Sunnyvale Gardens Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunnyvale, California.
- Location
- 1150 Tilton Drive, Sunnyvale, California 94087
- CMS Provider Number
- 555444
- Inspections on file
- 22
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sunnyvale Gardens Post Acute during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy and other serious conditions did not receive prescribed Rifaximin due to the facility's inability to obtain it from the pharmacy. The medication was later found in the resident's drawer, having been brought upon admission but not documented. Facility staff failed to inform the physician of the missed doses, and the resident was later hospitalized and transitioned to comfort care.
A resident suffered first-degree facial burns after an e-cigarette exploded while she was on oxygen therapy in her room. The facility failed to inform residents of the smoking policy upon admission, and the admission packet lacked a smoking policy acknowledgment form. Interviews revealed that several residents were unaware of the smoking restrictions, and the facility's policy on electronic cigarettes was not adequately enforced.
The facility failed to ensure dietary support staff were competent in food and nutrition services, leading to incorrect sanitizer testing and thermometer calibration. One staff member did not know how to properly test the sanitizer solution, and two staff members failed to correctly demonstrate thermometer calibration. The registered dietitian admitted to not teaching the use of test strips, and recent in-services did not include a teach-back method.
The facility failed to maintain the privacy and dignity of five residents by posting personal care information in their rooms and not ensuring privacy during medical procedures. Notes with personal details were visible to visitors, and a resident's privacy was compromised during medication administration. These actions were against the facility's policy on dignity and privacy.
The facility failed to provide adequate supervision and fall management for residents identified as high risk for falls. Staff did not provide the required 1:1 supervision, and monitoring logs were absent for several residents. Observations revealed that staff were assigned to supervise multiple residents simultaneously, making it impossible to provide effective supervision. The Director of Nursing and the Administrator acknowledged the lack of 1:1 sitters and monitoring logs, compromising resident safety.
A facility failed to accurately account for controlled drugs and document medication administration for a resident with type 2 Diabetes Mellitus and Diabetic Neuropathy. Discrepancies were found between the Controlled Substance Accountability Sheet and the Medication Administration Records, with 13 oxycodone tablets unaccounted for. The Director of Nursing confirmed the findings, highlighting a breach in the facility's policy and procedures for medication administration.
A survey found a 10% medication error rate in an LTC facility. Errors included improper inhaler use instruction, failure to flush a G-tube between medications, and incorrect eye drop administration. Staff did not follow physician orders or facility policies, leading to these deficiencies.
The facility failed to ensure proper medication storage and labeling, with opened vials and bottles lacking open dates, latanoprost not refrigerated as required, and expired medications not removed. These issues were confirmed by the DON and LVNs, highlighting discrepancies with the facility's medication storage policy.
A long-term care facility failed to implement proper infection control practices, with staff neglecting hand hygiene protocols and improper maintenance of medical equipment. CNAs did not perform hand hygiene between resident interactions, and oxygen concentrators and nebulizer equipment were not maintained according to policy. Additionally, a wound nurse and an RN failed to follow hand hygiene protocols during care procedures.
A facility failed to follow its policy on self-administration of medication for a resident with multiple diagnoses, including COPD and anxiety disorder. Despite the resident's cognitive intactness, no assessment was conducted to determine the safety of self-administration. Eyedrops, one not prescribed, were found at the resident's bedside, contrary to facility policy. Both an LVN and the DON confirmed the lack of proper authorization for bedside medications.
The facility failed to develop comprehensive care plans for three residents with conditions such as depression, anxiety, Parkinson's disease, and low sodium levels. Despite being prescribed medications, these residents lacked care plans addressing their specific needs, as confirmed by the DON.
The facility failed to follow its enteral feeding policy for two residents, leading to potential complications. A resident with a G-tube did not have the tube placement or residual volume checked before flushing, contrary to policy. Another resident received medications via G-tube without placement verification. Both actions were against facility procedures, risking harm to the residents.
A resident with multiple sclerosis and a fracture had a bed rail installed without a documented physician's order or care plan. The facility did not attempt alternatives or assess entrapment risks before installation, contrary to its policy. Observations and staff interviews confirmed these deficiencies.
The facility failed to ensure staff competency in resident supervision, as a laundry aide was assigned to monitor residents without proper training or infection control adherence. The aide could not recall resident names, did not use a monitoring log, and handled call light buttons without hand hygiene. The DON confirmed aides should not provide direct care and must follow infection control protocols, which were not met, compromising resident safety.
A resident with a history of domestic violence and diagnoses including COPD, major depressive disorder, and anxiety disorder did not receive timely psychosocial support from social services. Despite the resident's request to see her psychiatrist and the care plan's indication for social services visits, there was no documentation of such visits. The Social Services Director and DON confirmed the lack of documented visits, which was against the facility's job description for providing necessary social services.
The facility failed to monitor a resident's edema while on Lasix and had duplicate oxycodone orders for another resident. The DON confirmed the lack of monitoring and duplicate orders, which could lead to adverse effects.
Three residents were administered psychotropic medications without prior non-pharmacological interventions or proper monitoring. One resident received anti-anxiety and antidepressant medications without documented attempts at non-drug interventions. Another was prescribed Abilify without behavior monitoring, despite a diagnosis of psychosis and Alzheimer's. A third resident was given Trazodone for insomnia without sleep monitoring. The facility's policies on non-pharmacological interventions and monitoring were not followed.
The facility failed to monitor and document antibiotic use for two residents, leading to incomplete records in the Infection Control Log. One resident with acute osteomyelitis was not documented for antibiotic use, and another resident's antibiotic regimen was inconsistently logged. These lapses were confirmed by the IP and DON, contrary to the facility's policy requiring comprehensive documentation.
The facility failed to ensure call lights were accessible and functional for four residents, impacting their ability to communicate with staff. A resident's call light was out of reach due to entanglement, while two residents had non-functioning call lights despite reporting the issue. Another resident's call light was repeatedly found out of reach, contrary to their care plan. Staff confirmed these issues, highlighting a lapse in adherence to facility policy.
A CNA improperly cleaned a resident's dentures using liquid hand soap instead of a denture cleanser or toothpaste, contrary to facility policy and professional recommendations. This was confirmed by the CNA and the IP, highlighting a failure to adhere to proper denture cleaning standards.
A resident at high risk for falls due to medical conditions fell and fractured their wrist after attempting to return to bed from the bathroom without the required assistance. Despite documented needs for supervision and assistance, the facility staff failed to implement the necessary precautions, leading to the incident. The facility's Director of Nursing acknowledged the lapse in care, and staff interviews confirmed the resident's need for supervision.
A resident's personal belongings were not secured or returned after being transferred to a hospital. The facility's policy requires belongings to be stored and released to the resident or their representative, but staff failed to document or locate the items. Interviews confirmed the oversight, with no signatures on the inventory form to indicate the belongings were returned.
A resident with osteoporosis and other medical conditions sustained fractures in the left hand, which the facility did not report as required. The facility's staff deemed the fractures as pathological due to osteoporosis and did not follow the policy to report injuries of unknown source to the necessary agencies.
The facility failed to document and address abuse allegations for three residents. Nursing documentation was missing for abuse allegations made by two residents, and there were no care plans for any of the three residents involved. Interviews confirmed the lack of documentation and care plans, indicating a failure to follow the facility's policies and procedures.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who did not receive a medication ordered by the physician. The resident, who had a history of hepatic encephalopathy, alcoholic cirrhosis of the liver with ascites, liver cell carcinoma, and dementia, was prescribed Rifaximin to be taken twice daily. However, the medication was not administered from July 26 to August 6, 2024, due to the facility's inability to obtain it from the pharmacy because of its high cost. The medication was later found in the resident's drawer, having been brought upon admission, but was not listed in the inventory of personal effects. Interviews with facility staff revealed that the medication was initially available but was not administered during the specified period. The facility's policies on administering medications and managing personal belongings were not followed, as the medication was not documented upon admission, and the physician was not informed of the missed doses. The resident was later hospitalized for respiratory failure and transitioned to comfort care before passing away, but the report does not link these events directly to the missed medication.
Failure to Implement Smoking Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement and inform all residents of their smoking policy upon admission, which led to a serious incident involving a resident. The resident, who was on oxygen therapy, suffered first-degree facial burns after an electronic cigarette exploded while she was in her room. This incident resulted in the resident being intubated and hospitalized. The survey revealed that the facility did not have a signed acknowledgment of the smoking policy in the resident's admission packet, indicating a lack of proper communication and enforcement of the policy. During the survey, it was observed that several residents were not informed of the facility's smoking policy upon admission. Interviews with residents confirmed that they were unaware of the prohibition of smoking within the facility. The Director of Nursing (DON) acknowledged that the admission packet did not include a smoking policy acknowledgment form, which contributed to the residents' lack of awareness about the facility's smoking restrictions. The facility's policy and procedure on smoking, including the use of electronic cigarettes, were not adequately enforced. The policy stated that electronic cigarettes should only be used in designated areas with supervision, and residents should be assessed for their ability to handle such devices safely. However, the resident involved in the incident was not properly supervised or informed about the risks associated with using electronic cigarettes while on oxygen, leading to the explosion and subsequent injuries.
Removal Plan
- Resident was transferred to the hospital for further evaluation and treatment as indicated.
- Resident's attending physician and emergency contact were notified of the incident. The resident is still currently in the hospital.
- Resident was provided emotional support and re-assurance of the facility staff in relation to the incident.
- Resident was offered psychology consult which she declined. Resident currently feels safe and has not brought up concerns to the facility staff.
- Residents have now been notified of the no smoking policy and a copy of the policy is available to the residents.
- All residents have the potential to be affected because of the use of oxygen at the facility. The facility leadership reviewed and observed all the residents on oxygen and all residents with history of smoking and found no other safety concerns such as smoking inside the room or other parts of the facility.
- All residents will be informed of the facility's non-smoking policy and will be educated on the complication of oxygen use and smoking (whether real cigarettes, e-cigarettes, or vapes) with signed confirmation which has been initiated.
- The Director of Nursing (DON), Director of Development (DSD) or designee will in-service all staff on the facility Smoking Policy to promote resident and staff safety.
- The Director of Nursing (DON), Administrator or designee will in-service all Admission Department on informing new admissions of the facility's non-smoking policy including the imminent risks of smoking while using oxygen or near oxygen products.
- To ensure ongoing compliance, the interdisciplinary team (IDT) will conduct at least a weekly review of the removal plan on ensuring residents' safety and will verify that new admissions were informed of the facility's Non-Smoking policy and were educated on the complication of smoking while using oxygen in the weekly IDT meetings. Any concerns will be discussed by the Administrator or designee for immediate resolution.
- The IDT will also review daily in the IDT meeting on weekdays if there are new patients with history of smoking and/or new patients that require oxygen use and verify that proper evaluation and safety interventions have been initiated.
- Moreover, the Administrator, Director of Nursing (DON) or designee will audit compliance in ensuring safety of residents including informing all new patients of the Non-Smoking policy and education on the complication of smoking while using oxygen or near oxygen products. This audit will be done weekly for 4 weeks, then monthly for 6 months. Any concerns or issues will be discussed in the daily stand-up meeting for immediate resolution and/or re-assessment by the interdisciplinary team.
- The Administrator or DON will provide a written quality assurance report that includes evaluation of the effectiveness of the plan of correction in the quarterly QAPI meeting for 6 months using pertinent compliance audit information and resolutions.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that dietary support staff were competent in carrying out the functions of the food and nutrition services department according to facility policy and standards of practice. One dietary support staff member did not know how to properly test the sanitizer in the red bucket, which is used for sanitizing food contact surfaces. During an observation, the staff member incorrectly tested the sanitizer solution, resulting in a concentration that was not at the correct level. The dietary manager verified the error, and the registered dietitian admitted that she did not teach staff how to use the test strips, only instructing them to test the solution when the sanitation water is changed. Additionally, two dietary support staff members failed to correctly demonstrate how to calibrate a thermometer used to test food temperatures. During an observation, one staff member attempted to calibrate a thermometer but did not achieve the correct temperature reading. The registered dietitian had recently conducted in-services on thermometer calibration and kitchen sanitation but did not include a teach-back method to ensure staff understood the procedures. The facility's policies and procedures outlined the correct methods for sanitation and thermometer calibration, but the staff did not adhere to these guidelines, potentially exposing residents to bacterial contamination.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of five residents by posting personal information and care instructions in their rooms, visible to visitors. For Residents 29, 11, 100, and 76, notes containing personal care details were posted in their rooms, which could be seen by visitors, compromising their privacy. For instance, Resident 29 had notes about their hearing and communication needs, while Resident 11 had notes about their blanket and shower schedule. Resident 100 had notes about dietary restrictions and care instructions, and Resident 76 had a note about diaper usage. These postings were confirmed by RN U, who acknowledged that such information should not be openly displayed. Additionally, the facility failed to ensure privacy during medical procedures. RN L did not close the privacy curtain or door while administering medication through a gastric tube to Resident 64, leaving the resident's abdomen exposed. RN L admitted to forgetting to close the curtains, which was against the facility's policy of maintaining resident privacy during care. The Director of Nursing confirmed that privacy should have been maintained during such procedures. The facility's policy on dignity, revised in February 2021, clearly states that staff should protect confidential clinical information and ensure resident privacy during care. Despite this, the observations and interviews revealed that the facility did not adhere to these guidelines, potentially affecting the residents' emotional and psychosocial well-being.
Inadequate Supervision and Fall Management
Penalty
Summary
The facility failed to implement fall management and safety supervision policies for nine out of ten residents identified as high risk for falls. Specifically, staff did not provide the required 1:1 supervision for Residents 18, 76, and 106, who were identified as high risk of falling. Observations revealed that Resident 18 was left without supervision multiple times, despite a care plan intervention requiring close supervision up to 1:1. Similarly, Resident 76 was observed without a sitter or staff oversight, even though their care plan required close monitoring. Resident 106 was also left unsupervised on several occasions, despite a care plan indicating the need for supervision up to 1:1 every shift. The report further details that staff were assigned to supervise multiple residents simultaneously, making it impossible to provide adequate supervision. For instance, CNA V was assigned to supervise Residents 18, 28, 76, and 106, but was observed seated between Residents 18 and 28's doors, unable to effectively monitor all assigned residents. CNA T was also observed using a personal cell phone while supposed to be supervising multiple residents, further compromising the supervision required for high-risk residents. Additionally, the facility failed to maintain monitoring logs for Residents 26, 30, 90, 108, 116, and 122, who were also identified as high risk for falls. CNA D, assigned as a sitter for these residents, confirmed the absence of monitoring logs and expressed difficulty in preventing falls due to the high number of residents under her supervision. The Director of Nursing and the Administrator acknowledged the lack of 1:1 sitters and the absence of monitoring logs, which are essential for documenting resident activities and ensuring adequate supervision.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled drugs and proper documentation of medication administration for one resident. The resident, who was admitted with type 2 Diabetes Mellitus and Diabetic Neuropathy, had physician orders for oxycodone to manage pain. However, discrepancies were found between the Controlled Substance Accountability Sheet (CSAS) and the Medication Administration Records (MARs). On multiple occasions, nursing staff signed out oxycodone tablets on the CSAS but did not document their administration on the MARs. During an interview and record review, the Director of Nursing confirmed that 13 oxycodone tablets were unaccounted for. The facility's policy and procedures require nurses to document the administration of medications, including the time, dosage, and signature of the administering nurse. The failure to adhere to these procedures resulted in a lack of accountability for the controlled substances administered to the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 10% during a survey, with three errors occurring out of 30 opportunities. One incident involved a Licensed Vocational Nurse (LVN) who failed to instruct a resident on the proper use of an inhaler, Dulera, which is used to control asthma symptoms. The LVN did not guide the resident to breathe deeply, hold her breath, or wait the appropriate time between puffs, and also neglected to instruct the resident to rinse her mouth afterward, as per the physician's order and facility policy. Another error was observed when a Registered Nurse (RN) administered medications via a gastrostomy tube (G-tube) to a resident without flushing the tube with water between medications. The RN confirmed the oversight, acknowledging that she should have flushed the G-tube with water between each medication, as per the facility's policy and procedure. A third error involved an LVN administering eye drops to a resident. The LVN instilled the drops directly onto the iris without creating a pocket by pulling down the lower eyelid and did not instruct the resident to look up, contrary to the facility's policy. The Director of Nursing confirmed the correct procedure, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, which was identified during an inspection of the medication refrigerator and medication carts. On one occasion, an opened multi-dose vial of insulin and two opened bottles of lorazepam oral solution were found without open date labels. The manufacturer's instructions for these medications require them to be discarded after a specific period once opened, which was not adhered to. Additionally, unopened latanoprost bottles were not stored in the refrigerator as required by the manufacturer's labeling, and expired medications were not removed from active stock. Further inspections revealed additional issues with medication storage and labeling. An unopened bottle of latanoprost was improperly stored at room temperature instead of being refrigerated, and an opened bottle of the same medication was not dated with an open date. Other medications, such as nitroglycerin tablets and a Trelegy inhaler, were found to be expired or undated, and a fluticasone propionate diskus was used beyond its recommended period after opening. These findings were confirmed by the Director of Nursing and Licensed Vocational Nurses, who acknowledged the discrepancies with the facility's policy and procedure for medication storage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple observations of staff neglecting hand hygiene protocols. Certified nursing assistants (CNAs) were observed setting up meal trays for residents without performing hand hygiene between tasks, even after touching their faces or other potentially contaminated surfaces. This was confirmed by the CNAs themselves and the infection preventionist, who stated that hand hygiene should be performed between resident interactions and after touching any body parts. Additionally, the facility did not maintain proper maintenance and storage of medical equipment. Oxygen concentrators for two residents had filters with grayish substance build-up, and staff were unsure of the protocol for changing these filters. Nebulizer masks and tubing for several residents were improperly stored, with some equipment not being changed for over a month, contrary to the facility's policy of changing them every seven days. The infection preventionist and director of nursing confirmed these observations and acknowledged the failure to adhere to the facility's protocols. Further deficiencies were noted in the handling of wound care and medication administration. A wound nurse did not change gloves between handling clean and dirty areas during wound treatment, and a registered nurse failed to perform hand hygiene between glove changes during medication administration. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing healthcare-associated infections. The director of nursing confirmed the need for staff to follow proper hand hygiene protocols.
Failure to Implement Self-Administration of Medication Policy
Penalty
Summary
The facility failed to implement its policy and procedure on self-administration of medication for Resident 59, who was admitted with diagnoses including chronic obstructive pulmonary disease, respiratory disorders, major depressive disorder, and anxiety disorder. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, there were no assessments performed to determine if Resident 59 was safe to self-administer medications. During an observation, two bottles of eyedrops were found on Resident 59's overbed table, one of which was given by a roommate and not prescribed by a physician. Licensed Vocational Nurse J confirmed that Resident 59 should not have medications at the bedside and acknowledged the lack of a physician's order for the tetrahydrozoline hydrochloride eyedrops. The Director of Nursing also confirmed that medications should not be at the bedside without proper authorization. The facility's policy requires that the interdisciplinary team determine if self-administration is clinically appropriate and safe, and any unauthorized medications found at the bedside should be returned to the nurse in charge. This oversight had the potential for unsafe and improper administration of medications.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, which included target symptoms, measurable objectives, and interventions. Resident 6 was admitted with diagnoses of depression and anxiety, and although prescribed medications such as Venlafaxine and Alprazolam, there were no care plans developed for these conditions. The Director of Nursing (DON) confirmed the absence of care plans during a review. Resident 106, diagnosed with depression and Parkinson's disease, was prescribed Nortriptyline and Ropinole, yet lacked corresponding care plans. Similarly, Resident 111, with a history of alcoholic cirrhosis and consistently low sodium levels, had no care plan addressing this issue. The DON acknowledged the absence of care plans for these residents, which was contrary to the facility's policy requiring individualized comprehensive care plans for each resident.
Failure to Verify G-Tube Placement Before Administration
Penalty
Summary
The facility failed to adhere to its policy and procedures for enteral feeding care for two residents, leading to potential complications. Resident 110, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia following a stroke, had a gastrostomy tube (G-tube) for enteral feeding. The Licensed Vocational Nurse (LVN G) did not check the placement of the G-tube or the residual volume before flushing it with water, which was against the facility's policy. The Director of Nursing (DON) confirmed that the correct procedure was to check the G-tube placement and residuals before flushing or administering medications. Similarly, for Resident 64, the Registered Nurse (RN L) administered medications via the G-tube without verifying its placement. RN L admitted to forgetting to check the placement and typically not doing so before medication administration. The facility's policy required checking the G-tube placement with a stethoscope before administering medications. These oversights had the potential to cause harm to the residents due to possible enteral feeding complications.
Failure to Follow Bed Rail Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails for one resident. The resident, who was admitted with multiple sclerosis and a fracture of the right ulna, had a bed rail installed without a documented physician's order or a care plan for its use. Additionally, there was no documentation indicating that alternatives to bed rails were attempted prior to their installation, nor was there an assessment for the risk of entrapment. Observations revealed that the resident's bed had a 1/4 side rail in the upright position on the left side, with no rail on the right side. Interviews with facility staff, including the DON, confirmed the absence of necessary documentation and evaluations prior to the installation of the bed rail. The facility's policy requires an interdisciplinary evaluation and informed consent before using bed rails, which was not followed in this case.
Inadequate Staff Competency and Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff had the necessary competencies to respond to residents' needs, as evidenced by the involvement of a laundry aide in resident supervision without proper training or adherence to infection control protocols. During an interview, the laundry aide, who was assigned to supervise four residents, could not recall the names of the residents and admitted to not using a monitoring log. The aide was observed handling call light buttons for two residents without performing hand hygiene or sanitizing the equipment, which is a breach of infection control practices. The Director of Nursing confirmed that laundry aides could serve as sitters but were not to engage in direct patient care and were expected to follow infection control procedures. The care plans for the two residents involved required close supervision, which was not adequately provided. The facility's job description for laundry aides and its policy on safety and supervision of residents emphasize the need for individualized, resident-centered safety interventions, which were not effectively communicated or implemented in this instance.
Failure to Provide Social Services Support for Resident with Domestic Violence History
Penalty
Summary
The facility failed to provide appropriate social services support for a resident with a history of domestic violence, resulting in a lack of timely psychosocial support. The resident, who was admitted with diagnoses including COPD, major depressive disorder, and anxiety disorder, had requested to see her own psychiatrist, but no follow-up was conducted. The resident confirmed that social services never visited her regarding her request, despite her history of domestic violence and the presence of anxiety due to her husband's impending release from jail. The resident's care plan indicated a need for social services to visit and evaluate as needed, but there was no documentation of such visits. The Social Services Director confirmed the absence of documented visits to address the resident's mood and acknowledged that the resident should have had weekly social services visits. The Director of Nursing also confirmed the lack of documented social services visits, which was contrary to the facility's job description for the Social Services Director, which required the provision of medically related social services to maintain the highest practicable well-being of each resident.
Failure to Monitor Medication and Duplicate Orders
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 6, who was admitted with a diagnosis of heart failure, was prescribed Lasix to treat edema. However, the nursing staff did not monitor for edema as required, which was confirmed by the Director of Nursing (DON) during a review of the resident's records. The lack of monitoring for edema was a significant oversight in the resident's care plan. Resident 111, admitted with alcoholic cirrhosis and ascites, had duplicate orders for oxycodone 5 mg, a potent pain medication. The orders were dated differently, but both were active on the medication administration record (MAR). The DON confirmed the duplication and stated that one of the orders should have been discontinued. This oversight in medication management had the potential for excessive dosing and adverse effects.
Failure to Implement Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 59 was administered an anti-anxiety medication and two different antidepressants without any documentation of non-pharmacological interventions being attempted prior to the use of these medications. The resident had a history of physical abuse from her husband, which contributed to her anxiety and depression. The Director of Nursing (DON) confirmed that non-pharmacological interventions were only initiated during the recertification survey, indicating a lack of prior attempts to manage the resident's conditions without medication. Resident 63 was prescribed Abilify for delusional thoughts without any monitoring of the target behavior or documentation of non-pharmacological interventions. The resident was diagnosed with psychosis and Alzheimer's disease. Despite the prescription, there was no evidence of behavior monitoring related to the use of Abilify, and the DON confirmed the absence of such documentation. The resident was observed to be calm and smiling, with no reported behaviors that would necessitate the medication. Resident 6 was given Trazodone for depression manifested by insomnia, but there was no monitoring of the resident's sleep hours as required. The DON confirmed that the facility failed to monitor the number of hours the resident slept, which was a necessary component of evaluating the effectiveness of the medication. The facility's policies indicated the importance of using non-pharmacological interventions and monitoring, but these were not adhered to in the cases of the three residents.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Surveillance protocol effectively, as evidenced by the lack of monitoring and tracking of antibiotic use for two residents. Resident 331, who had a PICC line for intravenous antibiotic administration due to acute osteomyelitis, was not documented in the November 2024 Infection Control Log despite starting antibiotics on November 5, 2024. This oversight was confirmed during an interview with the Infection Preventionist (IP), who acknowledged the omission in the documentation process. Similarly, Resident 111, who was on Bactrim DS for SBP prophylaxis and Rifaximin for hepatic encephalopathy, had incomplete documentation in the facility's Infection Control Log. The use of Bactrim DS was only logged in July 2024, missing entries for the subsequent months, while Rifaximin was logged in October 2024 but not in November 2024. These discrepancies were verified by both the IP and the Director of Nursing (DON) during a review of the resident's records. The facility's policy, revised in December 2016, mandates that all antibiotic regimens be documented on the surveillance tracking form, which was not adhered to in these cases.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that call lights were properly functioning and accessible for four residents, which could prevent them from communicating with staff for basic needs and emergencies. Resident 232's call light was found on the floor under the bed, out of reach, due to it being entangled with the bed/TV control. This was confirmed by a licensed vocational nurse who acknowledged that call lights should always be within reach. Residents 97 and 104 experienced non-functioning call lights. Resident 97's call light did not work for two weeks despite reporting it to staff, and the maintenance director was aware but had not fixed it. Similarly, Resident 104's call light sometimes failed to light up, and although the maintenance director was informed and planned to replace the wall panel, it was not done promptly, forcing the resident to rely on a roommate for assistance. Resident 122's call light was repeatedly found out of reach, either in a drawer or on the floor, despite a care plan intervention to keep it accessible. Various staff members, including a licensed vocational nurse, a certified nursing assistant, and a laundry aide, had to reposition the call light to make it accessible. The facility's policy emphasized the importance of keeping call lights within easy reach, but this was not consistently followed for Resident 122.
Improper Denture Cleaning Practices
Penalty
Summary
The facility failed to ensure that services provided were in accordance with standards of practice when a Certified Nurse Aide (CNA) used incorrect cleaning methods for a resident's dentures. During an observation, the CNA was seen removing the dentures from the resident's mouth and cleaning them with liquid hand soap and water in the restroom, instead of using a denture cleanser or toothpaste as per the facility's policy. This was confirmed by the CNA during the observation. An interview with the Infection Preventionist (IP) further confirmed that toothpaste should be used for cleaning dentures, not liquid hand soap. The facility's policy from 2017 and recommendations from The American College of Prosthodontists emphasize the use of a nonabrasive denture cleanser to effectively clean dentures and reduce harmful bacteria and fungi.
Failure to Provide Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, leading to a fall and subsequent injury. The resident, who had a history of falls and was at high risk due to various medical conditions including osteoporosis and arthritis, required supervision and assistance for bed mobility, transfers, and toileting. Despite these needs being documented in the resident's care plan and assessments, the facility staff did not implement the necessary precautions and assistance. On the night of the incident, the resident attempted to return to bed from the bathroom without the required assistance and fell, resulting in a wrist fracture. The resident had previously called for help but did not receive the necessary support from the staff. The facility's Director of Nursing acknowledged that the staff failed to provide the supervision and assistance as outlined in the resident's care plan, which was crucial to prevent such falls. Interviews with the facility's staff, including the Director of Rehabilitation and a Certified Nursing Assistant, confirmed that the resident required supervision for mobility and toileting. The facility's policy on assisting with activities of daily living emphasized the need for appropriate support and assistance, which was not adhered to in this case, leading to the resident's fall and injury.
Failure to Secure and Return Resident's Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure for securing and returning personal belongings of a resident who was transferred to an acute hospital and did not return. The resident, who had a significant family member assigned as their representative, was admitted to the facility and later discharged to the hospital following a fall. Upon discharge, the inventory of personal effects form lacked signatures from both the resident's representative and facility staff, indicating that the personal belongings were neither returned nor accounted for. Interviews with the resident's representative and facility staff revealed that the personal belongings could not be located, and there was no documentation of their return. The facility's social service assistant and director of nursing acknowledged the oversight, confirming that the belongings should have been stored and returned according to the facility's policy. The policy, revised in March 2017, mandates that personal belongings be released to the resident or their representative, with a signed release required for such items.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement its abuse policy and procedure for a resident when it did not report the resident's injury of unknown source. The resident, who had a history of osteoporosis and other medical conditions, was found with fractures in the left third and fourth metacarpals, which were not reported to the required agencies. The facility's interdisciplinary team and attending physician deemed the injury as likely a spontaneous pathological fracture due to the resident's osteoporosis, and thus, did not report it. The resident was admitted with several diagnoses, including sequelae of cerebral infarction, vascular dementia, and osteoporosis, which required substantial assistance with mobility and personal care. The resident's quarterly MDS assessment indicated severe impairment in daily decision-making and memory problems. Despite these conditions, the facility did not report the fractures as injuries of unknown source, as required by their policy. Interviews with facility staff, including the DON and administrator, confirmed that the fractures were not reported because they were considered pathological due to osteoporosis. The facility's policy required that all injuries of unknown origin be reported to local, state, and federal agencies, but this was not followed in this case, potentially compromising resident safety.
Failure to Document and Address Abuse Allegations
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for three residents. Specifically, there was a lack of nursing documentation for allegations of abuse made by Residents 1 and 2. Resident 1 alleged that a certified nursing assistant attempted to provide care despite the resident's refusal, but there were no progress notes documenting this incident. Similarly, Resident 2 reported feeling unsafe and threatened by a licensed vocational nurse, yet there were no nursing progress notes documenting these allegations. Additionally, the facility did not have care plans addressing the abuse allegations for Residents 1, 2, and 3. Resident 3's significant family member reported that a facility employee mishandled the resident, but there was no care plan in place to address this allegation. The absence of care plans for these residents indicates a failure to systematically organize and document the necessary interventions and responses to the allegations of abuse. Interviews with the facility's medical record director and the registered nurse unit manager confirmed the lack of documentation and care plans for the abuse allegations. Both staff members acknowledged that licensed nurses should have documented the allegations and initiated care plans to address them. The facility's policies and procedures for documentation and suspected resident abuse assessment were not followed, contributing to the deficiencies in maintaining accurate records and care plans for the residents involved.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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