Southern California Hosp At Culver City D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Culver City, California.
- Location
- 3828 Delmas Terrace, Culver City, California 90232
- CMS Provider Number
- 555874
- Inspections on file
- 24
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Southern California Hosp At Culver City D/p Snf during CMS and state inspections, most recent first.
A resident with acute respiratory failure did not receive a stat EEG as ordered when the EEG technician was verbally instructed by the house neurologist, who was not the ordering provider, to delay the test. The verbal hold was not documented, and the technician did not consult the ordering provider or notify nursing staff, resulting in a delay of the procedure.
The facility did not submit its PBJ Staffing Data Report for Q4 FY 2024 to CMS. The ADM stated that the CNM was responsible for the submission, which was not done on time. The facility lacked a validation report and a policy for the PBJ report. CMS policy mandates electronic submission of staffing data by a specified deadline.
Two residents did not receive scheduled showers due to a broken shower hose, resulting in only bed baths being provided. One resident was observed to be poorly groomed, and another expressed frustration over not feeling fully clean. Additionally, a CNA stood while feeding a resident, contrary to protocol, which could impact the resident's self-esteem. The facility's policies on bathing and dignity were not followed.
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management, who acknowledged that the NOMNC forms were missing. The absence of these forms could prevent residents from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges.
The facility failed to ensure annual competencies were signed and dated by three employees, potentially leading to inadequate care. A review of employee files revealed missing signatures and dates on competencies for two LVNs. The Director of Quality and Risk Management acknowledged the risk of incomplete competencies, which could result in inadequate care.
The facility failed to maintain proper food storage and temperature monitoring practices. A walk-in refrigerator lacked a thermometer, risking food spoilage, while the reach-in freezer contained unlabeled and undated food items, potentially leading to expired food. The Sous Chef acknowledged these issues, which contravened the facility's policies requiring labeling and temperature monitoring.
A facility failed to cover a resident's indwelling catheter with a privacy bag, compromising the resident's dignity. The resident, who had multiple health issues and required assistance with daily activities, was observed without the catheter cover, contrary to facility policies. An RN acknowledged the importance of the cover for maintaining the resident's modesty.
The facility did not post survey results and complaint investigation reports in a location accessible to residents and the public, as required by CDPH regulations. The DQRM acknowledged that these documents were kept in her office instead of being available at the nursing station hallway. The CNM confirmed the importance of making these documents accessible to demonstrate compliance and quality of care. This deficiency was noted during a survey.
A facility failed to resubmit the PASARR Level I screening for a resident with anxiety, depression, and psychosis, as indicated by the MDS. The initial screening incorrectly stated no serious mental illness, closing the case without a Level II evaluation. Staff interviews revealed reliance on the transferring facility for initial screening and acknowledged the need for resubmission based on updated assessments.
A facility failed to label and date the ventilator tubing for a resident, which is crucial for preventing respiratory infections. The oversight was confirmed by a respiratory therapist who admitted to changing the tubing without dating it. A registered nurse also acknowledged the importance of dating the tubing, as it is changed daily or as scheduled. The facility's policy on mechanical ventilation did not specify the need to date and label the tubing, contributing to the deficiency.
A resident with a history of acute respiratory failure and on gastrostomy tube feeding was observed with the head of the bed elevated at only 10 degrees, contrary to the care plan requiring 45 degrees to prevent aspiration. A nurse confirmed the risk of aspiration due to the improper elevation.
A resident receiving IV antibiotic treatment for sepsis had unlabeled and undated IV tubing, contrary to the facility's policy requiring tubing to be changed every three days and labeled. The inconsistency in practice was noted by a nurse, and the clinical nurse manager confirmed the labeling responsibility of the nursing staff.
A facility failed to remove expired medication from its storage, risking potential medication errors. During an inspection, Vancomycin prescribed for a resident with respiratory failure was found expired in the medication storage refrigerator. Staff acknowledged the oversight and the risk it posed, noting that expired medications should be returned to the pharmacy as per protocol.
A resident with thyroid cancer and other conditions did not receive a required TSH level test as ordered by a physician. The test was not conducted in November, which was confirmed by a nurse and pharmacist, potentially affecting the resident's medication management. Facility policy mandates that lab tests requested by physicians be provided, but this was not adhered to in this case.
A resident with multiple health conditions, including dysphagia, did not receive necessary dental services despite expressing a desire for dental care. Interviews with staff confirmed the absence of a dental contract and the lack of adherence to the facility's policy requiring oral assessments and arrangements for dental services.
The facility did not hold Quality Assurance Performance Improvement (QAPI) meetings quarterly as required. The last meeting was in December 2024, with the previous one in May 2024, missing the August 2024 meeting. This failure could lead to systemic issues, as confirmed by the Director of Quality and Risk Management (DQRM). The facility's policy requires quarterly meetings and monthly subcommittee meetings, which were not adhered to.
A facility failed to label and date ventilator tubing for a resident, as observed during a survey. The respiratory therapist admitted to changing the tubing without dating it, which is crucial for preventing infections. The facility's policy did not specify the need for dating the tubing, leading to a risk of respiratory infections.
The facility failed to meet nursing professional standards for two residents. One resident's elevated heart rate was not documented or addressed for over three hours, despite facility procedures requiring reassessment and documentation. Another resident did not have documented range of motion services on two scheduled days, risking contractures. These deficiencies highlight lapses in adhering to the facility's documentation policies.
A facility failed to prevent neglect and investigate alleged violations involving three residents. An LVN tied a sheet to a broken bedrail, leading to a resident's fall, ignored a wound vac alarm, leaving another resident in the dark, and failed to report critical test results for a third resident. The facility lacked investigation reports and corrective actions for these incidents.
A resident with severe cognitive and physical impairments fell from bed due to a broken bedrail that was inadequately secured with a sheet. The night shift nurse did not report the issue, and a replacement bed was not ordered, leading to the resident's unwitnessed fall. The facility's policies on equipment failure and fall prevention were not followed, resulting in a deficiency.
A facility failed to ensure an LVN in the subacute unit had a current BLS certification, as required by the job description. This deficiency was identified during a review of care for a resident with chronic respiratory failure and a preference for resuscitation/CPR. The LVN's BLS certification had been expired for over nine months, potentially delaying emergency care for the resident and others in the unit.
The facility failed to maintain room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. Temperatures were recorded as high as 89.7 degrees, and spot coolers were ineffective in reducing the heat. Residents and staff reported discomfort, and the facility's HVAC system was insufficient to manage the temperature, leading to an Immediate Jeopardy situation.
Delay in Stat EEG Due to Unverified Verbal Hold Order
Penalty
Summary
A deficiency occurred when a stat (immediate) EEG order for a resident was not completed as directed by the physician. The resident, who had been admitted with acute respiratory failure, had a stat EEG ordered by a covering physician. The EEG was a contracted service to be performed by an outside technician. Although the technician arrived to perform the test, the house neurologist verbally instructed the technician to hold off on conducting the EEG, despite not being the ordering provider and without a written order to do so. The EEG was subsequently delayed until the following day. Facility policy indicated that non-emergent verbal orders should not be accepted, and emergent verbal orders must be signed by the physician prior to leaving the nursing unit. In this case, the verbal instruction to hold the EEG was not documented as a formal order, and the technician did not consult the ordering provider or inform the assigned nurse about the hold. This sequence of actions and inactions resulted in the stat EEG not being performed as ordered.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to submit its Payroll-Based Journal Staffing Data Report (PBJ) for Quarter 4 of the Fiscal Year 2024 to the Center of Medicare/Medicaid Services (CMS). This deficiency was identified during a record review on December 12, 2024, which revealed that the staffing data for the specified period had not been submitted. During an interview on December 15, 2024, the Administrator (ADM) acknowledged that the Clinical Nurse Manager (CNM) was responsible for submitting the staffing data but had not done so in a timely manner. The ADM also admitted that the facility could not provide a validation report to prove data submission and lacked a policy regarding the PBJ Staffing Data Report. The CMS policy requires facilities to electronically submit direct care staffing information based on payroll and other auditable data, with a deadline for the reporting period of July 1st to September 30th, 2024, being November 14th, 2024.
Failure to Provide Scheduled Showers and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that two out of six sampled residents received their scheduled showers twice a week. Resident 5, who was admitted with diagnoses including respiratory failure and anoxic encephalopathy, was observed to be poorly groomed, with dirt around the ears and arms. The responsible party for Resident 5 reported that the resident had not appeared clean since admission, despite staff claims that the resident was being bathed in bed. Similarly, Resident 8, who had diagnoses including respiratory distress and thyroid cancer, reported not having received a shower in weeks due to a broken shower hose, resulting in only bed baths being provided. This lack of proper bathing was confirmed by a review of the Sub-Acute Shower Log, which showed that neither resident received showers from late November to mid-December. Additionally, the facility failed to maintain dignity during meal assistance for Resident 8. During a dining observation, a CNA was seen standing while feeding Resident 8, rather than sitting at eye level as per protocol. The CNA acknowledged that standing while feeding could negatively impact the resident's self-esteem. The Clinical Nurse Manager confirmed that the protocol required staff to sit at eye level to avoid creating a power imbalance and to prevent residents from feeling intimidated. The facility's policies and procedures, including those for bathing and resident rights, were not adhered to, as evidenced by the lack of regular showers and the improper feeding posture. The facility's policy stated that residents should receive showers or tub baths at least twice weekly and be treated with dignity and respect. The failure to provide these basic care services and maintain dignity during feeding compromised the residents' rights to a dignified existence and proper hygiene.
Failure to Provide NOMNC Forms to Residents
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management (DQRM), who acknowledged that the NOMNC forms were missing for the residents in question. The DQRM explained that the absence of these forms could prevent residents and their responsible parties from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges. The facility's policy and procedures, titled Medicare Beneficiary Discharge Dispute Process, require informing Medicare patients of their rights to dispute a discharge through the Important Message from Medicare (IMM) form. However, the failure to provide the NOMNC forms as part of this process was noted as a deficiency, impacting the residents' ability to make informed decisions regarding their Medicare coverage and potential liabilities.
Incomplete Employee Competencies
Penalty
Summary
The facility failed to ensure that annual competencies were signed and dated by three employees, which could potentially lead to incompetent and inadequate care for all residents. During a record review of five randomly selected employee files, it was found that a Licensed Vocational Nurse (LVN 1) had missing employee and preceptor signatures on their Restraints, Skills Fair, and Critical Clinical Alarm competencies. Additionally, another Licensed Vocational Nurse (LVN 2) had missing dates and no facilitator's name or signature on their General Hiring Orientation form and Care of the Post-Op Bariatric Surgery Patient In-service quiz. Furthermore, LVN 2's Nursing Intravenous (IV) Medication Mixing Skills Checklist was incomplete, with no date and the facilitator's name struck out. During a concurrent interview and record review with the Director of Quality and Risk Management (DQRM), it was stated that all staff competencies and skill fairs should be completed upon hire and annually with the facility's education department and unit. The DQRM acknowledged that all competencies should have been signed by the employees, facilitators, and dated once completed. The DQRM also noted that the risk of incomplete employee competencies could result in inadequate care and uncertainty about whether the competency was truly authenticated with what was taught and learned. The facility's policy and procedures indicated that the Sub Acute Unit should have sufficient nursing to provide services to maintain the highest practical well-being of each patient, as determined by patient assessments and individual care plans.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper temperature monitoring and labeling of food items in the kitchen, which could potentially lead to food spoilage and expiration. During an observation and interview with the Sous Chef, it was noted that the walk-in refrigerator, which stored vegetables and fruits, lacked a thermometer. The Sous Chef acknowledged that a thermometer was necessary to monitor the temperature and prevent food spoilage, and speculated that it might have been removed by someone. Additionally, during an inspection of the reach-in freezer, it was observed that there were opened and unlabeled Ziplock bags containing Uncrustables peanut butter and jelly sandwiches, as well as unlabeled and undated pureed rice and breakfast kosher meals. The Sous Chef admitted that the absence of labels and dates on frozen foods could result in uncertainty about their expiration status. The facility's policy and procedures require that unused portions and open packages be covered, labeled, and dated, and that each refrigerator storage unit have an independent thermometer.
Failure to Maintain Resident Dignity by Not Covering Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was covered with a privacy bag, which is a practice intended to protect the resident's modesty and dignity. This deficiency was observed during an inspection involving Resident 8, who was admitted to the facility with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder. The resident's Minimum Data Set (MDS) indicated that they were cognitively able to understand and required assistance with range of motion, toileting hygiene, showering, and dressing. Despite these needs, the facility did not adhere to its policy of covering the indwelling catheter, potentially leading to feelings of humiliation for the resident. During an interview, a registered nurse (RN) confirmed that the indwelling catheter should have been covered with a privacy bag to maintain the resident's dignity, likening the cover to a piece of clothing that would improve the resident's appearance. The facility's policies on resident rights and guidelines emphasize the importance of treating residents with kindness, dignity, and respect, and providing necessary care to maintain their highest practicable wellbeing. However, the failure to cover the catheter was a deviation from these policies, as it did not align with the facility's commitment to ensuring residents' comfort and dignity.
Failure to Post Survey Results and Complaint Reports
Penalty
Summary
The facility failed to ensure that survey results and complaint investigation reports from the previous three years were posted in a location readily accessible to residents and the public. During an observation and interview, the Director of Quality and Risk Management (DQRM) admitted that these documents were kept in a separate binder in her office and were not available at the nursing station hallway as required. This practice was contrary to the facility's policy and the California Department of Public Health (CDPH) regulations, which mandate that such information be accessible to residents, visitors, and family members. The Clinical Nurse Manager (CNM) confirmed that the survey results and complaint investigation reports should be easily accessible to ensure transparency about the facility's compliance and quality of care. The facility's Resident Orientation Packet and the California Standard Admission Agreement for Skilled Nursing Facilities both emphasize the residents' right to examine survey results and plans of correction. However, the facility did not adhere to these guidelines, resulting in a deficiency noted by the surveyors.
Failure to Resubmit PASARR Level I Screening for Resident with Psychiatric Disorders
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident with diagnoses of anxiety disorder, depression, and psychosis. This oversight was identified during a review of the resident's Minimum Data Set (MDS), which indicated active psychiatric disorders. The initial PASARR Level I screening, completed by the facility, incorrectly stated that the resident had no serious mental illness diagnosis and was not receiving psychotropic medications, leading to the case being closed without a Level II mental health evaluation. Interviews with facility staff revealed that the Clinical Nurse Manager relied on the transferring facility to complete the Level I screening before transfer, and the Registered Nurse responsible for PASARR acknowledged the need to resubmit a new Level I screening based on the updated MDS assessment. The PASRR reference manual requires facilities to notify the state authority of significant changes in a resident's mental condition, which was not done in this case, potentially impacting the resident's access to appropriate psychiatric care.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one resident was labeled and dated, which is a critical step in preventing respiratory infections. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but neglecting to date it. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is essential to prevent bacterial growth and subsequent respiratory infections. Further interviews with a registered nurse corroborated the requirement for the respiratory tubing to be dated, as it is changed daily or as scheduled by the respiratory therapist. The facility's policy and procedure on mechanical ventilation, dated December 2023, highlighted the risk of infection as a common hazard associated with mechanical ventilation. However, the policy did not explicitly state the need to date and label the ventilator tubing, which contributed to the deficiency observed.
Improper Bed Elevation for Resident on Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving tube feeding was provided care in accordance with professional standards of practice. Specifically, the head of the bed for a resident on gastrostomy tube feeding was not elevated to the required 30 to 45 degrees, as observed during a survey. Instead, the head of the bed was elevated at approximately 10 degrees while the resident was receiving continuous tube feeding. This practice was contrary to the resident's care plan, which specified that the head of the bed should be elevated at 45 degrees to prevent aspiration. The resident involved had a history of acute respiratory failure and was receiving tube feeding due to dysphagia and respiratory failure. The facility's policy on gastric tube feeding, dated September 2022, indicated that patients fed by gastric tubes should receive appropriate treatment to prevent aspiration and other complications. During an interview, a registered nurse confirmed that the head of the bed should be elevated at least 30 to 45 degrees for residents receiving continuous tube feeding to prevent aspiration, acknowledging that the resident was at risk due to the improper bed elevation.
Failure to Label and Date IV Tubing
Penalty
Summary
The facility failed to ensure that intravenous (IV) tubing was labeled and dated for a resident receiving IV antibiotic treatment. This deficiency was observed in the case of a resident who was admitted with diagnoses including tracheostomy and anemia and was in a comatose state. The resident had an active order for Zosyn, an antibiotic, to be administered intravenously every eight hours for the treatment of sepsis. During an observation, it was noted that the IV tubing connected to the medication was unlabeled and undated, and the registered nurse present was unable to determine when the tubing was last changed. The facility's policy and procedure for intravenous therapy indicated that IV tubing should be changed every three days and labeled with the date of change. However, the registered nurse stated that the tubing should be changed twice a week, on Thursdays and Sundays, which was inconsistent with the facility's policy. The clinical nurse manager confirmed that it was the responsibility of the licensed nursing staff to label the IV tubing with the date it was changed, as part of the standard practice to track when it needs to be replaced. The failure to label and date the IV tubing had the potential to place the resident at risk for infection and IV therapy complications.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to ensure that expired medication was not kept in the medication storage refrigerator, which could potentially lead to administering expired medication. During an observation of the facility's medication storage room refrigerator, a medication prescribed for a resident with a diagnosis of respiratory failure was found to be expired. The medication, Vancomycin, was labeled with an expiration date and time that had already passed. During an interview, a registered nurse acknowledged that the expired medication should have been returned to the pharmacy and recognized the risk of storing expired medication, which could result in a medication error. The clinical nurse manager also confirmed that the protocol for expired medication was to contact the pharmacy for replacement. The facility's policy indicated that expired medications should be removed and stored separately from those available for administration.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to ensure that a laboratory test was completed for one of the sampled residents, identified as Resident 8. The resident was admitted with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder, and was dependent on staff for various activities of daily living. A physician order dated 11/4/2024 required a thyroid stimulating hormone (TSH) level test to be conducted, but this test was not completed for the month of November. This oversight was confirmed during an interview with a registered nurse, who acknowledged that the absence of the TSH test could place the resident at risk for not receiving the correct dose of thyroid medication. Further interviews with the facility's pharmacist corroborated the failure to conduct the TSH test as ordered. The pharmacist emphasized the importance of monitoring TSH levels to ensure the resident's thyroid levels remain within a normal range, as deviations could exacerbate the resident's thyroid condition. The facility's policy indicated that lab tests requested by physicians should be provided to residents, but this protocol was not followed in this instance, leading to the deficiency.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide dental services to one of the six sampled residents, identified as Resident 13. Resident 13 was admitted with a diagnosis of dysphagia and had additional medical conditions including peripheral vascular disease, chronic renal failure, and congestive heart failure. Despite being independent in oral hygiene, Resident 13 expressed discontent about not receiving dental services and desired to have his teeth cleaned. Interviews with the resident and staff, including a social service worker and a registered nurse, confirmed that no dental services were provided, and there was no dental contract in place for the unit. The facility's policy and procedure on dental services, dated July 2022, required an oral assessment upon admission and arrangements for necessary dental services. However, the policy was not followed, as evidenced by the lack of dental care for Resident 13. The social service worker and registered nurse acknowledged the importance of dental care to prevent oral health issues, yet no actions were taken to ensure Resident 13 received the necessary services. The deficiency was identified through interviews and record reviews, highlighting a failure to adhere to the facility's established procedures for dental care.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held quarterly as required. During an interview and record review with the Director of Quality and Risk Management (DQRM), it was revealed that the last QAPI meeting was conducted in December 2024, with the previous meeting held in May 2024. The DQRM acknowledged that a meeting should have been held in August 2024, but it did not occur. This lapse in holding quarterly meetings was identified as having the potential to result in systemic issues within the facility. The facility's policy, titled Quality Council/Leadership Committee, dated July 2022, mandates that the committee meet at least quarterly. Additionally, a subcommittee, including the Program Director, Medical Director, and Director of Nursing, along with any appropriate staff, is required to meet monthly. The failure to adhere to this schedule was confirmed by the DQRM, who noted the risk of systemic issues arising from not meeting the quarterly requirement.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one of the sampled residents was labeled and dated. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but not labeling it with the date. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is crucial for preventing bacterial growth and respiratory infections. Further interviews with a registered nurse corroborated the requirement for the tubing to be dated, as it is typically changed daily or as scheduled by the respiratory therapist. The facility's policy on mechanical ventilation, while addressing infection control practices, did not specifically mandate the dating and labeling of ventilator tubing. This omission in the policy and the failure to date the tubing placed the resident at risk for respiratory infections.
Deficiencies in Documentation and Care Standards
Penalty
Summary
The facility failed to ensure nursing professional standards were met for two residents. For the first resident, there was no documentation of an assessment in the electronic health record (EHR) when the resident's heart rate was elevated at 106 beats per minute, which is above the normal range. This elevated heart rate was not addressed for over three hours, from 8:19 p.m. to 11:38 p.m. The resident, who was bed-bound with a tracheostomy and a G-tube, had a care plan that required monitoring for physical or nonverbal indicators of discomfort or distress. Interviews with registered nurses revealed that the facility's procedure for abnormal vital signs was to reassess and document the vital signs, administer any necessary PRN orders, and notify the attending physician if needed. However, the documentation was missing during the specified time frame. For the second resident, the facility failed to document the provision of range of motion (ROM) services on two specific dates. The resident, who was in a persistent vegetative state with chronic respiratory failure and flaccid quadriplegia, had a care plan that included maintaining muscle strength and preventing contractures through ROM exercises. The EHR indicated that passive ROM was scheduled to be provided weekly on specific days, but the records for two of these days were blank, indicating a lack of documentation for the services rendered. An interview with the Assistant Chief Nursing Officer confirmed the absence of documentation for the ROM services on the specified dates. The facility's policy and procedure on documentation, revised in September 2022, stated that continuous reassessment and documentation of patient care activities are expected. However, the lack of documentation for both residents' care activities indicates a failure to adhere to these standards, resulting in deficiencies in the care provided to the residents.
Neglect and Investigation Failures in LTC Facility
Penalty
Summary
The facility failed to prevent potential neglect and thoroughly investigate alleged violations involving three residents. In the first case, a Licensed Vocational Nurse (LVN) tied a sheet to a resident's bed frame and broken bedrail, which resulted in the resident falling out of bed. The resident, who was nonverbal and quadriplegic, required assistance with all activities of daily living. Despite the incident, the LVN continued to be assigned to the resident's care without any corrective action being taken. In the second case, the same LVN refused to assess another resident's wound vacuum when it was alarming, instead shutting the door and turning off the light, leaving the resident in the dark without assistance. The resident, who had a chronic lower extremity ulcer and a recent hip debridement, expressed feeling unsafe in the care of the LVN. The facility's former manager confirmed that the LVN did not follow standard nursing care procedures to assess the wound or seek assistance from more knowledgeable staff. In the third case, the LVN failed to report a resident's KUB test results to the physician, which indicated a possible ileus or obstruction. The resident had a history of chronic encephalopathy and dysphagia. The failure to report the results delayed the physician's awareness and potential treatment. The facility was unable to provide investigation reports or corrective actions for these incidents, despite having a policy in place for mandatory reporting and investigation of abuse and neglect.
Failure to Address Broken Bedrail Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medical equipment failure and supervision, resulting in a deficiency. A resident with a complex medical history, including chronic respiratory failure, quadriplegia, and severe cognitive impairment, was involved in an incident where a broken bedrail was inadequately secured with a sheet by a night shift nurse. This makeshift solution was not reported to the house supervisor, and a replacement bed was not ordered, leaving the resident at risk. The resident, who required assistance with all activities of daily living and was nonverbal, fell from the bed due to the broken bedrail. The incident was unwitnessed, and the resident was found on the floor by a respiratory therapist. The day shift nurse, upon discovering the situation, requested a new bed, but the fall had already occurred. The facility's Director of Risk Management confirmed that the root cause analysis identified the failure to report the broken bedrail and the inadequate temporary fix as the primary issues. The facility's policies on medical equipment failure and fall prevention were not followed. The policy required immediate removal and securing of malfunctioning equipment and appropriate clinical intervention, which did not occur. Additionally, the fall prevention program outlined strategies to minimize fall risks, such as ensuring bedrails are functional and beds are in the lowest position, which were not adequately implemented in this case.
Expired BLS Certification for LVN in Subacute Unit
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) assigned to the subacute unit had a current Basic Life Support (BLS) certification, as required by the facility's job description. This deficiency was identified during a review of the care provided to a resident with a history of chronic respiratory failure, recent tracheostomy, cardiac arrest, and anoxic encephalopathy. The resident's Practitioner Orders for Life Sustaining Treatment (POLST) indicated a preference for resuscitation/CPR in life-threatening situations. Despite this, LVN 1, who was responsible for the resident's care on multiple occasions, had an expired BLS certification for over nine months. The issue was discovered during an interview and record review with the Operational Manager of Human Resources, who acknowledged that a report had been sent to the unit manager regarding the expired certification. However, the Manager of the Subacute unit admitted that the expiration was overlooked due to a flaw in the process where employees upload their certificates, but Human Resources does not always see them. This oversight had the potential to delay emergency care for the resident and other residents in the subacute unit who required full treatment in life-threatening situations.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. This deficiency was observed during a survey conducted on September 9, 2024, where temperatures in the residents' rooms and common areas were recorded as being above the acceptable range, with some rooms reaching as high as 89.7 degrees Fahrenheit. The issue was first noticed on September 8, 2024, by an engineer who reported the temperatures were out of range and requested an increase in the chiller's capacity. Interviews with staff and residents revealed that the facility's HVAC system was running at full capacity, yet it was insufficient to maintain the required temperature range. Spot coolers were brought in to assist with cooling, but residents reported that these measures were ineffective in bringing the temperature down. Residents expressed discomfort due to the heat, and staff members, including a Licensed Vocational Nurse, also noted the high temperatures and took personal measures to cope with the heat, such as using portable fans. The facility's policies and procedures indicated that the sub-acute unit should provide a safe and comfortable environment, with specific temperature ranges outlined. However, the facility was unable to adhere to these guidelines, resulting in an Immediate Jeopardy situation being called by the Department. The facility's failure to maintain a safe and comfortable environment for its residents was a significant deficiency, as it placed residents at risk for heat-related health issues.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
