Spring Lake Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 5555 Montgomery Drive, Santa Rosa, California 95409
- CMS Provider Number
- 555268
- Inspections on file
- 15
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Spring Lake Village during CMS and state inspections, most recent first.
A resident accused a CNA of sexual abuse, and although the CNAs reported the allegation to an LPN, the LPN did not escalate the report to the DON or Administrator as required. The incident was not reported to the Department of Public Health within the mandated timeframe, resulting in a delay in notifying authorities and initiating an investigation.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices, as staff were unaware of the guidelines. Personal care items were improperly labeled and stored, increasing cross-contamination risks. A resident's urinal was unlabeled, and a nasal cannula was found on the floor, contrary to facility policies.
The facility did not maintain an effective infection control training program related to Enhanced Barrier Precautions (EBP). The Infection Preventionist RN and the Director of Staff Development were unaware of EBP, resulting in no policy, procedure, or staff training on the matter. This was contrary to CDC guidance and the California Department of Public Health's directive for skilled nursing facilities to implement EBP to reduce the transmission of multidrug-resistant organisms.
The facility failed to follow food safety and sanitation guidelines, with staff not wearing hair nets, cutting boards in poor condition, dented cans not discarded, and improper storage of dry goods. Expired and unlabeled food items were found, and expired sanitizer was used for washing vegetables, posing a risk to the medically fragile resident population.
The facility failed to meet the needs of two residents. A resident with Alzheimer's disease had a call light out of reach, contrary to facility policy. Another resident with congestive heart failure experienced delays in receiving assistance to get out of bed, impacting her ability to attend therapy. Staff acknowledged these issues, which were observed during the survey.
The facility failed to maintain a safe and homelike environment by not properly labeling and storing personal use items. Personal items were found in unlabeled wash basins in shared restrooms, and a resident's item was misplaced on a roommate's table. Staff interviews confirmed these practices were against facility policy, which requires labeling and proper storage to prevent cross-contamination.
The facility failed to implement care plans for two residents, one with Alzheimer's and another with dementia. A resident at risk for falls did not have fall mats on both sides of the bed, and another resident with heel redness had heels touching the mattress despite needing elevation. These oversights were confirmed by RNs during observations.
A facility failed to document weekly skin assessments for a resident with a right heel pressure ulcer, despite policy requirements. The resident, diagnosed with Parkinson's disease, had a Stage II pressure ulcer, but assessments were missing for several weeks, potentially delaying treatment. Interviews confirmed the expectation for weekly assessments, which were not documented in the electronic health record.
The facility failed to store shower disinfectant in a locked container as required by policy. An unlocked container with disinfectant was found in the shower room, despite signage indicating it should be locked. Interviews with staff confirmed the disinfectant should have been secured, and the facility's policy mandates that chemicals be stored in a locked area when not in use.
A resident with cancer under hospice care experienced unrelieved pain due to delays in administering prescribed pain medications. Despite having orders for Oxycodone and Morphine, the staff failed to provide timely relief, with significant delays noted in medication administration. Interviews revealed that the facility's pain management protocol was not followed, leading to the resident's ongoing discomfort.
A facility experienced a 12.2% medication error rate due to improper administration of medications. A resident received Pradaxa without sufficient water and Furosemide despite low blood pressure. Another resident's medications, including Aspirin, Oxybutynin, and Potassium Chloride, were administered late. These errors were against the facility's medication administration guidelines.
A resident with chronic hepatitis received excessive doses of acetaminophen, exceeding the prescribed 2,000 mg daily limit over several months. The DON and MD acknowledged the error, and the pharmacist had recommended order clarification, which was not acted upon. This failure to adhere to medication administration policies posed a risk of hepatotoxicity.
The facility failed to properly store and label drugs and biologicals. Controlled drugs were discarded in an unsecured Smart Sink, risking drug diversion. Additionally, a resident's oxygen humidifier bottle was opened and undated, contrary to facility policy, increasing the risk of bacterial growth.
The facility failed to ensure kitchen staff were competent in testing sanitizer levels in the 3-compartment sink, leading to incorrect readings outside the recommended range. The Executive Chef admitted to not properly demonstrating the procedure, and a Dishwasher was unable to correctly test the sanitizer mixture. This posed a risk of serving food on unclean dishes to 47 medically fragile residents.
The facility failed to label and date resident personal foods in the communal refrigerator, risking the consumption of expired food. During an observation, a pizza box and a package with crackers, cheese, and salami were found unlabeled and undated. An LVN confirmed the need for proper labeling, as per the facility's policy requiring outside food to be stored in labeled containers with the resident's name, room number, date brought, and use-by date.
The facility failed to ensure that one of two outside dumpsters had a lid, potentially attracting pests and rodents. During an observation with the Executive Chef, it was noted that the compactor dumpster was missing a lid and contained overflowing garbage with food and waste. The FDA Food Code and the facility's policy both require tight-fitting lids on outside receptacles.
Failure to Immediately Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policy requiring the immediate reporting of abuse allegations when a resident accused a Certified Nursing Assistant (CNA) of sexual abuse. On 4/13/25, the resident informed staff of the alleged abuse, and both CNAs present reported the incident to a Licensed Nurse (LN). The LN removed the resident from the CNA's assignment but did not report the allegation to the Director of Nursing (DON) or the Administrator as required by facility policy. The incident was not reported to the California Department of Public Health until 4/15/25, which was outside the mandated reporting timeframe. Interviews confirmed that the CNAs followed internal reporting procedures by notifying the LN immediately after the resident's accusation. However, the LN failed to escalate the report to higher management or the appropriate authorities in a timely manner. The facility's policy, revised in August 2022, mandates that all employees report known or suspected abuse immediately, and that a report must be sent to the licensing agency within two hours of forming the suspicion. This lapse resulted in a delay in notifying the authorities and potentially delayed the investigation and protective actions for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Four residents were identified as not receiving the necessary precautions, including the use of gowns and gloves during high-contact care activities. Staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, were unaware of EBP guidelines, and there was no signage to alert staff of the required precautions. The Infection Preventionist and Director of Staff Development also confirmed their lack of knowledge about EBP, resulting in no policy or training being implemented. Additionally, the facility did not properly label and store personal care items, increasing the risk of cross-contamination. A resident's urinal was found unlabeled on a bedside table, contrary to the facility's policy that requires labeling and proper storage in a plastic bag. This oversight was acknowledged by a Licensed Vocational Nurse, who confirmed the urinal should have been labeled and stored correctly. Furthermore, another resident's nasal cannula was found on the floor instead of being stored in a plastic bag when not in use, as per the facility's oxygen therapy policy. A Certified Nurse Assistant admitted the nasal cannula should have been placed in a bag to prevent contamination. The Infection Preventionist confirmed the facility's policy for storing nasal cannulas to prevent infection was not followed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control training program concerning Enhanced Barrier Precautions (EBP), as per the Centers for Disease Control (CDC) guidance. During an interview, the Infection Preventionist Registered Nurse (IP/RN) and the Director of Staff Development (DSD) admitted they were unaware of what EBP entailed. Consequently, they had not developed a policy or procedure nor trained the staff regarding EBP. This oversight was identified during a review of an All Facilities Letter from the California Department of Public Health, which indicated that skilled nursing facilities should implement EBP as part of their infection control measures. The CDC Recommendations highlighted that EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes, particularly for residents with wounds or indwelling medical devices.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. Two kitchen staff members were found not wearing hair nets while in the kitchen, which is against the facility's policy requiring hair restraints for all kitchen personnel. Additionally, five green cutting boards were in poor condition, with deep grooves and grime buildup, making them unsuitable for use according to the facility's policy. Dented cans were found in the dry storage room, which should have been discarded as per the facility's guidelines. Furthermore, six boxes of dry goods were improperly stored directly on the floor, violating the policy that requires items to be stored at least six inches above the floor. The survey also revealed multiple expired food items in the dry storage room and refrigerators, which should have been discarded according to the facility's policy. Several food items were found unlabeled and undated, which is against the policy requiring all unused portions and open packages to be labeled and dated. Additionally, the sanitizer used for washing vegetables was expired, posing a risk to food safety. These deficiencies collectively posed a risk for foodborne illness among the facility's medically fragile resident population of 47.
Failure to Meet Residents' Needs and Preferences
Penalty
Summary
The facility failed to ensure that Resident 29's needs were met when the call light was not within reach. During an observation, it was noted that Resident 29, who has Alzheimer's disease and weakness, was lying in bed without the call light accessible. This was confirmed by a Registered Nurse who acknowledged that the call light should have been within reach. The facility's policy on the resident call system mandates that the means to call for assistance should be within the resident's reach. Additionally, the facility did not meet the needs of Resident 37, who has congestive heart failure and requires assistance with dressing, toileting, and transferring out of bed. Resident 37 expressed frustration over the delay in receiving assistance, which affected her ability to attend a scheduled therapy session. Observations confirmed that Resident 37 was still in bed wearing a gown, waiting for staff assistance. A Certified Nurse Assistant acknowledged Resident 37's complaints about the delay in getting out of bed. The facility's policy on ADL care requires nursing staff to provide daily care to meet each resident's individual needs.
Failure to Properly Label and Store Personal Use Items
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents by not properly labeling and storing personal use items. During observations, personal items such as toothbrushes, toothpaste, and combs were found in a shared restroom for multiple residents, stored in an unlabeled wash basin. This oversight was confirmed during an interview with a Certified Nurse Assistant (CNA), who acknowledged that the room number should be on the wash basin, but not the resident's name. This lack of proper labeling and storage had the potential to cause illness and cross-contamination among the medically compromised population. Additionally, a specific incident was noted where a resident's personal use item was found on their roommate's bedside table, contrary to the facility's policy. Interviews with staff, including another CNA and the Director of Staff Development (DSD), confirmed that wash basins should not be shared and should be labeled with the resident's first and last name. The facility's policy, reviewed during the investigation, clearly stated that bedside equipment should be labeled and stored in a plastic bag between uses to prevent cross-contamination. The failure to adhere to these procedures was identified as a deficiency in maintaining a safe and homelike environment for residents.
Failure to Implement Care Plans for Fall Prevention and Skin Integrity
Penalty
Summary
The facility failed to implement the care plan for Resident 29, who was at risk for falls due to Alzheimer's disease and weakness. Despite having a care plan intervention to place fall mats on both sides of the bed, an observation on February 10, 2025, revealed that Resident 29 was lying in bed without a fall mat on the right side. This was confirmed by Registered Nurse 5, who acknowledged the need for fall mats on both sides to prevent serious injury. Similarly, the facility did not adhere to the care plan for Resident 22, who had dementia and right heel redness requiring elevation of the heels while in bed to prevent further skin breakdown. Observations from February 9 to February 12, 2025, showed that Resident 22's heels were in contact with the mattress, contrary to the care plan's instructions. Registered Nurse 8 confirmed the need for heel elevation to prevent worsening of the skin condition.
Failure to Document Weekly Skin Assessments for Pressure Ulcer
Penalty
Summary
The facility failed to conduct and document weekly skin assessments for a resident with a right heel pressure ulcer. The resident, who was admitted with Parkinson's disease, had a documented Stage II pressure ulcer on the right heel as of November 8, 2024. Despite the facility's policy requiring weekly monitoring of skin conditions, there was no documentation of assessments for several weeks, specifically on December 19, 2024, December 26, 2024, January 16, 2025, January 23, 2025, and January 30, 2025. Interviews with the Infection Preventionist/Registered Nurse revealed that the nursing staff was expected to perform head-to-toe skin assessments weekly and document the findings, including the appearance and measurements of the pressure ulcer. However, the electronic health record lacked evidence of these assessments during the specified weeks, which could have delayed necessary treatment and services to promote wound healing. The facility's policy, dated August 2022, emphasized the importance of monitoring any skin discoloration or breakdown at least weekly.
Failure to Securely Store Shower Disinfectant
Penalty
Summary
The facility failed to ensure that shower disinfectant was stored in a locked storage container, as required by their policy. During an observation in the shower room, an unlocked storage container was found on top of a cupboard, despite signage indicating it should be kept locked at all times. The container held a clear liquid labeled as shower disinfectant. Interviews with a Restorative Nursing Aide and the Director of Nursing confirmed that the disinfectant should have been stored securely. A review of the facility's policy on cleaning and disinfection indicated that chemicals must be stored in a locked container or area inaccessible to others when not in use or under staff observation.
Failure in Timely Pain Management for Hospice Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident admitted with disseminated malignant neoplasm and under hospice care. The resident had orders for Oxycodone and Morphine Sulfate to manage pain, but there were significant delays in administering these medications. On multiple occasions, the resident reported severe pain and requested medication, but the staff did not administer the pain relief promptly. For instance, on one occasion, the resident reported pain at 7/10 and requested morphine, but it took over two hours for the medication to be administered. Interviews with the nursing staff revealed lapses in following the pain management protocol. A nurse admitted to not reevaluating the resident's pain after administering Oxycodone and acknowledged the delay in providing morphine. The facility's policy required immediate response to pain complaints, but this was not adhered to, resulting in the resident experiencing unrelieved pain. The care plan for the resident emphasized the need for timely administration of analgesics and anticipation of pain relief needs, which was not effectively implemented.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.2% error rate. This was observed through five medication errors out of 41 opportunities. One unsampled resident was administered Pradaxa without a full glass of water, contrary to the medication's instructions, which could lead to potential complications such as ulceration. Additionally, the same resident received Furosemide despite having a systolic blood pressure below the prescribed threshold, which could have caused a further drop in blood pressure. Another resident experienced three separate medication timing errors. Aspirin, Oxybutynin, and Potassium Chloride were all administered past their scheduled times. The nurses involved acknowledged they were behind schedule, and the Director of Nursing confirmed that medications should be administered within a specific timeframe, which was not adhered to in these instances. The facility's policy and procedure for medication administration were not followed, as medications were not given as prescribed or within the required timeframes. The errors were identified through observations, interviews, and record reviews, highlighting a significant deviation from the facility's established guidelines for medication administration.
Excessive Acetaminophen Dosage Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of acetaminophen. The resident, who had a history of chronic hepatitis, was prescribed acetaminophen with a maximum daily dosage of 2,000 mg. However, the Medication Administration Records (MAR) revealed that the resident received dosages exceeding this limit, with instances of 3,500 mg and 4,500 mg administered on certain days. This excessive administration occurred over several months, with the Director of Nursing (DON) acknowledging the error and stating that the order should have been clarified. The Medical Director (MD) and the pharmacist both recognized the need for clarification of the acetaminophen order, especially given the resident's medical history. The pharmacist had recommended clarifying the order in the Monthly Medication Review, but this was not acted upon. The facility's policies on physician orders and medication administration required verification of orders for clarity and appropriateness, which was not adhered to in this case. The pharmacist noted that exceeding the daily limit of acetaminophen for an extended period posed a risk of hepatotoxicity for the resident.
Improper Storage and Labeling of Drugs and Biologicals
Penalty
Summary
The facility failed to properly store and label drugs and biologicals, leading to potential risks. Controlled drugs were being discarded in a Smart Sink, a container that was not secure or permanently affixed to the wall, which could result in drug diversion. During an observation, a Registered Nurse indicated that narcotic medications were disposed of in this manner when the Director of Nursing was not present. The Director of Nursing was unfamiliar with the Smart Sink's purpose and location, and the facility's policy on medication disposal required special handling and storage for controlled substances. Additionally, the facility did not properly label an oxygen humidifier bottle for a resident with pneumonia. The humidifier bottle was found opened and undated, which could increase the risk of bacterial growth and respiratory illness. A Registered Nurse incorrectly stated that humidifiers did not need to be dated, while the Director of Staff Development confirmed that they should be dated upon opening. The facility's policy on oxygen therapy required humidifiers to be labeled with the date opened.
Inadequate Training in Sanitizer Testing in Kitchen
Penalty
Summary
The facility failed to ensure that all kitchen staff were evaluated for competency in testing the sanitizer levels in the 3-compartment sink, which is crucial for cleaning and sanitizing dishes. During an observation, the Executive Chef (EC) tested the quaternary ammonium (quat) sanitizer and found the levels to be higher than the recommended range of 200-400 ppm, with readings of 600-800 ppm and 1000 ppm. The EC was unsure why the readings were high and admitted to not properly demonstrating the testing procedure to the staff. Further observations revealed that a Dishwasher (DW) was also unable to correctly test the sanitizer mixture, resulting in a reading of 400-600 ppm, which was outside the normal range. The EC acknowledged responsibility for training all kitchen staff and the facility's policy indicated that on-the-job training should include the use of specific hazardous substances. This lack of proper training and competency evaluation had the potential to result in residents being served food on unclean dishes, posing a risk of foodborne illnesses to the medically fragile population of 47 residents.
Failure to Label and Date Resident Personal Foods
Penalty
Summary
The facility failed to ensure that all resident personal foods were properly labeled and dated in the communal refrigerator, which could lead to the consumption of expired food and an increased risk of foodborne illness. During an observation in the Residents' communal refrigerator located in the Hydration Room, a pizza box and a package containing crackers, cheese, and salami were found unlabeled with resident names, room numbers, and undated. This was confirmed during an interview with an LVN, who acknowledged the need for labeling with the date and room number. A review of the facility's policy and procedure titled 'Use and Storage of Food Brought to Residents From the Outside' indicated that outside food must be stored in an appropriate container, labeled with the resident's name, room number, the date the food was brought to the resident, and the use-by date.
Dumpster Lid Missing at Facility
Penalty
Summary
The facility failed to ensure that one of two outside dumpsters had a lid, which could potentially attract pests and rodents. This deficiency was observed during a concurrent observation and interview with the Executive Chef in the outside loading dock area, where it was noted that the compactor dumpster was missing a lid and contained overflowing garbage with food and waste. The Executive Chef acknowledged that the dumpster should have a lid. A review of the U.S. Food and Drug Administration's Food Code from 2022 indicated that outside receptacles used with materials containing food residue should have tight-fitting lids, doors, or covers. Additionally, the facility's policy and procedure on Solid Waste Disposal, dated January 2025, stated that lids should be kept closed on all outside trash receptacles.
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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