St Elizabeth Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fullerton, California.
- Location
- 2800 N. Harbor Blvd., Fullerton, California 92835
- CMS Provider Number
- 055570
- Inspections on file
- 22
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at St Elizabeth Healthcare Center during CMS and state inspections, most recent first.
Two residents with diabetes did not receive the required monitoring for signs and symptoms of hypoglycemia and hyperglycemia as outlined in their care plans. Nursing staff and the DON confirmed that the necessary assessments and documentation were not completed, despite the residents being at high risk for blood glucose fluctuations.
A resident who sustained a fall and subsequent femoral fracture did not have the possible cause of injury documented in the facility's initial investigation, and there was no evidence of IDT collaboration or meeting following the change in condition, as confirmed by the DON.
Nursing staff did not accurately document the administration of a controlled substance for a resident, as hydrocodone-acetaminophen tablets were signed out in the Controlled Drug Record but not recorded on the Medication Administration Record, contrary to facility policy. Staff and the DON confirmed the discrepancy during interviews and record reviews.
A resident with impaired mobility and incontinence waited nearly an hour for assistance after activating the call light following a bowel movement. Two CNAs responded but did not provide immediate care, instead turning off the call light and leaving to find the assigned CNA, resulting in a significant delay. The resident, who was cognitively intact, expressed distress over the prolonged wait and lack of timely care.
A resident received narcotic pain medications without documented evidence that nonpharmacological interventions (NPIs) were attempted first, despite physician orders requiring NPIs such as repositioning, relaxation, and distraction before medication administration. Nursing staff and the DON confirmed that NPIs should have been implemented and documented, but this was not reflected in the resident's medical record.
A resident received IV fluids at a rate higher than ordered, with the IV bag and administration set lacking required labeling. After the infusion was completed, the clamp remained open and the empty IV bag was not removed from the pole, leaving air in the tubing and the set still attached to the resident. Facility policy for IV administration and documentation was not followed.
Surveyors found that two residents did not have their respiratory equipment, including a Yankauer suction tip and nebulizer tubing, stored in bags or labeled with dates as required by facility policy. Staff confirmed the equipment was left exposed to air and undated, contrary to infection control protocols.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility failed to ensure three residents were free from unnecessary restraints, using Tab and pad alarms without obtaining necessary physician's orders, informed consent, or completing restraint assessments. A resident was observed with a Tab alarm without an active order or consent, while another had a pad alarm without documentation. A third resident had a Tab alarm with an order but no consent. Staff confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in their care. A resident refused essential care without a corresponding care plan, another experienced significant weight loss due to lack of meal assistance, a third lacked a care plan for oxygen and CPAP use, and a fourth had a care plan that did not address prescribed insulin use. These omissions risked the residents' receipt of appropriate and individualized care.
A resident's GT was not flushed between the last three of eight medications administered by an LVN, contrary to facility policy and NIH guidelines. This oversight could disrupt medication flow and clog the GT. The DON confirmed the findings.
A facility failed to implement the RD's recommendations for a resident who experienced severe weight loss. The RD's suggestions to fortify the diet and provide nutritional supplements were not communicated to the physician or documented in the medical record. This oversight was confirmed through interviews and record reviews, highlighting a lapse in following the facility's Nutrition Care Management policy.
A resident did not receive appropriate respiratory care due to incomplete physician orders for CPAP use and maintenance. The CPAP lacked a schedule for application and removal, and there was no documentation of its use over a specific period. Additionally, the CPAP cleaning instructions were incorrect, as the device did not have a humidified container but a filter, which was not cleaned due to the absence of a proper order.
A resident with spine fractures did not receive appropriate pain management as staff failed to assess pain levels or offer alternatives before administering oxycodone. The resident experienced delays and expressed frustration over the lack of assessment, which was confirmed by the DON.
The facility failed to ensure accurate documentation of controlled medications and secure storage of medication carts. A resident's oxycodone administration was not documented, and narcotic sheets lacked required signatures. Additionally, a medication cart was left unlocked, accessible to unauthorized individuals. These issues were confirmed by the DON and an LVN.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident lacked a specific goal to monitor the effectiveness of mirtazapine, while another did not have documented non-pharmacological interventions for escitalopram use. The facility's policies required psychotropic drug reviews and non-pharmacological interventions, but these were not followed, leading to deficiencies in medication management.
A facility's medication error rate was found to be 19.35%, exceeding the acceptable limit of 5%. An LVN failed to administer full dosages of six out of eight prescribed medications to a resident via GT, leaving medication residue in the cups. The DON confirmed these findings, highlighting a significant deficiency in medication administration practices.
The facility failed to properly label and store medications, as observed during an inspection. An LVN confirmed that a single-use Puracol wound dressing was improperly stored for reuse, and a jar of zinc oxide skin protectant lacked an expiration date. The DON verified these findings, indicating non-compliance with the facility's policies on medication access and storage.
The facility failed to maintain accurate medical records for two residents. One resident's POLST was not updated to reflect an existing advance directive, while another resident's wound care treatments were not properly documented in the TAR. Staff confirmed these documentation lapses, which could impact resident care.
The facility failed to maintain infection control practices, including not testing water temperatures as per policy, neglecting hand hygiene after glove removal, and not disinfecting medication vials before use. These deficiencies were acknowledged by staff and management.
A resident requested bilateral grab bars to assist with repositioning in bed, but the facility failed to follow up on this request. The resident expressed frustration as the request was not communicated to the physician. An LVN informed an RN, but no further action was taken, resulting in the resident's needs not being met.
A resident's privacy was compromised during medication administration via GT when an LVN failed to fully close the privacy curtain, leaving the resident exposed to the hallway. The incident was observed, and both the LVN and DON confirmed the lack of privacy.
A resident with severe cognitive impairment was sexually abused by another resident who had a history of inappropriate behavior. Despite this history, the facility did not take adequate precautions, leading to the incident. The facility's investigation confirmed the abuse, highlighting a deficiency in protecting residents from such incidents.
A resident's pressure injury worsened from Stage 1 to unstageable due to the facility's failure to ensure follow-up care by a wound specialist. Despite a physician's order, the wound specialist only evaluated the resident once, and no further visits were documented. Interviews confirmed the lack of follow-up, with the wound specialist being on vacation.
Failure to Implement Diabetes Monitoring Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents with diabetes mellitus, specifically regarding the monitoring, documentation, and reporting of signs and symptoms of hypoglycemia and hyperglycemia. For both residents, the care plans included detailed interventions to monitor for symptoms such as sweating, tremor, increased heart rate, confusion, and other indicators of blood glucose fluctuations. Despite these documented interventions, medical record reviews revealed no evidence that the required monitoring was performed or documented for either resident during their stays. Interviews with nursing staff and the Director of Nursing confirmed that the monitoring for hypoglycemia and hyperglycemia was not conducted as outlined in the residents' care plans. Both residents were identified as being at high risk for blood sugar fluctuations due to their diagnoses of diabetes, with one also having diabetic chronic kidney disease. The lack of monitoring was acknowledged by staff, who stated that licensed nurses should have performed and documented these assessments as part of the residents' individualized care plans.
Failure to Investigate Fall and Collaborate After Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident remained free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, after a resident experienced a fall from bed, the facility's investigative report did not include a possible cause for the injury in the initial investigation statement, despite the facility being aware of the cause. The Director of Nursing (DON) confirmed that the cause of the fracture should have been documented in the investigation statement, but it was omitted. Additionally, after the resident was found to have sustained an acute, displaced comminuted distal femoral shaft fracture as revealed by a radiology report, there was no documented evidence that the Interdisciplinary Team (IDT) collaborated or held a meeting to review the resident's change in condition. The DON verified that the IDT meeting and documentation should have occurred following the x-ray results, but this did not happen.
Failure to Document Controlled Substance Administration in Medication Records
Penalty
Summary
The facility failed to implement its pharmaceutical procedures for controlled substances when nursing staff did not ensure accurate accountability for a resident's medication. Specifically, hydrocodone-acetaminophen tablets were signed out of the Controlled Drug Record (CDR) for a resident on multiple occasions, but there was no corresponding documentation of administration on the Medication Administration Record (MAR) for those dates and times. The facility's policy requires that controlled medications be documented both in the CDR and the MAR, but this process was not followed. Interviews with nursing staff and the Director of Nursing confirmed that the expected procedure is to document the administration of controlled medications in both the CDR and the MAR. Review of the resident's records verified that the medication was signed out in the CDR but not recorded as administered in the MAR, despite an active order for the medication during the relevant period. The discrepancy was acknowledged by staff during interviews and concurrent record reviews.
Failure to Provide Timely Incontinence Care Following Call Light Activation
Penalty
Summary
A deficiency occurred when staff failed to provide timely assistance to a resident who required help with incontinence care. The resident, who was cognitively intact and had a care plan addressing bowel and bladder incontinence due to impaired mobility and general weakness, activated the call light after a bowel movement. Despite the facility's policy requiring call lights to be answered within a reasonable time and care needs to be met before turning off the call light, the resident waited nearly an hour before being attended to. Two CNAs responded to the call light but did not provide immediate care; instead, they turned off the call light and left the room to locate the assigned CNA, delaying the resident's care further. Interviews confirmed that the CNAs were aware of the resident's need but did not act promptly, and the assigned CNA only provided care after being informed at the nurses' station. The Director of Nursing verified that the response time was not acceptable and that the CNAs should have provided care immediately rather than leaving the resident unattended. The resident expressed distress over the delay, stating she had not been changed since early morning and was upset by the lack of timely assistance.
Failure to Document and Implement Nonpharmacological Interventions Prior to Administering Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions (NPIs) were consistently implemented and documented prior to administering narcotic pain medications to a resident. Medical record review showed that the resident had physician orders for NPIs such as repositioning, dim lighting, relaxation, distraction, music, and massage to be attempted before administering hydrocodone-acetaminophen or Ultracet for moderate to severe pain. Despite these orders, there was no documented evidence that NPIs were attempted before administering these medications on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that NPIs should have been implemented and documented prior to giving pain medication, but the resident's medical record did not reflect this practice on the specified dates. The lack of documentation and implementation of NPIs prior to administering narcotic medications constituted a failure to prevent unnecessary medication use for the resident reviewed.
Failure to Safely Administer and Document IV Fluids
Penalty
Summary
The facility failed to administer intravenous (IV) fluids in accordance with professional standards of practice and physician orders for a resident who lacked capacity to make decisions. Specifically, the IV fluids were administered at a rate of 80 ml per hour instead of the ordered 60 ml per hour. Additionally, the IV fluid bag was not labeled with the date and time it was hung, and the administration set was not labeled as required by facility policy. When the infusion was completed, the clamp was not closed, and the empty IV container was not removed from the IV pole, leaving air in the tubing and the administration set still attached to the resident's IV access. These deficiencies were confirmed through observation, interview, and medical record review. The nurse responsible for the resident's care was unable to state when the IV solution was hung, and the Director of Nursing verified that the IV fluids were not administered as ordered and that labeling requirements were not followed. The facility's policies required IV solutions and administration sets to be labeled with date, time, and nurse's initials, and for the clamp to be closed and the container removed when empty, but these procedures were not followed in this instance.
Failure to Properly Store and Date Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to its own policies regarding the storage and maintenance of respiratory equipment. For one resident who required suctioning for increased oral secretions, the Yankauer suction tip was observed exposed to air and not enclosed in a bag, and was placed on top of a suction canister containing fluid. Both the suction tip and canister were undated. Facility staff confirmed that the equipment was not stored as required for infection control, and the Director of Nursing stated that the expectation was for the equipment to be bagged and dated. For another resident receiving multiple nebulized medications, the nebulizer tubing was found left uncovered on the nightstand and not stored in a bag, with no date label to indicate when the tubing or bag had last been changed. The resident reported that the nurse left the tubing uncovered after the previous treatment. Facility staff verified that the nebulizer administration set should have been enclosed in a labeled bag and dated according to policy. These lapses were observed during surveyor visits and confirmed through staff interviews and review of facility policies.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or record review, indicating that the required protocols for protecting confidential information or proper documentation of medical records were not followed as expected. No additional details regarding specific residents, their medical history, or the exact nature of the information or records involved are provided in the report.
Failure to Obtain Orders and Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary restraints, specifically the use of Tab and pad alarms, without obtaining the necessary physician's orders, informed consent, and completing restraint assessments. Resident 40 was observed with a Tab alarm in bed and wheelchair without an active order, informed consent, or a completed restraint assessment. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) confirmed the absence of these documents, and the facility's policy was not followed. Resident 38 was found with a pad alarm in both bed and wheelchair, yet there was no informed consent or completed assessment for its use. The DON and LVN were unable to provide documentation to support the use of the alarm, and a Certified Nursing Assistant (CNA) stated the alarm was used due to the resident's attempts to get up unassisted. This indicates a lack of adherence to the facility's policy on restraint use. Resident 12 had a physician's order for a Tab alarm, but there was no informed consent documented. The resident was observed with the alarm in place, and staff confirmed the absence of informed consent. The DON acknowledged the findings, indicating a failure to comply with the facility's policies regarding restraint use, which could compromise the residents' independence and psychosocial well-being.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in their care. Resident 22, who had the capacity to understand and make decisions, refused showers, repositioning, diaper changes, and medications. Despite the facility's policy requiring a care plan to address such refusals, no care plan was developed for Resident 22's refusals, as confirmed by the Director of Staff Development (DSD). Resident 49, who also had decision-making capacity, experienced significant weight loss of 36 pounds in 26 days. The resident had a physician's order for 1:1 meal assistance, but during observations, the resident was seen eating alone and refusing meals without staff assistance. The Licensed Vocational Nurse (LVN) verified that the 1:1 meal assistance was not implemented, contributing to the resident's weight loss. Resident 456, who used oxygen and a CPAP machine, did not have a care plan addressing these needs, despite having physician orders for their use. The Director of Nursing (DON) confirmed the absence of a care plan for these interventions. Similarly, Resident 2, who was prescribed insulin for diabetes management, had a care plan that failed to address the use of insulin, as verified by an LVN. These omissions in care planning placed the residents at risk of not receiving appropriate, consistent, and individualized care.
Failure to Flush GT Between Medications
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice for the administration of medications via gastrostomy tube (GT) for one resident. During an observation of medication administration, it was noted that LVN 4 did not flush the GT between the administration of the last three of eight medications for the resident. This action was contrary to the facility's policy and procedure, which requires flushing the tube with at least 5 ml of water between medications, and the NIH's guidelines, which recommend flushing with 15 ml of water to prevent tube obstruction and ensure proper medication delivery. The resident involved had several medications prescribed to be administered via GT, including aspirin, sodium chloride, cyanocobalamin, multivitamin, Cozaar, Azithromycin, demeclocycline hcl, and acetaminophen. During the administration process, LVN 4 acknowledged missing the flushing step for the last three medications, which could potentially disrupt the flow of medications and clog the GT. The Director of Nursing (DON) verified these findings during an interview, confirming the deviation from the established medication administration protocol.
Failure to Implement RD's Recommendations for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the recommendations made by the Registered Dietitian (RD) on December 12, 2024, were communicated to the physician and addressed in the Interdisciplinary Team (IDT) weight variance meeting for a resident who experienced severe weight loss. Resident 49, who had the capacity to understand and make decisions, was admitted to the facility and experienced a significant weight loss of 36 pounds over 26 days. The RD recommended fortifying the current diet order, providing one pack of Arginaid twice daily for 14 days, and administering 30 ml of ProStat daily. However, these recommendations were not communicated to the resident's physician, nor were they documented in the resident's medical record. The medical record review and interviews with the RD and Director of Nursing (DON) confirmed that the RD's recommendations were not followed. The facility's policy and procedure for Nutrition Care Management required that recommendations be communicated via an electronic system and confirmed by a licensed nurse to document the physician's prescription. The failure to follow these procedures resulted in the potential for Resident 49 not receiving the necessary interventions to prevent further weight loss. The DON acknowledged the findings during an interview conducted on December 17, 2024.
Inadequate Respiratory Care and CPAP Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 6, who required the use of a CPAP machine. The physician's order for the CPAP lacked a specific schedule for when the CPAP should be applied and removed, and there was no documentation indicating that the CPAP was used from December 9 to December 11, 2024. Interviews with the LVNs and the DON confirmed that the order was incomplete and should have included specific times for application and removal. Additionally, the resident reported not using the CPAP for two nights, and it was not offered by the staff, despite the resident's moderate cognitive impairment and need for nightly CPAP use to assist with breathing. Furthermore, the facility failed to ensure accurate cleaning and maintenance of the CPAP equipment. The physician's order incorrectly instructed staff to clean a humidified container, which the resident's CPAP did not have. Instead, the CPAP had a filter, which was not cleaned as there was no physician's order for it. The DON acknowledged the error in the physician's order and the lack of documentation for cleaning the CPAP filter. The oversight in cleaning and maintaining the CPAP equipment could have impacted the effectiveness of the device, as noted by the DON.
Failure to Assess and Manage Pain for Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for Resident 354, who was admitted with spine fractures and required pain management. The facility's policy required documentation of pain using a scale of 1-10 and monitoring of pain characteristics, but these procedures were not followed. On December 11, 2024, Resident 354 requested pain medication before physical therapy, but the staff did not assess the resident's pain level or offer nonpharmacological interventions. The resident expressed frustration over the delay and lack of assessment, which had occurred previously. RN 2 acknowledged not assessing the resident's pain level or offering alternatives, and LVN 4 administered oxycodone without evaluating the pain characteristics. The Director of Nursing confirmed these findings. The failure to assess and manage the resident's pain according to the facility's policy potentially caused increased pain and distress for Resident 354.
Deficiencies in Pharmaceutical Services and Medication Security
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring accurate and complete documentation of controlled medications for a resident. Specifically, the facility did not document the administration of oxycodone for a resident on a specific date, despite the medication being removed from the narcotic count. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who verified the findings. Additionally, the facility did not ensure that narcotic sheets had the required nurses' initials and signatures during shift changes for one of the medication carts. Multiple entries were missing signatures and initials on various dates, which was confirmed by the DON. Furthermore, a medication cart was left unlocked in an area accessible to residents, staff, or visitors, as observed during an interview with an LVN, who acknowledged the oversight. These failures could lead to medication errors and opportunities for drug diversion or misuse.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 6, there was no specific resident-centered goal to monitor the effectiveness of mirtazapine, an antidepressant prescribed for depression manifested by poor oral intake. Despite the administration of mirtazapine, the resident's meal intake remained low, with numerous episodes of eating less than 50% of meals. The facility's Director of Nursing (DON) acknowledged the lack of a specific order to monitor the effectiveness of mirtazapine for Resident 6. For Resident 49, the facility did not implement or document non-pharmacological interventions for the use of escitalopram (Lexapro), an antidepressant prescribed for depression. Although the care plan included non-pharmacological interventions such as back rubs, redirection, and encouragement to express feelings, there was no evidence that these interventions were implemented or monitored for effectiveness. The Licensed Vocational Nurse (LVN) and the DON confirmed the absence of documentation for these interventions. The facility's policies and procedures required that psychotropic drug use be reviewed by a Psychotropic Drug Review Committee and that non-pharmacological interventions be implemented for residents with psychotropic medication orders. However, these procedures were not followed for Residents 6 and 49, leading to deficiencies in the management and monitoring of their psychotropic medication use.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 19.35%. During a medication administration observation, LVN 4 was found to have made errors in administering medications to Resident 8. Specifically, LVN 4 did not ensure the full dosages of six out of eight prescribed medications were administered as per the physician's orders. The medications involved included aspirin, demeclocycline, Azithromycin, vitamin B12, multivitamins with minerals, and acetaminophen. After administration, medication residue was found in the cups used, indicating incomplete administration. Resident 8, who was admitted to the facility on an unspecified date, had specific physician's orders for medication administration via GT. These orders included aspirin, sodium chloride, cyanocobalamin, multivitamin, Cozaar, Azithromycin, demeclocycline, and acetaminophen. The Director of Nursing (DON) verified the findings during an interview, confirming the medication administration errors made by LVN 4. The failure to administer the full dosages as prescribed had the potential to negatively affect the resident's health.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during an inspection of the treatment cart. An opened package of Puracol wound dressing, which is intended for single use only, was found with a small cut-out piece inside the treatment cart. The Licensed Vocational Nurse (LVN) stated that if only a small piece was needed, the remaining dressing was placed in a storage bag, dated, and used within 24 hours. However, the LVN confirmed that the package was meant for single use, indicating a failure to adhere to the facility's policy and procedure (P&P) for medication access and storage. Additionally, the treatment cart contained a 16-ounce jar of zinc oxide skin protectant without an expiration date, which was verified by the LVN and subsequently discarded. The facility's P&P for the administration of medications and fluids requires that the expiration date of solutions and medications be ascertained prior to administration. The Director of Nursing (DON) confirmed these findings, highlighting a lapse in the facility's adherence to its own policies and procedures regarding medication labeling and storage.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential unmet healthcare needs. For Resident 456, the POLST was not updated to reflect the existence of an advance directive, despite the resident having the capacity to make decisions and the family being aware of the directive. The SSD confirmed that the POLST should have been updated, but it remained inaccurate, indicating a lapse in ensuring the resident's medical records were current and complete. For Resident 904, the facility did not ensure that the Treatment Administration Record (TAR) was accurately documented. Multiple wound treatment orders were not recorded as completed on specific dates, despite the treatments being administered. LVN 7 and LVN 2 confirmed the missing documentation for various wound care treatments, and the DON acknowledged the requirement for licensed nurses to document after providing ordered treatments. This lack of documentation resulted in incomplete medical records for Resident 904, potentially affecting the resident's care.
Infection Control Deficiencies in Water Management and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its water management program, which is crucial for preventing the growth and spread of Legionella and other opportunistic pathogens. The facility's policies and procedures required regular testing of water temperatures to ensure they were maintained within the desired range of 105 to 120 degrees Fahrenheit. However, there was no documented evidence that these water temperatures were tested monthly as required. This oversight was acknowledged by both the Maintenance Supervisor and the Administrator during interviews. The facility also failed to ensure proper hand hygiene practices among its staff, as outlined in its infection control policies. Several instances were observed where staff members did not perform hand hygiene after removing gloves or after potential contamination. For example, an LVN did not wash hands after removing gloves during wound treatment, and another LVN failed to perform hand hygiene after picking up a sharpie from the floor and after using a computer. These lapses were confirmed by the staff involved and acknowledged by the Infection Preventionist and the Director of Nursing. Additionally, the facility did not follow best practices for infection prevention during medication preparation. An RN was observed preparing an IV medication without disinfecting the vial before connecting it to the solution bag, contrary to CDC guidelines. This failure was confirmed by the RN, who stated that she was trained to disinfect the vial to prevent contamination. The Director of Nursing verified these findings, indicating a systemic issue with adherence to infection control protocols.
Failure to Accommodate Resident's Request for Grab Bars
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not following up on a request for bilateral grab bars. The resident, who was observed awake and sitting up in bed, had turned on the call light and expressed that he had requested the grab bars the previous day to assist with turning or repositioning in bed and sitting in the middle of the bed. The resident felt upset because the staff member did not respond to his request. Licensed Vocational Nurse (LVN) 5 acknowledged the resident's request and stated that it needed to be communicated to the resident's physician. However, LVN 5 only informed Registered Nurse (RN) 1 and did not follow up further. RN 1 confirmed that she had not informed the physician about the resident's request. This lack of communication and follow-up resulted in the resident's needs not being addressed in a timely manner.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy of a resident during medication administration. Specifically, a Licensed Vocational Nurse (LVN) did not completely pull the privacy curtain when administering medications via gastrostomy tube (GT) to a resident. The room door was open, exposing the resident to the hallway where other residents and staff members were passing by. This incident was observed, and the LVN later confirmed that complete privacy was not provided during the procedure. The Director of Nursing (DON) verified these findings during an interview.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. On 7/28/24, a CNA observed Resident 2 inappropriately touching Resident 1's genitals. Resident 1, who had severe cognitive impairment and advanced dementia, lacked the capacity to consent to such contact. Despite Resident 2's known history of verbally inappropriate behavior towards staff, the facility did not take adequate precautions to prevent this incident. Resident 1 was admitted to the facility with a diagnosis of advanced dementia and required assistance for most activities of daily living. Resident 2, who was cognitively intact, had a care plan addressing verbally inappropriate behaviors towards staff, but no measures were in place to prevent inappropriate interactions with other residents. On the day of the incident, Resident 2 was seen touching Resident 1's genitals, and despite being stopped by a CNA, Resident 2 returned to Resident 1's bedside shortly after. Interviews with staff and family members confirmed the incident and Resident 2's inappropriate behavior. The facility's investigation substantiated the incident, acknowledging that Resident 2's actions were purposeful and due to a need for sexual gratification. The facility's failure to implement effective measures to prevent such incidents resulted in a deficiency in protecting residents from abuse.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure injury received the necessary care and services to prevent the development and worsening of the injury. The resident was initially evaluated to have a Stage 1 pressure injury on the sacral coccyx, which advanced to a Stage 2 pressure injury within a week. Despite a physician's order for a wound care consult, the wound specialist only evaluated the resident once and did not follow up, leading to the injury becoming unstageable. The medical records lacked documented evidence of follow-up visits or reasons for discontinuation of the wound specialist's services. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Director of Nursing (DON) confirmed the absence of follow-up visits from the wound specialist. The Wound Specialist Manager verified that the resident had only one initial consultation and no subsequent visits, attributing the lack of follow-up to the wound specialist being on vacation. The DON acknowledged the findings and indicated a need to work with the wound care specialist to address the issue.
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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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