St. Catherine Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fullerton, California.
- Location
- 245 E Wilshire Avenue, Fullerton, California 92832
- CMS Provider Number
- 055689
- Inspections on file
- 25
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at St. Catherine Healthcare during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity had an alleged abuse incident reported by a family member, with police involvement and documented right hand discoloration. Facility records showed psychosocial support by Social Services on some days but no comprehensive care plan addressing the alleged abuse was developed, despite facility policy requiring an IDT care plan for each resident. An RN and the DON confirmed that no abuse-related care plan existed, and the DON stated staff did not create one because the allegation was unsubstantiated, no harm was identified, and there was no change in condition, although a care plan was completed for the hand discoloration.
Surveyors found that several residents received supplemental oxygen at higher flow rates than ordered by their physicians, and that documentation of PRN oxygen administration was incomplete or missing. Nursing staff confirmed the discrepancies, and medical record reviews showed that facility policies for oxygen administration and medication documentation were not followed.
A resident in a LTC facility did not receive prescribed medications for two days due to pending delivery, and the facility failed to notify the physician as required by policy. The resident, with a history of diabetes, hypertension, and hyperlipidemia, was not administered critical medications, leading to a high blood sugar reading upon transfer to an acute care facility. The DON confirmed the oversight and acknowledged the lack of physician notification.
The facility failed to implement fall prevention measures for three residents, as their care plans were not followed. Observations revealed that beds were not in the lowest position, and floor mats were improperly placed, increasing fall risks. Staff confirmed these deficiencies, indicating a lack of adherence to safety protocols.
A facility failed to ensure the accuracy of the MAR for a resident, leading to discrepancies in medication administration records. The resident, admitted for respite care, had fluctuating decision-making capacity and was prescribed carvedilol and ezetimibe. Despite the MAR indicating these medications were administered, they were actually pending delivery and not given, as confirmed by the DON.
The facility failed to follow food safety and sanitation protocols, including improper thawing of meats, unsanitary storage of kitchen utensils, and inadequate maintenance of food preparation equipment. Additionally, a food preparation sink lacked an air gap for backflow prevention, posing a risk of food-borne illnesses to residents.
The facility failed to implement its infection control surveillance program effectively, limiting it to residents prescribed antimicrobials and not accurately tracking infections. Additionally, proper infection control practices were not followed for a resident under transmission-based precautions, and hand hygiene was not performed during a GT dressing change. These deficiencies were confirmed by staff interviews.
A resident was found with medications at their bedside without an assessment, physician's order, or care plan for self-administration. The RN acknowledged the error, and the DON confirmed the absence of necessary documentation, despite the resident's capacity to make decisions.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan. The resident, with schizophrenia, anxiety disorder, and major depressive disorder, required special services as per the PASARR evaluation. However, the facility did not document these recommendations in the care plan, nor was there evidence of an IDT meeting to discuss them. Interviews with the MDS Coordinator and DON confirmed the lack of documentation and follow-up.
A facility failed to ensure proper care for a resident's gastrostomy tube (GT). The GT was not checked for placement before medication administration, nor was it flushed with water between medications or after administration, as per facility policy and physician's orders. An LVN confirmed these lapses during an interview.
A facility failed to monitor a resident's PICC line by not measuring the right upper arm circumference upon admission and during dressing changes. This oversight, confirmed by RN 2, was contrary to physician orders and posed a risk for complications. The facility also did not develop a care plan for the PICC line, which is essential for proper management.
A facility failed to provide adequate dialysis care for a resident by not monitoring fluid intake as per physician's orders and neglecting to assess the dialysis access site before and after treatments. The resident's fluid intake exceeded the prescribed limit on multiple occasions, and there were missing assessments for the dialysis site on several dates. These deficiencies were confirmed by an LVN during a review.
The facility failed to attempt alternative measures before using bed rails for two residents, contrary to its policy. One resident had a physician's order for bed rails as an enabler for mobility, but no alternatives were documented. Another resident had a similar order for grab bars, with no alternatives attempted. An RN confirmed these findings.
A facility failed to ensure a resident had a physician's order for nasal moisturizing spray, which was found in her bedside drawer. The resident was evaluated as safe to self-administer medications and had no cognitive impairment. However, the medical records lacked an order for the nasal spray, as confirmed by an LVN during a review.
The facility failed to ensure safe storage of medications and supplies. An inspection revealed expired supplies and items without manufacturing or expiration dates in the IV Cart, verified by an RN. Additionally, an opened bottle of Gerilanta without an open date was found in Medication Cart 2, confirmed by an LVN. These deficiencies could lead to unsafe medication administration.
A resident with a diagnosis of unspecified protein-calorie malnutrition did not receive a fortified diet as ordered, as the facility failed to add margarine to the resident's meal. The facility's policy required fortification for residents needing additional calories and protein, but this was not followed, as confirmed by the DSS and acknowledged by the DON and Administrator.
A facility failed to follow dietary texture guidelines for a resident with dysphagia, serving a meal that did not meet the required pureed consistency. The resident's lunch tray included runny beans and rice mixed with pureed pork, which did not hold its shape as required. The Dietary Services Supervisor confirmed the inconsistency, and the facility's leadership was informed of the findings.
The facility failed to educate staff and family/visitors on safe food handling of outside food, as per its policy. The DSS did not provide specific education on cooking and cooling temperatures, nor literature on safe practices. The LVN indicated the RD was responsible for discussing guidelines, but no evidence of this was found. The DSD and DON revealed gaps in staff education, with reheating done by kitchen staff and no reheating available after hours, risking foodborne illnesses for residents.
The facility failed to implement its antibiotic stewardship program by not properly assessing infections using McGeer's criteria. Several residents were prescribed antibiotics without meeting the necessary criteria, as evidenced by incomplete Surveillance Data Collection Forms. Interviews with staff confirmed these findings, highlighting a systemic issue in the facility's practices.
A facility failed to obtain informed consent for an increased dosage of diazepam for a resident. The resident's physician noted increased anxiety and pain, leading to a dosage increase from 10 mg to 15 mg. However, consent was only documented for the initial dose. Interviews with an LVN and the DON confirmed the oversight, posing a risk of uninformed medication changes.
A facility failed to obtain and maintain a resident's advance directive in their medical record, despite policy requirements and indications in assessments that such directives existed. The resident had a DNR status and comfort-focused treatment preferences, but the facility did not follow up to secure a copy of the advance directives, as confirmed by interviews with the SSD and DON.
A resident with multiple diagnoses, including Parkinson's disease and cognitive deficits, experienced a fall from a wheelchair. The facility failed to perform neuro-checks at the required intervals as per their 72-hour monitoring protocol. The checks were conducted at irregular intervals, and the resident was later transferred to an acute care hospital. Interviews with staff confirmed the deviation from protocol.
A resident received Norco for severe pain, but the administration was inaccurately documented on the MAR. The medication was taken from the E-kit and given immediately, but the nurse delayed documentation, leading to a discrepancy. This failure to document accurately posed a risk of medical error and treatment delay.
Failure to Care Plan for Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing an alleged abuse incident for one resident. The facility’s care planning policy, revised in 2/2021, requires the IDT to develop a comprehensive care plan for each resident. The resident was admitted on an unspecified date and had an H&P dated 10/17/25 indicating the resident did not have the capacity to understand and make decisions. On 1/9/26, a progress note documented that police arrived around noon after the resident’s wife reported to them that the resident had been abused, bruised, and burned. An eINTERACT Change in Condition Evaluation dated 1/9/26 documented right hand discoloration. Progress notes from 1/9 and 1/13–1/15/26 showed that Social Services provided psychosocial support to the resident. Further review of the medical record showed there was no documentation of psychosocial support from 1/10–1/12/26 following the alleged abuse incident on 1/9/26, and no care plan was developed to address the alleged abuse. During an interview and concurrent record review on 2/3/26, an RN confirmed there was no care plan related to the alleged abuse and stated that a licensed nurse should have created one so staff could monitor the resident and have goals and interventions in place. In a separate interview on 2/3/26, the DON also verified that no care plan was developed for the alleged abuse, explaining that staff did not create an alleged abuse care plan because the allegation was unsubstantiated, no harm was identified, and there was no change in condition. The DON stated that psychosocial support was provided daily by the social worker and that a care plan was completed for the resident’s hand discoloration, but not for the alleged abuse itself.
Failure to Follow Oxygen Administration Orders and Documentation Protocols
Penalty
Summary
The facility failed to follow physician orders and its own policies regarding the administration and documentation of supplemental oxygen for four residents. For three residents, oxygen was administered at higher flow rates than prescribed by their physicians. Specifically, one resident with an order for continuous oxygen at 2 liters per minute (LPM) was observed receiving 5 LPM, while two other residents with orders for 2 LPM PRN were observed receiving 4 LPM and 3 LPM, respectively. Nursing staff confirmed that they had not adjusted the oxygen flow during their shifts, and medical record reviews verified that the physician orders were not followed. For another resident, there was a lack of proper documentation regarding the administration of PRN oxygen. Although the medical record and various nursing summaries indicated that the resident received oxygen daily over a period of several weeks, the Medication Administration Record (MAR) only documented a single instance of PRN oxygen administration. Interviews with nursing staff and the Director of Nursing confirmed that the resident was on continuous oxygen, despite the physician's order specifying PRN use, and that the MAR did not accurately reflect the frequency of administration. These deficiencies were identified through direct observation, interviews with nursing staff, and review of medical records and facility policies. The facility's policies required that oxygen be administered as ordered by the physician and that all medication administration be properly documented. The failure to adhere to these protocols resulted in both inaccurate administration of oxygen and incomplete documentation for the affected residents.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not administering medications as per the physician's orders on two consecutive days. The medications were not delivered on time, and the facility did not follow its policy to notify the prescriber when medication delivery was delayed. This oversight was identified during a review of the facility's policies and procedures, which stated that the prescriber should be contacted for direction when medication delivery is delayed. The facility's failure to adhere to this policy resulted in the resident not receiving critical medications for conditions such as hypertension, diabetes, and depression. The resident, who had a history of Type II diabetes mellitus, hypertension, and hyperlipidemia, was admitted to the facility and later transferred to an acute care facility. The resident's medical records indicated fluctuating capacity to understand and make decisions. Despite having physician's orders for multiple medications, including antihypertensives, antidiabetics, and antidepressants, the medications were not administered due to pending delivery status. The facility's Medication Administration Record (MAR) and electronic MAR (eMAR) showed that several medications were marked as pending delivery, and there was no documentation of physician notification regarding the missed doses. The Director of Nursing (DON) confirmed that the resident's medications were not administered due to pending delivery and acknowledged that the physician was not notified. The DON also stated that the resident's family was responsible for providing medications, and the facility would order and notify the physician if medications were not brought in a timely manner. However, this process was not followed, and the resident's blood sugar levels were not monitored until the day of transfer to the acute care facility, where a high blood sugar reading was recorded. The failure to administer medications and notify the physician as per the facility's policy had the potential to negatively impact the resident's health condition.
Failure to Implement Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to ensure that three residents remained free from accident hazards, as evidenced by observations and interviews. Resident 3's care plan included interventions such as keeping the bed in the lowest position and using bilateral floor mats. However, during an observation, the bed was not in the lowest position, and the right-side floor mat was folded up against the wall. The Director of Nursing (DON) and the Administrator confirmed these findings, indicating a failure to adhere to the care plan designed to mitigate fall risks. Resident 4's care plan required maintaining a clear pathway free of obstacles to prevent falls. Despite this, an observation revealed that the bedside table was placed on top of the floor mat, with one end of the mat flipped up. RN 1 verified the improper placement of the table and expressed concern about the resident's fall risk due to frequent movement. This situation demonstrated a lack of compliance with the care plan's safety measures. Similarly, Resident 5's care plan included keeping the bed in the lowest position and ensuring a clear pathway. However, the bed was observed not in the lowest position, and the bedside table was placed on top of the floor mat. CNA 2 confirmed these observations and adjusted the bed and table accordingly. The DON acknowledged that the table should not be on the floor mat, highlighting a failure to implement the prescribed interventions to prevent falls.
Inaccurate Medication Administration Record for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Medication Administration Record (MAR) for one of the sampled residents, identified as Resident 2. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy on documentation, dated May 2007, requires that a resident's clinical record be a concise and accurate account of treatment and care. However, discrepancies were found in Resident 2's MAR for November 2024. Specifically, medications that were documented as pending delivery were erroneously recorded as administered. Resident 2, who was admitted for respite care, had fluctuating capacity to understand and make decisions. The resident's Order Summary Report indicated prescriptions for carvedilol and ezetimibe. Despite the MAR showing these medications as administered on specific dates, interviews with the Director of Nursing (DON) confirmed that the medications were not actually administered due to pending delivery. This error in documentation was acknowledged by both the DON and the Administrator Assistant during a review of the closed medical record.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures (P&P) regarding food safety and sanitation in the kitchen, which posed a risk of food-borne illnesses to its residents. The thawing process for meats was not followed correctly, as evidenced by a bag of thawed chicken labeled with an outdated use-by date. The Director of Support Services (DSS) confirmed that the chicken should have been discarded, and an employee admitted to incorrectly labeling the chicken. Additionally, the facility's P&P required daily checks of the refrigerator to discard perishable foods, which were not adequately performed. The facility also failed to maintain kitchen utensils and equipment in sanitary conditions. Observations revealed that storage bins for clean cooking utensils contained dry particles, and the plate warmer had debris and broken plate pieces. The DSS confirmed these findings, and the Maintenance Director stated he had not been informed to clean the plate warmer recently. Furthermore, fans inside refrigerators and freezers were found with fuzzy substances, indicating a lack of regular cleaning, which the DSS verified. The facility did not ensure that food preparation equipment was in good condition. Cutting boards were heavily marred with knife marks, and a spatula was cracked, both of which were confirmed by the DSS. Additionally, a bag of frozen ham with freezer burn was found, indicating improper storage. The facility also failed to provide an air gap for backflow prevention in a food preparation sink, which was used for washing vegetables and fruits. These deficiencies were acknowledged by the Administrator, DON, and DSS.
Infection Control Deficiencies in Surveillance and Practices
Penalty
Summary
The facility failed to implement its infection control surveillance program effectively from January through August 2024. The surveillance was limited to residents prescribed antimicrobials, excluding those with signs and symptoms of infection who met McGeer's criteria but were not on antimicrobial medications. Additionally, the facility did not accurately track and monitor infections for February, May, and June 2024, as evidenced by incomplete documentation on the Infection Prevention and Control Surveillance Log regarding whether residents had healthcare-associated infections (HAI), community-acquired infections (CAI), or did not meet McGeer's criteria. The facility also failed to implement proper infection control practices for a resident under transmission-based precautions. During a medication administration observation, a licensed vocational nurse (LVN) did not don a gown as required for a resident with enhanced barrier precautions for a gastrostomy tube (GT). This oversight was acknowledged by the LVN during an interview, indicating a lapse in adherence to infection control protocols. Furthermore, the facility did not ensure staff performed hand hygiene during a GT dressing change for a resident. An LVN was observed changing gloves multiple times without performing hand hygiene in between, contrary to the facility's infection control policy. The supplies used during the dressing change were also placed on an unsanitized surface, which was not in line with the expected standards. These actions were confirmed by the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews, highlighting a failure to follow established infection control practices.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for one resident, identified as Resident 77. During an observation, medications were found inside a medicine cup at the resident's bedside without an assessment, physician's order, or care plan problem addressing the self-administration of medications. This oversight was confirmed by RN 1, who acknowledged that the medications should not have been left at the bedside. A review of Resident 77's medical records revealed that there was no documented evidence of a physician's order, assessment, or care plan problem for self-administration of medications, despite the resident having the capacity to understand and make decisions as per their H&P examination. The Director of Nursing (DON) verified the absence of these critical documents, indicating a lapse in following the facility's policy and procedure for self-administration of medications.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination were followed and incorporated into the care plan for a resident diagnosed with schizophrenia, anxiety disorder, and major depressive disorder. The resident was admitted and readmitted to the facility, and a PASARR Level II Evaluation was conducted, which recommended special services due to the resident's medical and mental health conditions. However, the facility did not document the incorporation of these recommendations into the resident's care plan, nor was there evidence of an interdisciplinary team (IDT) meeting to discuss the PASARR Level II recommendations. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the lack of documentation and follow-up on the PASARR recommendations. The MDS Coordinator acknowledged that the facility should have obtained and printed the determination results and incorporated them into the resident's care plan. The DON was informed of these findings and acknowledged the deficiency. This oversight had the potential to impact the adequacy of care provided to the resident.
Failure in Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services related to the use of a gastrostomy tube (GT) for one resident. Specifically, the facility did not ensure that the GT was checked for placement prior to medication administration, nor was it flushed with at least 5 ml of water between each medication as per the facility's policy and procedure (P&P). Additionally, the GT was not flushed with 20 to 30 ml of water following medication administration as per the physician's order. These actions were observed during a medication administration session conducted by an LVN for the resident. The resident involved was admitted to the facility on an unspecified date and readmitted on another unspecified date. A review of the resident's order summary report showed a physician's order dated July 4, 2024, which required checking the tube placement before medication administration and flushing the tubing with 20 to 30 ml of water after medications. During an interview, the LVN verified the findings, confirming the failure to adhere to the established procedures for GT care, which had the potential to affect the resident's health and well-being.
Failure to Monitor PICC Line in Resident
Penalty
Summary
The facility failed to provide necessary care and services related to a PICC line for a resident, identified as Resident 537. Upon admission, the facility did not obtain the measurement of the resident's right upper arm circumference, which is crucial for monitoring potential complications such as deep vein thrombosis. Additionally, the facility did not develop a care plan problem to address the use of the PICC line catheter, which is essential for ensuring proper management and monitoring of the device. During an observation on 9/23/24, Resident 537 was noted to have a PICC line on the right upper arm, covered with a transparent dressing. Despite physician orders requiring daily measurement of the external catheter and site dressing, as well as administration of antibiotics for leukocytosis and MRSA, the medical record lacked documentation of the arm circumference measurements. An interview with RN 2 confirmed that these measurements were not taken, highlighting a lapse in the facility's adherence to care protocols for residents with PICC lines.
Failure to Monitor Dialysis Care and Fluid Restriction
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident, identified as Resident 63, who required such services. The deficiencies were identified through observation, interviews, medical record reviews, and a review of the facility's policies and procedures. Specifically, the facility did not monitor Resident 63's fluid intake as per the physician's order, which restricted fluid intake to 1200 ml per 24 hours. The resident's fluid intake exceeded this limit on multiple occasions, with recorded intakes ranging from 1220 ml to 1500 ml on various dates. Additionally, there were several instances where the facility failed to document the resident's fluid intake for specific shifts and dates. Furthermore, the facility did not ensure that Resident 63's dialysis access site was assessed before and after dialysis treatments as required. The medical records lacked documentation of assessments for the dialysis site on several pre- and post-dialysis dates. These failures were acknowledged by LVN 2 during an interview and concurrent medical record review, indicating a lapse in following the facility's policy to maintain the resident's well-being and ensure proper dialysis care.
Failure to Implement Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to implement alternative measures before resorting to the use of bed rails for two residents, which is a violation of their policy. The policy requires that appropriate alternatives be attempted prior to the installation of bed rails. For Resident 63, who was observed with bilateral bed rails elevated, the medical record review showed a physician's order for the use of bed rails as an enabler for bed mobility and positioning. However, the Bed Rail Safety Evaluation did not document any alternative interventions attempted before the use of bed rails. Similarly, Resident 537 was observed with bilateral bed rails elevated, and the medical record review revealed a physician's order for grab bars as an enabler for bed mobility and positioning. The Bed Rail Safety Evaluation for this resident also lacked documentation of any alternative interventions attempted prior to the use of bed rails. An interview with RN 2 confirmed these findings, indicating a failure to adhere to the facility's policy of attempting alternatives before using bed rails.
Failure to Ensure Physician's Order for Nasal Spray
Penalty
Summary
The facility failed to ensure that a resident was provided medications as ordered by the physician. Specifically, the resident had three bottles of nasal moisturizing spray in her bedside drawer without a physician's order for its use. The facility's policy requires medications to be administered as prescribed by the attending physician, and the resident's medical records did not include an order for the nasal spray. The resident was deemed safe to self-administer medications and had no cognitive impairment, as per evaluations conducted prior to the incident. However, the absence of a physician's order for the nasal spray was confirmed during an interview and medical record review with an LVN.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage of medications and supplies, as observed during an inspection. The IV Cart contained expired supplies and items without manufacturing or expiration dates, including 78 Red Plus Luer Lock Caps, five Vial Mate Adapters, and seven BD Vacutainer Luer Lock Access Devices. Additionally, two BD Blue Insyte Autoguard Winged Catheters were found with past expiration dates. These findings were verified by RN 4. Furthermore, an opened bottle of Gerilanta, a laxative medication, was found in Medication Cart 2 without an open date, as confirmed by LVN 2. These deficiencies had the potential to result in unsafe administration of medications.
Failure to Follow Fortified Diet Plan
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the fortification of food for residents requiring additional caloric and protein intake. Specifically, the facility did not follow the prescribed fortified diet for a resident diagnosed with unspecified protein-calorie malnutrition. The facility's policy outlined that fortification should be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein. The resident in question had a physician's order for a fortified, puree texture diet with nectar thick consistency, which was not followed as the margarine was not added to the red beans and rice entree as required. During an observation of the lunch meal tray line, it was noted that the dietary staff did not add the necessary margarine to the resident's meal, which was confirmed by the Dietary Services Supervisor (DSS). The DSS acknowledged that the cook should have added the margarine before the tray was delivered. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that residents with fortified diet orders should receive meals prepared according to those specifications. The failure to follow the fortified diet plan was acknowledged by the facility's administration.
Failure to Follow Dietary Texture Guidelines
Penalty
Summary
The facility failed to adhere to dietary texture guidelines for a resident on a pureed diet, as per the facility's policy and procedure. The resident, who was diagnosed with dysphagia affecting the oropharyngeal phase, was prescribed a fortified, pureed diet with nectar thick liquids. During an observation of the lunch meal tray line, it was noted that the resident's meal did not meet the required consistency. Specifically, the beans and rice on the plate were runny and mixed into the pureed pork with gravy, which did not hold its shape as required for a pureed diet. The deficiency was identified during a review of the resident's medical records and a direct observation of the meal service. The Dietary Services Supervisor (DSS) confirmed that the pureed entree should maintain its shape and acknowledged that the beans and rice were not prepared to the correct consistency. The facility's Administrator, Director of Nursing (DON), and DSS were informed of these findings, which highlighted a failure to provide food in a form designed to meet the individual needs of the resident, potentially leading to choking or aspiration.
Deficiency in Safe Food Handling Education for Outside Food
Penalty
Summary
The facility failed to ensure that education was provided to staff and family/visitors on safe food handling of outside food, as per the facility's policy and procedure (P&P). The facility's P&P required that foods brought by family or visitors be accepted by the resident, inspected before storage, and stored and served according to food safety professional standards. However, interviews revealed that the Dietary Services Supervisor (DSS) did not provide specific education on proper cooking and cooling temperatures, nor did she provide literature on safe food handling practices to family/visitors. Additionally, the Licensed Vocational Nurse (LVN) indicated that the Registered Dietitian (RD) or designee was responsible for discussing safe food handling guidelines with visitors, but there was no evidence of this education being provided. Further interviews with the Director of Staff Development (DSD) and Director of Nursing (DON) revealed gaps in staff education regarding safe food handling practices. The DSD stated that she reviewed the facility P&P with staff but did not provide education on safe cooking and cooling temperatures. The DON confirmed that reheating of food was done by kitchen staff, and if residents wanted to consume food after kitchen hours, the facility was unable to reheat it. These deficiencies in education and communication had the potential to cause foodborne illnesses among the medically vulnerable resident population.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the lack of proper assessment using McGeer's criteria to determine true infections. This deficiency was identified through interviews, medical record reviews, and facility document reviews. The facility's policy, dated September 2017, outlined the need for an Antibiotic Stewardship Program to promote appropriate antibiotic use and optimize infection treatment. However, the facility did not adhere to this policy, as shown by the incomplete assessments on the Surveillance Data Collection Forms for several residents. These forms were intended to assess whether infections met the criteria for community-acquired infection (CAI) or healthcare-associated infection (HAI), but many forms were incomplete or incorrect. The medical records of several residents revealed that antibiotics were prescribed without meeting the necessary criteria. For instance, one resident was prescribed cefuroxime despite only meeting one of the required criteria for infection. Other residents were prescribed antibiotics such as azithromycin, ofloxacin, doxycycline, and vancomycin, but their forms did not indicate whether the infections were CAI, HAI, or did not meet the criteria. Interviews with the Infection Preventionist (IP), Director of Staff Development (DSD), and Director of Nursing (DON) confirmed these findings, indicating a systemic issue in the facility's antibiotic stewardship practices.
Failure to Obtain Informed Consent for Increased Psychotropic Medication Dosage
Penalty
Summary
The facility failed to properly obtain informed consent for the use of psychotropic medications for one of the residents, identified as Resident 23. According to the facility's policy and procedure, informed consent must be obtained before initiating or changing the dosage of psychotropic medications. Resident 23 was admitted to the facility and later seen by a physician who noted increased anxiety and pain, leading to a decision to increase the dose of diazepam from 10 mg to 15 mg twice a day. However, the medical records showed that informed consent was only obtained for the initial 10 mg dose, and there was no documented evidence of consent for the increased 15 mg dose. Interviews with the Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) confirmed the oversight. LVN 1 verified the physician's order for the increased dose and acknowledged that informed consent should have been obtained when the dose was increased. The DON was also informed of the findings and verified the lack of documented consent for the increased dosage. This failure posed a risk for Resident 23 and their responsible parties to not be fully informed of the medication changes and potential side effects.
Failure to Maintain Advance Directives in Medical Record
Penalty
Summary
The facility failed to obtain and maintain copies of the advance directive in the medical record for one of the sampled residents, identified as Resident 10. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P) regarding advance directives. According to the facility's P&P, it is required that a resident's advance directives be included in their medical record. However, despite indications in Resident 10's assessments that advance directives existed, the facility did not have a copy of these directives in the resident's medical record. Resident 10 was admitted and readmitted to the facility, with medical records indicating a Do Not Resuscitate (DNR) status and comfort-focused treatment preferences. The resident's social services assessments noted the existence of advance directives and included instructions to obtain a copy for the medical record. However, the facility failed to follow up and secure a copy of the advance directives, as confirmed by interviews with the Social Services Director (SSD) and the Director of Nursing (DON). This oversight had the potential to cause confusion or failure to provide care in accordance with the resident's treatment wishes.
Failure to Conduct Timely Neuro-Checks Post-Fall
Penalty
Summary
The facility failed to adhere to its 72-hour Neuro-check Monitoring process following a fall incident involving a resident. The protocol required neuro-checks to be conducted every 30 minutes for two times, every hour for three times, every two hours for two times, every four hours for four times, and every eight hours for six times. However, the neuro-checks for the resident were only conducted at 0300, 0330, 0630, 0930, and 1230 hours, which did not meet the specified time frames. This lapse in monitoring occurred after the resident fell from a wheelchair and hit their left hip on the floor. The resident, who had been admitted with diagnoses including Parkinson's disease, OPD, lack of coordination, difficulty in walking, cognitive communication deficits, muscle weakness, and osteoarthritis, was transferred to an acute care hospital later that day. Interviews with the LVN and the DON confirmed that the neuro-checks were not performed according to the facility's protocol. The failure to conduct timely neuro-checks had the potential for medical complications to go unnoticed post-fall.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medication administration documentation on the Medication Administration Record (MAR) for a resident. The facility's policy and procedure (P&P) for medication administration requires that the individual administering the medication records the administration on the MAR immediately after giving the medication. Additionally, when PRN medications are administered, the date, time, dose, route, complaint, and results achieved must be documented. However, in this case, the documentation was not completed accurately or timely. A resident had a new order for Norco 10 mg/325 mg for severe pain, which was documented in the nurse's notes. The medication was taken from the emergency kit at 1110 hours, but the MAR inaccurately showed the medication was administered at 1230 hours. Interviews with the LVN and the Director of Nursing (DON) revealed that the medication was given immediately after being taken from the E-kit, but the nurse was busy and did not document the administration until later. This discrepancy in documentation posed a risk of error in medical care and delay in treatment.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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