Sunny Village Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 1428 S. Marengo Ave., Alhambra, California 91803
- CMS Provider Number
- 055203
- Inspections on file
- 46
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Sunny Village Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required documentation showing that an outside contractor was performing scheduled preventive maintenance on the HVAC system. The Maintenance Supervisor reported having no logs or reports of semi-annual HVAC service visits and acknowledged that such records should have been kept to monitor compliance and system function. The Administrator also confirmed that copies of HVAC maintenance records were not on file, despite facility policy assigning the maintenance director responsibility for maintaining maintenance schedules and related reports in the maintenance office.
The facility failed to maintain ethical standards and resident rights by purchasing a prescribed continuous glucose monitoring device from a resident for staff training. A cognitively intact resident with type 2 DM and cardiac conditions had an order for blood sugar monitoring using a Brand 1 device. The DON agreed to buy one of the resident’s devices using facility petty cash, documented the transaction with the resident and an LVN, and then used the device in a training session on sensor application. The BOM and Administrator later acknowledged that paying a resident for a prescribed device was not usual practice, that such items should be obtained through a vendor, and that there was no policy permitting such transactions, creating an inappropriate business relationship between the facility and the resident.
A resident with multiple medical conditions experienced an acute behavioral change, leading to a physician's order and care plan update for a psychiatric consult. Despite facility policy requiring prompt notification and follow-up, nursing staff did not inform the psychiatrist or document any actions taken, resulting in a 25-day delay before the consult was completed.
A resident with quadriplegia and multiple sclerosis, who was fully dependent on staff for all ADLs, did not have a care plan specifying the need for two-person assistance despite staff and assessment documentation confirming this requirement. The care plan only generally referenced assistance with mobility and ADLs, lacking the detail needed for consistent, individualized care as confirmed by interviews with the LVN and DON.
Three residents were labeled as 'feeders' and addressed with generic terms during meals, contrary to facility policy. This practice, acknowledged by staff as inappropriate, failed to promote dignity and respect for residents with cognitive impairments.
The facility failed to maintain appropriate room temperatures for several residents, with one room being too cold and another too hot, both outside the acceptable range of 71-81°F. Additionally, a resident's report of missing personal belongings was not addressed according to the facility's policy, as the Laundry Staff did not report the issue, and the Administrator was not informed, preventing an immediate search.
The facility failed to provide adequate respiratory care for three residents. A resident was observed without a nasal cannula despite orders for continuous oxygen therapy. Another resident received oxygen at an incorrect rate, not following physician orders. Additionally, a third resident's oxygen tubing was not changed weekly as required, and was improperly stored, potentially leading to respiratory infections.
The facility failed to follow proper food handling practices, including labeling food items and maintaining cleanliness in the kitchen. Observations revealed unlabeled food, dirty equipment, and improper trash placement. Dietary staff did not perform proper hand hygiene, and the facility lacked complete cleaning logs for the ice machine, violating its policies.
A facility failed to obtain informed consent from a resident's representative before administering Seroquel, an antipsychotic medication, to a resident with dementia and psychosis. The resident's medical records lacked the necessary consent form, and staff interviews confirmed the oversight, which violated the facility's policy requiring informed consent for antipsychotic use.
A facility failed to ensure an accurate MDS assessment for a resident by incorrectly documenting the discharge status. Despite multiple records indicating the resident was discharged home with home health services, the MDS was inaccurately recorded as a discharge to a hospital. The MDS Coordinator admitted to the error, which affects the facility's quality of care reporting.
A facility failed to implement a baseline care plan within 48 hours for a resident with dementia and psychosis, who was prescribed Seroquel. The absence of this care plan, confirmed by LVNs, could affect the resident's quality of care by hindering continuity and communication among staff.
The facility failed to provide communication boards for two residents with language barriers, hindering their ability to communicate needs. One resident was observed in pain and unable to communicate effectively with staff due to the absence of a communication board, while another resident's request for assistance was not understood by staff. The facility's policy required communication boards for residents with language barriers, but these were not accessible, as confirmed by the DON.
A resident with Parkinson's disease and limited mobility was found with long, dirty fingernails, indicating a failure in personal hygiene care. The resident's care plan required assistance with grooming, but staff interviews revealed that nail care was neglected, contrary to facility policy. This oversight had the potential to impact the resident's self-esteem and posed a risk for infection.
A facility failed to set a low air loss (LAL) mattress correctly for a resident with a stage 4 pressure ulcer, as per the facility's policy and manufacturer's guidelines. The resident, at high risk for skin breakdown, had the LAL mattress set incorrectly on two occasions, which was not effective for wound management. The settings were not adjusted according to the resident's weight, as confirmed by LVNs during observations.
A resident with an indwelling catheter experienced improper catheter care when a CNA moved the catheter bag above bladder level, risking urine backflow. The resident, cognitively impaired and dependent on assistance, had their catheter bag placed on blankets and held above bladder level, contrary to facility policy. This posed a potential risk for a UTI.
A resident with diabetes mellitus type 2 did not receive Metformin hydrochloride within the prescribed time frame, as it was administered late by an LVN. The medication, ordered to be given with meals, was delayed, potentially affecting the resident's blood sugar management. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not adhered to in this instance.
A facility failed to conduct necessary laboratory tests for a resident with hypertensive heart disease and hyperlipidemia. Despite a Consultant Pharmacist's recommendation for lipid and liver panel tests to monitor the effects of prescribed pravastatin sodium, these tests were not ordered or performed. This oversight was confirmed through record reviews and an interview with a registered nurse, highlighting a lapse in ensuring timely laboratory services.
A resident with dysphagia and dementia was not provided with food that met her dietary preferences, as the pureed food was too thick, causing difficulty in eating. Despite the responsible party informing the Dietary Supervisor, no follow-up action was taken, leading to a deficiency in the facility's adherence to its food quality policy.
Two residents experienced delayed meal service, with lunch trays delivered significantly later than the scheduled time. One resident, with colon cancer, received their meal at 12:45 PM, while another resident, with type 2 diabetes, received theirs at 12:47 PM, despite the scheduled lunch time being 12 noon. The Dietary Supervisor confirmed the delay was unacceptable, as it could affect residents' well-being.
A facility failed to document complete orthostatic blood pressure measurements for a resident on Seroquel, missing several lying position readings. Despite protocols requiring documentation or noting reasons for omissions, the resident's records were incomplete, potentially increasing fall risk. Interviews with nursing staff confirmed the oversight, highlighting a lapse in following the facility's policy on monitoring antipsychotic medication effects.
A CNA failed to change gloves and perform hand hygiene after providing peri-care to a resident with an indwelling catheter, subsequently touching clean bed linens with contaminated gloves. The facility's policy requires hand hygiene after contact with bodily fluids and before moving from a contaminated to a clean site, which was not followed.
A water leak in the kitchen ceiling was observed, with water pooling on the floor near the dishwashing area. The leak was due to a hole in the metal duct for ventilation, which collected rainwater. The issue was reported by kitchen staff, but maintenance rounds were not confirmed. Concerns about food contamination and kitchen usability were raised.
A facility failed to maintain accurate medical records by allowing a CNA to administer a topical cream while an LVN documented the administration in the TAR. The resident, with quadriplegia and multiple sclerosis, required hydrophilic wound dressing for skin maintenance. Despite facility policy requiring licensed nurses to administer and document medications, CNAs were observed applying the cream, and licensed nurses signed the TAR.
A resident's medication, carvedilol, was improperly disposed of by nursing staff at the resident's request, contrary to facility policy. The medication was still in use for managing the resident's heart conditions. The facility's policy requires medications to be disposed of only if unused or expired, which was not adhered to in this case.
A resident, capable of making their own decisions, was transferred to a GACH following a psychiatric emergency evaluation. The facility failed to provide the required written notice of bed hold policy, as mandated by their policy, which should have been given at the time of transfer or within 24 hours in emergencies. The administrator acknowledged the oversight, noting no bed hold order was placed due to the expectation that the resident would not return.
The facility failed to manage medications brought in by a resident's family, lacked documentation for an Ozempic injection site, and improperly stored expired medications. Additionally, temperature monitoring of a medication refrigerator was incomplete, potentially affecting medication efficacy.
A resident reported a missing dose of Ozempic, a diabetes medication, after the facility failed to log or inventory his personal medications. Despite the resident's practice of picking up medications from an outside pharmacy and handing them to the LVN, the facility did not maintain a record from September 2023 to August 2024, contrary to its policy requiring inventory and documentation of personal belongings.
A resident with diabetes and legal blindness was instructed by an RN to self-administer insulin due to the RN's phobia of needles and lack of recent experience with injections. The facility lacked a formal process for assessing nursing staff competency, contributing to this deficiency.
A resident with diabetes and legal blindness self-administered insulin after being instructed by an RN, despite lacking a physician's order or self-administration form. The facility's policy requires only licensed individuals to administer medications, which was not followed, leading to a deficiency.
A facility failed to provide a resident's legal representative with timely access to medical records, violating the resident's rights. Despite a request being made and received, the records were not provided within the facility's policy timeframe. The request was forwarded to the facility's lawyers, but there was no confirmation of the records being sent. This delay impacted the resident's ability to follow up on medical care.
Lack of Documentation for HVAC Preventive Maintenance by Outside Contractor
Penalty
Summary
The deficiency involves the facility’s failure to maintain documented evidence that its Heating, Ventilation, and Air Conditioning (HVAC) system was being serviced and maintained by an outside HVAC contractor to ensure it was safe and in good working condition. Review of the undated floor plan showed 54 resident rooms across two floors, and a census report showed 95 residents in the facility with a bed capacity of 99. During interviews and record review, the Maintenance Supervisor was unable to provide any logs, records, or reports of semi-annual HVAC maintenance visits by the outside company since he had been employed in the role. He acknowledged that he did not have a log or record of maintenance visits and that he should have been tracking HVAC maintenance by outside companies to monitor compliance and ensure the system remained safe and functional. Further interviews with the Administrator confirmed that the facility did not have copies of HVAC maintenance visit records on hand to verify that the system was being checked and maintained to keep temperatures within normal ranges. The Administrator stated that documentation of maintenance services from outside companies should be available to ensure the HVAC system was being checked, safe, and working properly, and noted that a request for past service records had only been sent on the day of the survey. Review of the facility’s “Maintenance Service” policy and procedure, dated 2001, indicated that the maintenance director (maintenance supervisor) is responsible for maintaining records and reports of work order requests and maintenance schedules, and that these records are to be maintained in the maintenance director’s office. Despite this policy, the required HVAC maintenance documentation was not available during the survey.
Inappropriate Purchase of Resident’s Prescribed Glucose Monitoring Device for Staff Training
Penalty
Summary
The deficiency involves the facility’s failure to maintain ethical standards of practice and resident rights by engaging in a business transaction with a resident for a prescribed medical device. Resident 1, who had type 2 DM, hypertensive heart disease with heart failure, and difficulty walking, was cognitively intact for daily decision-making and largely independent in ADLs. Resident 1 had an order allowing nursing staff to monitor blood sugar levels using a Brand 1 continuous glucose monitoring device. On 10/13/2025, an untitled facility document, signed by the DON, Resident 1, and LVN 1, indicated that Resident 1 had three Brand 1 devices and that the facility would purchase one device from the resident for $110 for education and training purposes. A petty cash receipt confirmed that the facility paid Resident 1 $110 for the Brand 1 device. During interviews, the DON stated that Resident 1 had offered to sell the Brand 1 device to the facility for training, and she agreed to purchase it with facility funds, later using the purchased device in a staff training session on how to apply the Brand 1 sensor. LVN 1 confirmed witnessing the cash payment to the resident. Resident 1 reported consenting to the sale and signing an agreement with the DON and LVN 1, and stated that at the time he did not know it was a violation. The Business Office Manager stated that paying a resident for a prescribed device was not usual practice, that such items should be obtained through a vendor, and that there was no policy allowing payment to residents for their prescribed devices because it could create an inappropriate business relationship. The Administrator acknowledged the facility purchased the device from the resident for training and to help the resident financially. The facility’s existing policies on Assistive Devices and Equipment and Resident Rights addressed supervision of assistive devices and the requirement to treat residents with kindness, respect, and dignity, but there was no policy regarding purchasing devices from residents.
Failure to Provide Timely Psychiatric Consult Following Acute Behavioral Change
Penalty
Summary
The facility failed to provide a timely psychiatrist or psychologist consult for a resident who experienced an acute behavioral change, as ordered by the physician and outlined in the care plan and facility policy. The resident, who had diagnoses including diabetes mellitus, hypertensive heart disease with heart failure, and difficulty walking, was admitted with intact cognitive skills and independence in daily activities. On the date of the behavioral change, the resident exhibited verbal aggression and refused a blood glucose fingerstick, prompting a physician's order for a psychiatric consult and an update to the care plan to include this intervention. Despite the order and care plan intervention, the psychiatric consult was not provided for 25 days. Interviews with nursing staff revealed that the facility's protocol required nursing to notify the psychiatrist of such consults the same day, with the expectation that the psychiatrist or physician assistant would evaluate the resident the following day. However, the psychiatrist was not informed of the consult order until he was at the facility for routine rounds nearly a month later. Nursing staff acknowledged that they did not follow up or endorse the consult order on subsequent shifts, and there was no documentation of the consult being offered, completed, refused, or of any physician notification during this period. A review of the resident's medical chart confirmed the absence of documentation regarding the psychiatric consult, refusals, or follow-up actions. Facility policy required thorough evaluation of new or changing behavioral symptoms by the interdisciplinary team to identify underlying causes, including psychiatric or psychological stressors. The lack of timely notification and follow-up by nursing staff resulted in the resident not receiving the ordered psychiatric evaluation as required by the physician's order, care plan, and facility policy.
Care Plan Lacked Specificity for Two-Person ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan was individualized and accurately reflected the resident's need for two-person assistance with activities of daily living (ADLs). The resident, who had diagnoses including quadriplegia and multiple sclerosis, was assessed as being dependent on staff for all ADLs such as eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. The Minimum Data Set (MDS) confirmed the resident's dependency and need for two or more helpers for these activities. Interviews with facility staff, including the Director of Staff Development and a Licensed Vocational Nurse, confirmed that the resident was always assigned two CNAs for mobility and transfers to ensure safety. Despite these assessments and staff practices, the resident's care plan did not specify the requirement for two-person assistance with ADLs. The care plan only generally stated that staff should assist with mobility and ADLs daily, lacking the necessary detail to guide all staff, especially those unfamiliar with the resident. Both the LVN and the Director of Nursing acknowledged during interviews that the care plan should have been more specific and resident-centered, explicitly stating the need for two-person assistance to maintain a safe environment.
Failure to Promote Resident Dignity During Meals
Penalty
Summary
The facility failed to promote dignity and respect for three residents by labeling them as 'feeders' during dining observations. Resident 10, who has severe cognitive impairment and requires assistance with eating, was referred to as a 'feeder' by a CNA, which was against the facility's policy. The Director of Nursing confirmed that staff should not use such labels as it affects the residents' dignity. Resident 244, who has moderately impaired cognitive skills and requires setup or clean-up assistance for eating, was addressed by a CNA using a generic term rather than their name. This practice was acknowledged by the CNA as inappropriate, as residents should be addressed by their first or last names to maintain their dignity. Similarly, Resident 58, who has severe cognitive impairment and requires substantial assistance, was repeatedly called 'Mama' by an LVN during meals. Both the LVN and the DON recognized that residents should be addressed by their names to ensure they are treated with respect. The facility's policy on dignity emphasizes that residents should be treated with respect and addressed by their names, not by labels or generic terms.
Temperature Regulation and Personal Belongings Management Deficiencies
Penalty
Summary
The facility failed to maintain a comfortable and safe environment for several residents, as evidenced by issues with room temperature regulation and the handling of personal belongings. Resident 187 was found in a room with a temperature of 66°F, which is below the facility's policy range of 71-81°F. This was confirmed by the Maintenance Supervisor using a laser temperature thermometer. The resident expressed discomfort due to the cold temperature, and the Director of Nursing acknowledged that such conditions could lead to hypothermia. Residents 18 and 54 were found in a room with a temperature of 86°F, exceeding the facility's acceptable range. The Maintenance Assistant confirmed the excessive heat, and Registered Nurse 1 emphasized the importance of maintaining comfortable temperatures to prevent harm such as dehydration and hyperthermia, especially for residents unable to communicate their discomfort. The facility's policy on maintaining a homelike environment was not adhered to, as routine checks of ambient air temperatures were not required, although the Maintenance Assistant and Supervisor claimed to check temperatures daily. Additionally, the facility failed to address the issue of missing personal belongings for Resident 69. The resident reported missing sweatpants to the Laundry Staff, who did not report the issue as required by the facility's Theft and Loss Program policy. The Social Service Assistant confirmed the missing item on the inventory list, and the Administrator stated that he was not notified of the missing items, which should have triggered an immediate search. This oversight in handling personal belongings could negatively impact the resident's emotional well-being.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents, leading to deficiencies in their care. Resident 15, who was moderately impaired cognitively and dependent on assistance for daily activities, was observed without a nasal cannula in her nostrils, despite physician orders for continuous oxygen therapy. This oversight was confirmed by both a registered nurse and the Director of Nursing, who acknowledged that the nasal cannula should have been properly placed to ensure the resident received the prescribed oxygen. Resident 71, diagnosed with pneumonia and hemiplegia, was found to have their oxygen set at seven liters per minute, contrary to the physician's orders. The Director of Nursing confirmed that the oxygen administration did not follow the prescribed orders, and a registered nurse acknowledged the discrepancy. The facility's policy and procedure for oxygen administration, which includes reviewing physician orders, was not adhered to in this case. Resident 73, who was on oxygen therapy and had moderate cognitive impairment, had their oxygen tubing unchanged for 37 days, despite the facility's policy of weekly changes. The tubing was also not stored in a plastic bag to protect it from dust, as required. Both a certified nursing assistant and a licensed vocational nurse noted the outdated tubing, and the Director of Nursing confirmed the need for weekly changes and proper storage. This failure to follow protocol could lead to respiratory infections due to potential inhalation of particles from the tubing.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Food items in the preparation area, refrigerators, and freezers were not labeled with the item name and date opened, which is against the facility's policy. This included unlabeled large food containers, bags of noodles, hotdogs, ice cream cups, condiments, and burger buns. The Dietary Supervisor acknowledged these lapses, noting that unlabeled items should be discarded to prevent potential foodborne illnesses among residents. Additionally, the facility did not maintain cleanliness in the kitchen and food preparation areas. Observations revealed food debris on preparation surfaces, dirty equipment, and improper storage of items such as a dirty peanut butter container and opened water bottles. Trash bins were placed too close to clean serving trays, increasing the risk of contamination. The facility's ice machine cleaning logs were incomplete, lacking weekly cleaning records as required by the facility's policy. The dietary staff also failed to perform proper hand hygiene and glove changes during food preparation and tray assembly. Staff members were observed not washing hands between tasks and using the same gloves for different activities, which could lead to contamination. The facility's policies on food storage, preparation, and equipment cleaning were not followed, as evidenced by the lack of proper labeling, cleaning, and hand hygiene practices.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident or their representative was informed in advance about the treatment risks, benefits, options, and alternatives for the use of antipsychotic medication. This deficiency was identified for one resident who was prescribed Seroquel, an antipsychotic medication, to manage psychosis symptoms. The resident's medical records did not contain an informed consent form, which should have been obtained from the resident or their representative prior to administering the medication. The absence of informed consent was confirmed through interviews with facility staff, including a Licensed Vocational Nurse, a Medical Records Designee, and a Registered Nurse, all of whom acknowledged that the informed consent process was not followed as per the facility's policy. The resident in question was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance, and was noted to be severely impaired in cognitive skills for daily decision-making. Despite these conditions, the facility did not secure informed consent from the resident's representative before administering the antipsychotic medication. The facility's policy, revised in July 2022, mandates that residents and their representatives be informed of treatment recommendations, risks, benefits, and potential adverse consequences of antipsychotic medications, and that they have the right to refuse such medications. The failure to obtain informed consent potentially affected the resident's right to direct their own medical treatment.
Inaccurate MDS Discharge Status for a Resident
Penalty
Summary
The facility failed to ensure an accurate assessment of the Minimum Data Set (MDS) for one of the sampled residents, identified as Resident 84. The deficiency occurred when the MDS Coordinator documented and transmitted the resident's discharge status incorrectly. Despite multiple records, including the Physician's Orders, Notice of Transfer/Discharge form, Post Discharge Plan of Care, and Physician's Discharge Summary, all indicating that Resident 84 was discharged to home with home health services, the MDS discharge status was inaccurately recorded as a discharge to a short-term general hospital. This error was acknowledged by the MDS Coordinator during an interview, where she admitted to confusing the discharge status with the admission status. The facility's policy and procedure on resident assessments, revised in March 2022, assigns the responsibility of accurate resident assessments to the resident assessment coordinator. This includes assessments for admission, quarterly, annual, significant changes in status, significant corrections to prior comprehensive assessments, and discharge assessments. The inaccurate MDS discharge status impacts the facility's quality of care reporting to the Centers for Medicare & Medicaid Services (CMS), as noted by the MDS Coordinator. The report does not mention any corrective actions taken following the identification of this deficiency.
Failure to Implement Baseline Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for a resident diagnosed with dementia, psychotic disturbance, and mood disturbance. The resident was admitted on November 15, 2024, and had a physician's order for Seroquel, an antipsychotic medication, to be administered twice daily for psychosis. However, a review of the resident's medical record revealed that there was no baseline care plan for the antipsychotic medication use as indicated in the physician's order. Interviews with Licensed Vocational Nurses (LVN) 4 and 3 confirmed that the baseline care plan should have been initiated upon the resident's admission and signed by the admitting Registered Nurse (RN). LVN 3 stated that the baseline care plan should be completed within 14 to 30 days from admission and kept in the resident's chart. The absence of this care plan had the potential to affect the resident's quality of care by not promoting continuity of care and communication among the nursing home staff.
Failure to Provide Communication Boards for Residents with Language Barriers
Penalty
Summary
The facility failed to ensure that two residents, Resident 15 and Resident 73, were provided and were using a communication board, which is essential for residents with communication barriers to express their needs. Resident 15, who was moderately impaired cognitively and dependent on staff for daily activities, was observed speaking in a non-English language and complaining about pain. The staff present did not understand the resident, and the communication board, which was supposed to be used as per the care plan, was found hidden and not in use. This oversight was acknowledged by LVN 3, who confirmed that the communication board should have been used to facilitate communication. Similarly, Resident 73, who had a language barrier and was dependent on staff for daily activities, was observed trying to communicate with CNA 2, who did not understand the resident's language. The communication board, which was supposed to be easily accessible as per the facility's policy, was not found in the room. The Director of Nursing confirmed that it was the facility's policy to provide communication boards to residents with language barriers to ensure they receive the necessary care. The facility's policy emphasized the importance of effective communication with limited English proficient persons to ensure they benefit from the services offered.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for a resident, identified as Resident 44. The resident was admitted with Parkinson's disease, hypertensive heart disease, and muscle weakness, and required partial/moderate assistance with activities of daily living, including personal hygiene. The resident's care plan indicated a need for assistance with self-care due to limited mobility and aimed to ensure the resident was clean, well-groomed, and neatly dressed daily. However, during an observation, the resident was found with long, untrimmed, and dirty fingernails, which had not been trimmed for a month, contrary to the resident's expectation of weekly trimming. Interviews with facility staff, including a CNA and an RN, confirmed the resident's fingernails were long and dirty, and it was the CNA's responsibility to trim and maintain the residents' nails to prevent skin injury and infection. The Director of Nursing also stated that nail care was part of the grooming duties performed on bath days. The facility's policy on fingernail care, revised in February 2018, emphasized the importance of keeping nails trimmed and clean to prevent infections. The failure to adhere to this policy and provide necessary nail care had the potential to negatively impact the resident's self-esteem and posed a risk for skin breakdown and infection.
Incorrect LAL Mattress Settings for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the low air loss (LAL) mattress was set correctly for a resident, in accordance with the facility's Pressure Injury policy and procedure. The resident, who was at high risk for skin breakdown with a Braden Scale score of 10, had a stage 4 pressure ulcer on the left buttock. The resident was dependent on staff for various activities of daily living and had moderately impaired cognitive skills. The physician's order specified the use of an LAL mattress for wound management, but the settings were not adjusted according to the resident's weight, as required by the facility's guidelines and the manufacturer's instructions. During observations, it was noted that the LAL mattress was set incorrectly on two separate occasions. On the first occasion, the mattress was set at 180 mmHg, which was not appropriate for the resident's weight of 124 pounds. On the second occasion, the mattress was set at 140 mmHg, while it should have been set at 130 mmHg according to the resident's weight. Licensed Vocational Nurses confirmed that the incorrect settings would not be effective for the resident's wound management. The facility's policy and the manufacturer's manual both indicated that the mattress settings should be adjusted based on the resident's weight to optimize comfort and reduce the incidence of pressure ulcers.
Improper Foley Catheter Bag Positioning
Penalty
Summary
The facility failed to maintain proper positioning of a foley catheter bag for a resident, identified as Resident 15, which is a critical aspect of catheter care. The resident, who was moderately impaired cognitively and dependent on assistance for daily activities, had an indwelling catheter due to urinary retention. During an observation, it was noted that a Certified Nursing Assistant (CNA) moved the resident's catheter bag from below the level of the bladder to above it, placing it on top of blankets at the foot of the bed. This improper positioning was observed again when the CNA held the catheter bag above the bladder level while untangling it, causing urine to flow back towards the resident. Interviews with the Licensed Vocational Nurse (LVN) and the Infection Preventionist Nurse (IPN) confirmed that the catheter bag should always be kept below the bladder level to prevent urine backflow, which could lead to a urinary tract infection (UTI). The facility's policy on urinary catheter care, revised in August 2022, also stipulated that the drainage bag must be positioned lower than the bladder at all times. The failure to adhere to this policy and the improper handling of the catheter bag posed a potential risk for the resident to develop a UTI.
Delayed Administration of Metformin for Diabetic Resident
Penalty
Summary
The facility failed to administer Metformin hydrochloride to a resident with diabetes mellitus type 2 within one hour of the prescribed time, as per the physician's order. The resident, who was admitted with multiple diagnoses including diabetes mellitus, cerebral infarction, dysphagia, and hemiplegia, required assistance with various activities of daily living. The physician's order specified that Metformin should be administered with meals, but it was given late by a Licensed Vocational Nurse (LVN), who admitted to forgetting the timing requirement. This oversight was observed during a medication administration process, where the LVN acknowledged the error and its potential impact on the resident's blood sugar levels. The facility's policy and procedure for administering medications, reviewed in October 2024, mandates that medications be given within one hour of the prescribed time and in accordance with specific instructions such as with meals. A Registered Nurse (RN) confirmed the importance of timely medication administration, particularly for diabetes medications, to prevent adverse effects like hypoglycemia or hyperglycemia. The Medication Administration Audit Report corroborated the delay, showing that Metformin was scheduled for 7:15 AM but was administered at 9:22 AM, highlighting a deviation from the prescribed protocol.
Failure to Conduct Required Laboratory Tests for a Resident
Penalty
Summary
The facility failed to ensure that laboratory orders were completed for a resident, identified as Resident 14, who was admitted with diagnoses of hypertensive heart disease and hyperlipidemia. Upon admission, the resident was prescribed pravastatin sodium to manage cholesterol levels and prevent cardiovascular events. However, a Consultant Pharmacist's recommendation for a lipid and liver panel test, necessary for monitoring the effects of the medication, was not executed. This recommendation was made on December 24, 2024, but the required tests were not ordered or performed as confirmed by a review of the physician's orders and an interview with a registered nurse. The deficiency was identified during a review of the resident's records and an interview with Registered Nurse 1, who confirmed that the lipid and liver panel tests were not carried out. The nurse explained that RN supervisors are responsible for verifying and entering physician orders into the electronic medical records, which should then trigger laboratory services. However, in this case, the necessary tests were not ordered, leading to a failure in providing timely laboratory services to meet the resident's needs.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, specifically for a resident with dysphagia and dementia. The resident was on a low sodium, low fat, and low cholesterol diet with pureed food and thin liquids, as per physician orders. However, the resident's responsible party (RP) reported that the pureed food was too thick, causing the resident to gag and making it difficult for her to eat. Despite informing the Dietary Supervisor (DS) about this issue months prior, no follow-up action was taken to address the concern. Observations confirmed that the pureed diet provided was indeed thick, which was not in line with the resident's dietary needs. The facility's policy on food quality and palatability, which requires food to be palatable and attractive, was not adhered to in this case. The lack of action from the DS after being informed of the issue contributed to the deficiency, potentially affecting the resident's meal intake and overall health.
Delayed Meal Service for Two Residents
Penalty
Summary
The facility failed to ensure timely meal service for two residents, resulting in meals being served later than the scheduled time. Resident 287, who was admitted with diagnoses including colon cancer and required assistance with daily activities, was observed without a lunch tray at 12:09 PM and expressed hunger at 12:30 PM. The lunch tray was only delivered at 12:45 PM. Similarly, Resident 38, who had diagnoses including cellulitis and type 2 diabetes, was observed waiting for a lunch tray at 12:23 PM and expressed hunger at 12:42 PM. The lunch tray was delivered at 12:47 PM, after the scheduled lunch time of 12 noon. The Dietary Supervisor acknowledged the delay in meal delivery, stating it was unacceptable as it could negatively affect residents' well-being. The facility's policy indicated that meals should be served within designated time frames unless there is an emergency or resident request. However, the delay was attributed to the CNA being busy with other residents, which was not an emergency situation. This deficiency in meal service timing had the potential to impact the psychosocial well-being of the residents involved.
Incomplete Documentation of Orthostatic Blood Pressure
Penalty
Summary
The facility failed to ensure complete documentation of orthostatic blood pressure measurements for a resident, specifically missing the lying position measurement. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance. The resident was prescribed Seroquel, an antipsychotic medication, with a physician's order to monitor blood pressure in both sitting and lying positions every Sunday. However, the Medication Administration Record (MAR) showed several instances where the lying position blood pressure was not documented. Interviews with nursing staff revealed that the facility's process requires nurses to follow physician orders and document blood pressure readings. If unable to do so, they must note the reason in the progress notes. Despite this protocol, the resident's orthostatic blood pressure was not consistently recorded, potentially increasing the risk of falls due to hypotension or dizziness. The facility's policy on antipsychotic medication use emphasizes the importance of monitoring and reporting adverse effects, which was not adhered to in this case.
Infection Control Breach During Peri-Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during the provision of peri-care to a resident. Specifically, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after providing peri-care to a resident who was dependent on staff for personal hygiene and had an indwelling catheter. The CNA was observed using the same gloves to touch the resident's clean bed pad and bed sheets, which is against the facility's policy and procedure for hand hygiene. The resident involved was moderately impaired in cognitive skills and required assistance with various activities of daily living, including personal hygiene. The facility's policy, revised in 2019, mandates hand hygiene after contact with bodily fluids and before moving from a contaminated to a clean body site. The Infection Preventionist Nurse confirmed that the CNA should have removed gloves, performed hand hygiene, and donned new gloves to prevent the spread of infection, as the use of gloves does not replace the need for hand hygiene.
Water Leak in Kitchen Ceiling
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not addressing a water leak in the kitchen ceiling from January 26 to January 27, 2025. During an initial observation on January 27, 2025, a moderate amount of water was found on the floor near the dishwashing area, with a wet/dry vacuum actively suctioning water and rolled bed sheets placed around the puddle. The Dietary Supervisor confirmed the presence of the water leak, which was traced back to a hole in the metal duct for ventilation between the roof and ceiling, as explained by the Maintenance Supervisor. The duct had collected rainwater, leading to the leak. Interviews revealed that the water leak was reported by kitchen staff on the night of January 26, 2025, but there was uncertainty about whether maintenance staff had conducted rounds on January 24, 2025. The Maintenance Assistant was informed of the leak on the morning of January 27, 2025, and confirmed the presence of leaking water. Concerns were raised about potential food contamination due to the leak, which could result in the kitchen being unusable and no food being available for residents. The facility's maintenance policy, revised in December 2009, states that the maintenance department is responsible for keeping the building in good repair and free from hazards, which was not adhered to in this instance.
Inaccurate Documentation and Unauthorized Medication Administration
Penalty
Summary
The facility failed to maintain accurate documentation in the medical records for one of the sampled residents by allowing a Certified Nursing Assistant (CNA) to administer a topical cream, while a Licensed Vocational Nurse (LVN) documented the administration in the Treatment Administration Record (TAR). This practice was observed during a review of the resident's TAR for November 2024, where it was noted that the treatment nurse was recorded as having applied the hydrophilic wound dressing to the resident's buttocks, despite the CNA being observed performing this task. The facility's policy and procedure require that only licensed nurses administer and document medications, which was not adhered to in this instance. The resident involved had a medical history of quadriplegia and multiple sclerosis, requiring assistance with various activities of daily living. The resident's physician orders specified the application of hydrophilic wound dressing to the buttocks every shift for skin maintenance. However, during an interview, the treatment nurse admitted that CNAs had been applying the cream, and licensed nurses were signing off on the TAR. This discrepancy between the facility's policy and the actual practice was confirmed by the Director of Nursing, who stated that only licensed nurses should complete and sign entries in the TAR.
Improper Disposal of Resident's Medication
Penalty
Summary
The facility failed to adhere to its policy for the proper disposal of medication, resulting in the inappropriate disposal of medication for one resident. The resident, who was admitted with diagnoses of hypertensive heart disease with heart failure and atherosclerotic heart disease, was prescribed carvedilol to manage these conditions. Despite the medication being actively used, 182 tablets of carvedilol were disposed of by a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) after the resident requested the disposal. This action was contrary to the facility's policy, which stipulates that medications should only be disposed of if they are unused or expired. Interviews with the nursing staff involved revealed that they signed the Medication Disposition Record/Pass Log and disposed of the medication based on the resident's request. However, the Director of Nursing (DON) confirmed that the facility's policy was not followed, as the medication was neither unused nor expired. The DON acknowledged the lack of a process for handling medications brought in by residents and the need for better coordination with the pharmacy to prevent overstocking and wastage of medications like carvedilol.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of bed hold policy to a resident during their transfer to a General Acute Care Hospital (GACH). The resident, who was cognitively intact and capable of making their own decisions, was transferred to the hospital following a psychiatric emergency evaluation. Despite the facility's policy requiring that residents or their representatives be given written information about bed hold policies at the time of transfer, this was not done for the resident in question. The facility's administrator admitted that the bed hold notice was not provided because they did not expect the resident to return after the psychiatric emergency transfer. The resident had a history of depression and agitation, and had refused psychotropic medications. The facility's policy, revised in October 2022, mandates that written notice regarding bed hold policies be provided to residents or their representatives at the time of transfer, or within 24 hours if the transfer was an emergency. However, this procedure was not followed, and no bed hold order was placed for the resident when they were transferred to the hospital. This oversight violated the resident's right to make informed decisions and receive information about their rights to have the bed held for their return.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to have a process in place for handling medications brought in by residents or their families, specifically in the case of a resident with type 2 diabetes mellitus. The resident's family brought in Ozempic, an injectable medication, which was stored at the bedside and administered by the facility's nursing staff. However, the facility's policy did not include procedures for managing such medications, and there was no log or inventory kept of the medications brought in by the resident from September 2023 to August 2024. The Director of Nursing (DON) confirmed that the procedures followed did not match the facility's policy. Additionally, the facility failed to document the injection site for one of the Ozempic injections administered to the resident in August 2024. The medication administration record for that month lacked documentation of the injection site for the dose given on August 14, 2024. The Registered Nurse (RN) confirmed that the Licensed Vocational Nurse (LVN) who administered the dose did not document the site, and there was no indication of the last injection site used in the nurse's notes. The facility also failed to properly store and discard expired and discontinued medications. During an inspection, expired medications and medications belonging to discharged residents were found in a medication refrigerator in the infection preventionist's office. The facility's policy required such medications to be removed from the current supply and disposed of in a timely manner. Furthermore, the temperature monitoring of the medication refrigerator was not documented for 30 out of 62 days in July and August 2024, which could affect the efficacy of the stored medications.
Failure to Inventory Resident's Medications
Penalty
Summary
The facility failed to log or take inventory of a resident's personal and current medications, which had the potential for misappropriation of resident properties. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, heart failure, muscle wasting, and legal blindness, reported a theft of his medication, Ozempic, which is used to manage diabetes. The resident stated that a dose of Ozempic was unaccounted for after he requested it in the dining room. He noted that there should have been one opened box with one dose left and two new unopened boxes in his personal medication refrigerator, but the opened box was missing. Interviews with the facility's administrator and director of nursing revealed that the resident had been personally picking up his medications from an outside pharmacy and dropping them off with the LVN on duty since the previous year. However, the facility did not maintain a log or inventory of these medications from September 2023 to August 2024. The facility's policy on personal property, dated December 2008, required that residents' personal belongings be inventoried and documented, which was not adhered to in this case.
RN Lacks Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was competent and skilled in administering medication via injection, specifically insulin, to a resident. The RN, who had a phobia of needles and had not administered an injection in a long time, instructed the resident to self-administer their insulin. This occurred despite the resident being legally blind and having a diagnosis of diabetes mellitus. The resident was capable of understanding and making decisions, as indicated in their medical records, but the RN's actions were not in accordance with the facility's policy and procedure for medication administration. The Director of Nursing (DON) and the Director of Staff Development (DSD) acknowledged that the facility lacked a formal process for assessing and documenting the competency of nursing staff in administering injections. The facility's policy required that only licensed individuals administer medications, and staff must demonstrate specific competencies. However, the DSD confirmed that the training for newly hired RNs and LVNs was primarily orientation and class discussion, without return demonstrations to verify competency. This lack of competency assessment contributed to the RN's inability to properly administer the insulin injection.
Resident Self-Administers Insulin Without Authorization
Penalty
Summary
The facility failed to adhere to its policy regarding medication administration, resulting in a deficiency related to a resident self-administering insulin without proper authorization. Resident 1, who has diabetes mellitus and legal blindness, was instructed by a registered nurse to self-administer his Humalog insulin injection. This occurred despite the absence of a physician's order or a self-administration form authorizing the resident to manage his own medication. The facility's policy, revised in April 2019, clearly states that only licensed or permitted individuals are allowed to prepare, administer, and document medication administration. Interviews with the staff revealed that on the morning of the incident, both a registered nurse and a licensed vocational nurse were involved in preparing the insulin pen for Resident 1, who then administered the injection himself. The Director of Nursing confirmed that there was no order in place for the resident to self-administer medications, highlighting a breach in protocol. The resident's Minimum Data Set indicated that he was independent in cognitive skills for daily decision-making, yet the facility's policy was not followed, leading to the potential for improper medication administration.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident or the resident's legal representative with a copy of the resident's medical records upon request and within the stipulated time frame of two working days, as per the facility's policy. The resident, who had been diagnosed with conditions including urinary tract infection, chronic obstructive pulmonary disease, pneumonia, and unspecified asthma, was deemed incapable of making decisions. The request for the resident's medical records was made by the resident's legal representative and was received by the facility via electronic mail. Despite the facility's policy requiring records to be released within 72 hours, excluding weekends and holidays, the records were not provided in a timely manner. Interviews with facility staff, including the Director of Nursing and Medical Record staff, revealed that the request was forwarded to the facility's lawyers, as it was made by the resident's lawyers. However, there was no confirmation that the records were actually sent. The Medical Record staff later confirmed that the resident's lawyers had not received the requested records, which were needed for the resident's follow-up medical care. The facility's policy on the release of information clearly states that residents have the right to access their records within the specified time frame, but this was not adhered to, resulting in a violation of the resident's rights.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
