use while providing care to two residents, which included administering medications and suctioning airways through tracheostomies. The facility's policy on hand hygiene was not followed, as confirmed by the Administrator/Director of Nursing.
Failure to Re-evaluate Restraint Use
Penalty
Summary
The facility failed to re-evaluate the need for a left-hand mitten restraint for Resident 14 after 90 days as per the physician's order. During an observation, a hand mitten restraint was found on the over bed table in Resident 14's room. A review of the physician's order dated 12/12/23 indicated that the restraint was to be re-evaluated after 90 days, which should have been done by 3/12/24. However, the Regulatory Registered Nurse confirmed that the order was out of compliance. Further review with the Administrator/Director of Nursing revealed that there was no current physician's order for the restraint, as the charge nurse did not re-evaluate the need for it. The facility's policy indicated that restraints should be initiated or continued only with a physician's order.
Failure to Elevate Head of Bed During G-Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving gastrostomy tube (g-tube) feedings. During an observation, the resident's head of bed was noted to be at a 25-degree position while the g-tube feeding was being administered. This was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the head of bed should be at least 35 degrees to reduce the risk of aspiration. The resident's physician's order and the facility's policy both indicated that the head of bed should be elevated to 30-35 degrees during feeding. The failure to comply with these instructions had the potential for aspiration and respiratory infection.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, Pantoprazole (Protonix), was available for administration to Resident 17, who required the medication to reduce excessive stomach acid. The Active Orders for Resident 17 indicated a daily dose of Pantoprazole 40 mg via gastric tube. During an observation and interview, an LVN stated that the medication was not available in the facility. Further review revealed that the medication had been ordered from the pharmacy two days prior but had not yet been received. The facility's policy on medication administration emphasizes the importance of timely and accurate drug administration, which was not adhered to in this instance.
Failure to Include Required Language in Arbitration Agreements
Penalty
Summary
The facility failed to ensure the required language was included in signed arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with federal, state, or local officials. During an interview, the Administrator/Director of Nursing (Admin/DON) stated that the facility does not offer arbitration agreements. However, a review of Resident 10's medical record revealed a signed arbitration agreement dated 6/29/19, which lacked the necessary language regarding the right to communicate with officials. This discrepancy was confirmed during a concurrent interview and record review with the Admin/DON, who acknowledged the existence of the signed arbitration agreement despite the facility's stated policy of not offering them. Similarly, during a concurrent interview and record review with Social Services (SS), it was found that Resident 12 also had a signed arbitration agreement that did not include the required language about the right to communicate with officials. The facility was unable to provide a copy of the policy and procedure for arbitration agreements when requested. This failure to include the necessary language in the arbitration agreements could lead to residents and their representatives being unaware of their rights to communicate with various officials.
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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