Sunnyvale Post-acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunnyvale, California.
- Location
- 1291 S Bernardo Avenue, Sunnyvale, California 94087
- CMS Provider Number
- 555792
- Inspections on file
- 29
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sunnyvale Post-acute Center during CMS and state inspections, most recent first.
A resident reported to a nurse that a CNA was rough while changing another resident's incontinent brief during the night shift. Despite the report, neither the CNA nor the LVN acknowledged receiving or acting on the allegation, and the DON was not informed until contacted by surveyors. The facility did not follow its policy requiring immediate reporting of suspected abuse to the administrator and authorities.
A resident with documented bilateral sensorineural hearing loss and observed hearing impairment was incorrectly coded as having adequate hearing on the MDS assessment. Staff interviews and medical records confirmed the resident's highly impaired hearing, but the MDS Coordinator verified that the assessment did not reflect this condition.
Surveyors observed an uncovered, overflowing blue garbage bin at the back door, which was confirmed by the IP to be in violation of facility policy requiring covered and non-overflowing containers. This failure resulted in improper disposal and storage of garbage.
A resident with hypertension, hypotension, and epilepsy received Losartan Potassium without documented verification that systolic blood pressure was above 100, as required by physician order. Both the LVN and DON confirmed the absence of documentation, and the resident later experienced a seizure and low blood pressure, resulting in hospital transfer.
A resident with hemiplegia, hemiparesis, epilepsy, muscle weakness, and moderate cognitive impairment was not accurately assessed for fall risk or assistance needs. Staff failed to provide required supervision during toileting, leaving the resident alone in the bathroom, which resulted in an unwitnessed fall. Documentation and interviews confirmed that the resident needed one-person assistance, but this was not provided, and assessments did not reflect the resident's true needs.
The facility failed to maintain safe and sanitary food storage and preparation conditions. Observations included expired mighty health shakes, lack of thermometers in refrigerators, moldy onions, improperly labeled tuna salad, and unclean ice machine filters. Additionally, a grease trap was uncovered and dirty, and plastic bins were improperly stored wet. These practices violated facility policies and FDA Food Code standards.
A long-term care facility failed to follow infection control practices, including improper hand hygiene by a CNA between residents on transmission-based precautions, outdated oxygen equipment maintenance, and lack of a water management program to prevent Legionella growth. Additionally, licensed nurses did not perform hand hygiene during medication administration, and an unlabeled urinal was found in a shared bathroom, increasing the risk of cross-contamination.
The facility's dish machine failed to reach the required temperature of 120°F for proper cleaning and sanitizing, with readings between 108°F and 115°F. Despite being aware of the issue for two months, the Dietary Aide, Dietary Director, Maintenance Director, and Administrator had not resolved the problem, potentially risking foodborne illness for 97 residents. The Registered Dietitian also reported the issue a month prior, but did not verify the temperature after maintenance adjustments.
Staff at the facility failed to maintain respect and dignity for three residents by addressing them as 'mama' instead of using their names or appropriate titles. A nurse and a CNA admitted to using the term out of habit, despite the facility's policy requiring respectful communication. The residents involved had varying degrees of cognitive impairment and medical conditions.
The facility failed to maintain sufficient nursing staff levels, with DHPPD falling below the required 3.5 hours and CNA DHPPD below 2.4 hours on multiple occasions. Interviews confirmed low staffing, especially on weekends, due to staff transitions, sick calls, and vacations.
The facility failed to ensure proper medication storage and labeling, with multiple expired medications found in refrigerators and medication carts. Insulin pens lacked resident-specific labels, and controlled medications were not properly managed after resident discharge. Medications and keys were left unattended on carts, violating facility policies.
The facility failed to ensure kitchen staff competency in food and nutrition services, with issues in dish machine temperature and sanitizer testing. A dietary staff member incorrectly recorded wash temperatures, and two aides were unable to properly test sanitizer levels. These failures risked improper sanitization of dishes and surfaces, potentially exposing residents to food-borne illness.
The facility's kitchen failed to maintain an effective pest control program, as evidenced by the presence of cockroaches and debris in the ice machine's air filter. Observations and interviews revealed that pest control treatments were not conducted frequently enough, and pest activity was noted in pest control invoices. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents.
The facility failed to ensure call light devices were within reach for five residents, potentially delaying response to their needs. Residents with various medical conditions, including sepsis, Parkinson's disease, hemiplegia, and spinal stenosis, were observed unable to access their call buttons due to improper placement. CNAs confirmed these observations, acknowledging that call lights should be within easy reach, as per facility policy.
The facility did not provide the State LTC Ombudsman's contact information to residents, limiting their rights to confidentially discuss concerns. During interviews, residents reported the absence of this information, which was confirmed by the DON. The omission occurred after recent repainting, and the facility's policy indicated residents' rights to communicate with outside agencies.
The facility failed to make the most recent survey results readily accessible to residents and their families. During interviews, a resident and several others stated they did not know where to find the survey binder. An observation confirmed the binder was not visible in the lobby, and the front desk receptionist admitted it was stored in a drawer. The DON confirmed the binder should be easily accessible, as per the facility's policy on Resident Rights.
The facility did not follow its policy for advance directives and POLST forms for three residents. Sections related to advance directives were incomplete, and there was no evidence of signed directives or assistance offered. The Social Services Director confirmed these omissions, despite their role in ensuring completion and verification of such documents.
A resident's closet door in an LTC facility was broken and temporarily secured with tape, leading to an uncomfortable environment. Despite the resident's complaint, the issue was not reported to maintenance, and staff were unaware of the problem. The facility's policy requires maintenance to ensure rooms are in good repair, but this was not followed.
A resident with multiple health issues experienced a significant weight gain, but the MDS assessment inaccurately recorded this as a weight loss. The error was confirmed by the MDS Coordinator and Registered Dietitian, compromising the development of a proper care plan.
A resident with dementia and schizoaffective disorder was observed walking barefoot and shirtless in the hallway, contrary to their care plan which required supervision with ambulation and encouragement to wear appropriate clothing. The care plan also indicated the need for non-skid socks or shoes for safety. The DON confirmed these requirements were not met, highlighting a failure to implement the care plan interventions.
A facility failed to adhere to professional standards when a nurse applied a Lidocaine patch to a resident's shoulder instead of the lower back as ordered by the physician. Additionally, custom jewelry given by another resident was improperly stored in a narcotic box within a medication cart, contrary to facility policy.
A resident with a language barrier was not provided with communication aids or a baseline care plan upon admission, despite having conditions such as cerebral infarction and hemiparesis. The facility's policy required language assistance and a baseline care plan within 48 hours, but these were not implemented, affecting the resident's ability to communicate effectively.
A resident with multiple diagnoses and high fall risk experienced four falls without the facility updating their care plan or implementing new interventions. Despite the resident's falls, the facility did not revise the care plan or identify new contributing factors, leaving the resident unsupervised at times. The facility's policy required care plan revisions when conditions change, which was not followed.
A resident with morbid obesity and type 2 diabetes experienced a severe unplanned weight gain of 9.78% over three months due to the facility's failure to implement a comprehensive monitoring approach. Despite being on a cardiac diet, the resident's weight increased significantly without a care plan addressing the gain. Interviews revealed gaps in communication and follow-up, with the RD not interviewing the resident about his weight gain or food intake. The facility's policies on weight intervention and nutrition assessment were not followed, and necessary lab assessments were not conducted.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen was not turned on after being transferred to an E-tank, and no care plan was developed for their oxygen use. Another resident's room lacked an 'Oxygen in Use/No Smoking' sign, and their care plan for oxygen use was also not developed.
The facility did not post nurse staffing information in a visible and accessible location for residents and visitors. Observations revealed that the information was missing from nurse stations and was placed behind the receptionist desk, making it difficult to see. Both the front desk receptionist and the staffing coordinator confirmed the lack of visibility and acknowledged the need for better placement.
A facility failed to limit the use of a PRN psychotropic medication for a resident with depression and Alzheimer's disease. The resident's order for Lorazepam, used for anxiety, was not restricted to a 14-day period as required by policy. The DON confirmed the oversight during a review, and no rationale for extending the order was documented.
The facility did not comply with regulations by failing to post the staffing waiver approval letter where it could be easily read by visitors and residents. Observations and interviews confirmed the letter was not displayed on the facility's cork board, despite the requirement for it to be posted adjacent to the facility's license and provided to residents before admission agreements.
A resident with major depressive disorder experienced misappropriation of property when a housekeeper cashed her checks without permission. The resident was alerted by her bank and informed the facility administrator. An investigation revealed the housekeeper's involvement, leading to their arrest. The facility offered a communal safe for valuables, which the resident declined, and no other secure storage options were provided.
The facility failed to conduct thorough investigations and document outcomes for several alleged altercations between residents. Investigation summaries lacked conclusions, and a witness interview was not documented, contrary to facility policy.
A facility failed to report an alleged abuse incident involving two residents to the appropriate agencies. A resident's family member reported that another resident threw a fan at their relative, who had severe cognitive impairment. Despite being informed, the facility's staff decided not to report the incident, concluding it was not intentional. This decision violated mandated reporting requirements.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse reporting policy and procedure for one of three sampled residents. An allegation was made by a resident that a male CNA was rough when changing his roommate's incontinent brief during the night shift. The resident reported this incident to the charge nurse, who asked for more details. The resident's clinical records indicated he had a diagnosis of post-traumatic stress disorder and an intact cognitive status, as evidenced by a BIMS score of 15. Interviews with the CNA and LVN assigned to the resident on the night in question revealed that both denied any knowledge or report of the alleged rough handling. The DON confirmed that the allegation was not brought to her attention by staff and stated that, had they been notified, they would have reported it to the appropriate authorities. Review of the facility's policy indicated that any suspicion of abuse must be reported immediately to the administrator and other officials as required by law. The failure to report the allegation as per policy had the potential to compromise the resident's safety.
Inaccurate MDS Assessment of Resident's Hearing Ability
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident when the resident's hearing ability was not properly coded. During observation and interviews, the resident was noted to be hard of hearing, did not have or use a hearing aid, and required questions to be repeated multiple times before responding. Both a CNA and an LVN confirmed the resident's hearing impairment. The resident's medical record documented a diagnosis of bilateral sensorineural hearing loss. However, the MDS assessment incorrectly coded the resident's hearing as adequate instead of highly impaired, as confirmed by the MDS Coordinator during a record review. This inaccuracy was contrary to the coding instructions in the CMS RAI Manual.
Improper Disposal and Storage of Garbage
Penalty
Summary
During an observation at the back of the facility's parking area, surveyors noted an uncovered blue garbage bin that was overflowing with refuse and positioned at the back door. The infection control preventionist confirmed that the garbage was not only overflowing but also lacked a cover at the time of inspection. Review of the facility's policy and procedure on food-related garbage and rubbish disposal indicated that all garbage containers should have tight-fitting lids and must be kept covered when stored or not in continuous use. The facility failed to adhere to this policy, resulting in improper disposal and storage of garbage.
Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when the facility failed to administer medication in accordance with physician orders and professional standards of practice for a resident with diagnoses including hypertension, hypotension, and epilepsy. The physician's order specified that Losartan Potassium should be administered only if the resident's systolic blood pressure (SBP) was greater than 100. However, review of the Medication Administration Record (MAR) showed that the medication was given from 5/8/25 to 5/15/25 without documentation that the resident's blood pressure was checked and confirmed to be above the required threshold prior to administration. Both the LVN who administered the medication and the DON confirmed that there was no documentation of blood pressure being checked as required by the order. The resident experienced a change in condition on 5/15/25, including a seizure, unresponsiveness, and a recorded blood pressure of 80/54, which led to transfer to the hospital. The hospital discharge summary listed syncope and collapse as the principal diagnosis. Facility policy required that vital signs be checked and verified prior to medication administration when necessary, but this was not documented in the resident's records during the relevant period.
Failure to Accurately Assess and Supervise Resident Leads to Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, hemiparesis following a stroke, epilepsy, muscle weakness, and difficulty walking, was not accurately assessed for fall risk and required assistance levels. The resident's assessments, including the Fall Risk Observation/Assessment and Admission/readmission Evaluation/Assessment, did not accurately reflect the resident's need for assistance with ambulation and toileting. Documentation and interviews confirmed that the resident required at least one-person assistance for transfers and toileting, and had moderate cognitive impairment. Despite these needs, staff failed to provide adequate supervision and assistance during toileting. A CNA assisted the resident into the bathroom but left the resident unsupervised after being asked to close the door and then left to answer another call light. The resident was subsequently found on the bathroom floor after an unwitnessed fall, stating that they had slid down from the commode. Interviews with the DON and DOR confirmed that the resident required one-person assistance and that staff should have remained nearby to provide the necessary support. Record reviews and staff interviews further revealed that the licensed nurse did not accurately assess the resident's fall risk or assistance needs, and seizure precautions were not properly noted. Facility policies required that residents unable to perform activities of daily living independently receive necessary services, and that fall risk factors be evaluated to minimize risk. These failures resulted in the resident experiencing an unwitnessed fall while unsupervised during toileting.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage and preparation, as evidenced by several observations during a survey. Two bins containing thawed mighty health shakes were found in a reach-in refrigerator with expired dates, and the Dietary Director (DD) acknowledged that the shakes were stored past their use date, which could lower their nutritional value. Additionally, the facility lacked internal thermometers in a three-door reach-in refrigerator and a walk-in freezer, which are necessary to monitor and maintain adequate food temperatures. Further deficiencies were noted in the handling and storage of food items. A large yellow onion with mold-like spots was found in the dry storage room, and a plastic container of tuna salad in the walk-in refrigerator lacked a use-by date. The DD confirmed the onion was rotten, and the Dietary Aide (DA) explained the tuna salad preparation process but did not record a cool-down temperature, which is required for safety. The ice machine's air filter was covered with debris, and the water filters for the ice machine and coffee maker were expired, indicating a failure to follow manufacturer's maintenance guidelines. Additional issues included a medium grease trap floor hole near the food production area that was uncovered and dirty, and ten large plastic bins were stacked wet in the dish machine area. These practices were contrary to the facility's policies and the FDA Food Code, which require clean and dry storage conditions. Interviews with the Administrator and Registered Dietitian revealed expectations for proper task completion, but the observed conditions indicated a lack of adherence to these standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by multiple observations and interviews. A certified nursing assistant (CNA) did not wash hands between providing care to two residents on transmission-based precautions, which are intended to prevent the spread of germs. The CNA removed personal protective equipment after caring for one resident and only used hand sanitizer before attending to the next resident, despite both residents being infected with Methicillin-resistant Staphylococcus aureus (MRSA). This was confirmed by the director of nursing (DON) and the infection preventionist (IP), who acknowledged the necessity of handwashing between residents on such precautions. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment. A resident's nasal cannula oxygen tubing was not changed after seven days as required, and another resident's oxygen concentrator filter was found with a grayish substance buildup, indicating it had not been changed weekly as per facility policy. The staff, including registered nurses and the DON, confirmed these oversights, acknowledging that the equipment should have been maintained according to the established schedule. The facility also lacked a comprehensive water management program to prevent the growth of Legionella bacteria, which can cause illness. Interviews with the maintenance directors and the IP revealed that they were unaware of the requirements for such a program, and no system was in place to monitor or control potential bacterial growth in the water supply. Furthermore, licensed nurses failed to perform hand hygiene before and after glove use during medication administration, and an unlabeled urinal was found in a shared bathroom, both of which could contribute to cross-contamination and infection spread.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dish machine consistently provided accurate temperatures for cleaning and sanitizing dishes according to the manufacturer's guidelines. During an initial kitchen tour, it was observed that the dish machine did not reach the required temperature of 120°F for both the wash and rinse cycles, with temperatures recorded between 108°F and 115°F. Dietary Aide S confirmed these readings and stated that the machine had not been reaching the required temperature for the past two months, despite notifying the dietary manager and having the machine inspected by a technician. The Dietary Director, Maintenance Director, and Administrator were all aware of the issue, with the Maintenance Director having contacted the manufacturer to request a heat booster to increase the water temperature. The Registered Dietitian also noticed the malfunction a month prior and reported it to maintenance, but did not verify the temperature after adjustments were made. The facility's policy and the FDA Food Code require equipment to be maintained in proper working order, which was not adhered to in this case, potentially risking foodborne illness for the 97 residents consuming food at the facility.
Inappropriate Addressing of Residents by Staff
Penalty
Summary
The facility failed to maintain respect and dignity for three residents, identified as Resident 83, 91, and 249, by addressing them inappropriately. Registered Nurse F referred to Residents 83 and 91 as 'mama' during interactions. Resident 83, who has severe cognitive impairment due to dementia, was addressed as 'mama' by RN F while being redirected from entering another resident's room. Similarly, Resident 91, who has a moderate cognitive impairment and a history of cancer, was also addressed as 'mama' by RN F during a conversation in their room. RN F admitted to using the term 'mama' out of habit, acknowledging that residents should be addressed by their first names or with titles like Mister or Miss to maintain dignity. Certified Nursing Assistant G also addressed Resident 249 as 'mama' during an interaction. Resident 249, who has a moderate cognitive impairment due to Parkinson's disease and schizoaffective disorder, was addressed in this manner twice by CNA G. The Director of Nursing confirmed that staff should not use terms like 'mama' or 'honey' and should instead address residents by their preferred names. The facility's policy on dignity emphasizes that residents should be spoken to respectfully and addressed by their name of choice, not by labels or room numbers.
Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis, as evidenced by the Staffing Data Report submitted to CMS. The document review of the Census and Direct Care Services Hours Per Patient Day (DHPPD) from April through July 2024 revealed multiple dates where the actual DHPPD fell below the required 3.5 hours. Additionally, the certified nursing assistant (CNA) DHPPD was below the required 2.4 hours on several occasions. Interviews with the staffing coordinator, director of staff development, and director of nursing confirmed the low staffing levels, particularly on weekends during April to June 2024, due to staff transitions, sick calls, and vacations. The All Facilities Letter (AFL) 21-11 mandates a minimum of 3.5 DHPPD, with 2.4 hours provided by CNAs, as a requirement for skilled nursing facilities. The facility's waiver from the California Department of Public Health, valid from July 1, 2024, to June 30, 2025, also stipulated the maintenance of this minimum staffing level. Despite these requirements, the facility's staffing levels were insufficient, potentially affecting residents' care, health, and psychosocial well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as observed during a survey. Multiple expired medications were found in medication refrigerators, including latanoprost eye solution, Augmentin, vancomycin, and Pneumovax 23, with expiration dates ranging from June to October 2024. Additionally, expired Lorazepam oral concentrate, Amoxicillin and Clavulanate potassium, and a probiotic supplement were identified. The Nurse Supervisor confirmed these observations, acknowledging that expired items should be discarded to prevent medical errors. Further inspection revealed two insulin pens in a medication refrigerator that lacked resident-specific labeling. The Nurse Supervisor confirmed that these pens should have been labeled with the resident's name and room number. An expired oral inhaler was also found in the active stock of a medication room, which the Nurse Supervisor confirmed should have been discarded. During a medication cart inspection, expired and discontinued controlled medications, including morphine, Hydro/Apap, and oxycodone, were found. These medications were associated with residents who had been discharged, and the Registered Nurse acknowledged that they should have been given to the Director of Nursing. Additionally, medication and keys were left unattended on medication carts, posing a risk of unauthorized access. The facility's policies and procedures, dated 2001, were reviewed, indicating that medications should be labeled, expired drugs destroyed, and medication compartments locked when not in use.
Deficiency in Kitchen Staff Competency and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. A dietary staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine or maintaining the correct wash temperature. The dish machine, identified as a low-temperature model, was observed to have a wash temperature ranging from 110 to 115 degrees Fahrenheit, below the required 120 degrees Fahrenheit. Despite this, the Dietary Aide recorded the wash temperature as 120 degrees Fahrenheit on the log sheet. The Dietary Director and Maintenance Director were aware of the issue, and the facility was waiting for a water heater booster to address the problem. The chlorine sanitizer level was also incorrectly assessed, with the Dietary Aide stating it should be 100-200 ppm, while the correct level should have been 50 ppm. Additionally, two Dietary Aides did not know how to properly test the sanitizer in the red bucket. One Dietary Aide admitted to not knowing how to test the sanitizer, possibly due to missing an in-service training. Another Dietary Aide incorrectly tested the sanitizer strength, reading it as 300-400 ppm, while the correct concentration should have been 150-400 ppm according to the manufacturer's label. The Dietary Director and Registered Dietitian acknowledged the staff's lack of knowledge in correctly testing the sanitizer solution. The facility's policies and job descriptions were reviewed, indicating that the kitchen staff should observe water temperatures during dishwashing cycles and ensure proper sanitization of work surfaces. The manufacturer's operating requirements for the dishwasher and sanitizer were also reviewed, highlighting the discrepancies in the staff's practices. These failures in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces, exposing residents to food-borne illness.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the Food and Nutrition Services Department, specifically in the kitchen area. During an initial kitchen tour, a brown bug resembling a cockroach was observed moving across the floor in front of the tray line food preparation area. The kitchen staff member acknowledged seeing such bugs occasionally. The facility's Administrator mentioned that the kitchen was due for a quarterly fogging treatment to address pests like roaches. However, the Pest Company Technician indicated that only a spray-out treatment had been conducted a couple of months prior, and no fumigation treatment was performed. The technician suggested that more frequent treatments might be necessary. Further observations revealed that the ice machine's air filter screen was covered with black and gray debris, along with a dead brown bug resembling a cockroach. The Dietary Director and Maintenance Director confirmed the presence of debris and the dead bug, acknowledging that pests should not be present inside the ice machine. A review of pest control invoices from October 2023 through September 2024 showed findings of insect and rodent activity, with specific mentions of German roach activity in July and August 2024. The invoices included recommendations to seal cracks and crevices, empty trash regularly, and maintain cleanliness to prevent pest activity. The facility's pest control policy, dated May 2008, stated that an ongoing pest control program should be maintained to keep the building free of insects and rodents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call light devices were within reach for five residents, potentially delaying response to their needs. Resident 250, admitted with sepsis, pneumonia, and diabetes mellitus, was observed unable to reach his call button, which was lodged between the mattress and headboard. Similarly, Resident 249, with Parkinson's disease and schizoaffective disorder, had her call button placed on the opposite side of her bed, out of reach, as confirmed by a certified nursing assistant (CNA). Resident 39, suffering from hemiplegia and vascular dementia, was found with her call button attached to a bedside drawer handle, making it inaccessible. A CNA confirmed this improper placement. Resident 25, diagnosed with hemiplegia and PTSD, had her call button on the floor, which she could not locate. This was also confirmed by a CNA, who acknowledged the button should be within reach. Resident 48, with spinal stenosis, was unable to reach her call light placed on an oxygen concentrator. A CNA confirmed the observation and acknowledged the call light should be accessible. The facility's policy mandates that call lights be within easy reach when residents are in bed or confined to a chair, which was not adhered to in these cases.
Ombudsman Contact Information Not Provided to Residents
Penalty
Summary
The facility failed to provide the State Long-Term Care Ombudsman's contact information to all residents, which limited their rights to have a confidential avenue to discuss concerns and resolve issues. During a group interview, one sampled resident and six non-sampled residents reported that they did not have access to the Ombudsman's contact information within the facility. A concurrent tour and interview with the Director of Nursing (DON) confirmed the absence of this information in any part of the facility. The DON explained that the omission occurred because the facility had recently been repainted, and they forgot to replace the Ombudsman contact information on the walls. The facility's undated policy and procedure on Resident Rights indicated that residents have the right to communicate with outside agencies, including the state long-term care ombudsman.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were readily accessible to residents, family members, and legal representatives. During a group interview, one sampled resident and six non-sampled residents reported that they were unaware of where to find the survey binder containing the facility's survey results. An observation in the facility's lobby area confirmed that the survey binder was not visible. A follow-up interview with the front desk receptionist revealed that the survey binder was stored inside a drawer cabinet. The Director of Nursing confirmed these findings and acknowledged that the survey results binder should be placed on a table for easy access by residents and family members. The facility's policy and procedure on Resident Rights indicated that residents have the right to examine survey results, as guaranteed by Federal and State laws.
Failure to Complete Advance Directives and POLST Forms
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives (AD) and the completion of the Physician Order for Life-Sustaining Treatment (POLST) forms for three residents. Specifically, sections related to advance directives were not completed on the POLST forms for Residents 42, 16, and 26. Additionally, there was no documented evidence in the clinical records of these residents that an advance directive was signed by the resident or their responsible party, nor was there evidence that the facility offered assistance in establishing an advance directive prior to the survey period. During an interview and record review with the facility's Social Services Director (SSD), it was confirmed that the relevant sections of the POLST forms were not filled out for the three residents. The SSD acknowledged that it was the role of social services to ensure the POLST forms were completed and to verify the existence of an advance directive for each resident. The facility's policy indicated that staff should offer assistance in establishing advance directives if the resident or representative had not done so, and that copies of any executed advance directives should be maintained in the resident's medical record.
Failure to Maintain Homelike Environment Due to Unreported Maintenance Issue
Penalty
Summary
The facility failed to provide a homelike environment for Resident 69 due to a malfunctioning closet door that did not latch properly. This issue was observed during a visit to Resident 69's room, where the resident expressed dissatisfaction with the broken closet door, which had been temporarily secured with surgical tape by a housekeeper. Despite the resident's complaint to the housekeeper, no formal report was made to the maintenance department, and the issue remained unresolved. Interviews with facility staff, including the maintenance director, licensed vocational nurse, and certified nursing assistant, revealed a lack of awareness and communication regarding the broken closet door. The maintenance director confirmed that the issue was not logged in the maintenance log, which is the standard procedure for reporting repairs. The director of nursing acknowledged that staff should have reported the issue to maintenance. The facility's policy requires the maintenance department to ensure residents' rooms are in good repair, but this was not adhered to in this instance.
Inaccurate MDS Coding for Resident's Weight Gain
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident's weight gain, which compromised the ability to develop and implement a resident-centered care plan. Resident 78, who had multiple diagnoses including atrial fibrillation, Type 2 diabetes, and morbid obesity, experienced a severe weight gain of 9.78% over three months. However, the MDS assessment inaccurately recorded the resident's weight status, indicating a weight loss instead of a gain. During interviews and record reviews, it was confirmed that the MDS sections for weight gain were not coded correctly. The Minimum Data Set Coordinator and the Registered Dietitian both acknowledged the error, noting that the MDS should have reflected the resident's significant weight gain. The facility's policy requires accurate certification of the MDS, but this was not adhered to in this instance, leading to the deficiency.
Failure to Implement Care Plan Interventions for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident, identified as Resident 13, who required supervision with ambulation, encouragement to wear shirts or gowns while not in rooms, and non-skid socks or shoes while walking in the hallways. The resident, who was admitted with multiple diagnoses including unspecified dementia, schizoaffective disorder, generalized weakness, and a history of falling, was observed walking barefoot and shirtless in the hallway. This observation was confirmed by a certified nursing assistant (CNA) who stated that the resident should wear a shirt for dignity and socks or shoes for safety. The care plan for Resident 13, dated 7/11/24, indicated the need for behavior monitoring and interventions to encourage wearing a shirt or gown and ensuring the use of non-skid socks or shoes. Additionally, a care plan implemented on 4/24/24 required supervision with ambulation due to generalized weakness. During an interview, the director of nursing (DON) confirmed that the care plan required supervision for ambulation, assistance with dressing and eating, and behavior monitoring. The DON acknowledged that the resident should not pour juice from the medication cart alone and should be supervised when walking in the hallway.
Improper Medication Administration and Storage Practices
Penalty
Summary
The facility failed to provide care and service in accordance with professional standards of practice for two residents. For Resident 15, the licensed nurse did not apply a Lidocaine patch as ordered by the physician. The resident, who had a moderate cognitive impairment, was supposed to have the patch applied to his lower back for pain management. However, during a medication pass observation, the nurse applied the patch to the resident's left shoulder after the resident indicated pain in that area. The nurse later confirmed that this was against the physician's order and subsequently obtained a new order to apply the patch to the shoulder. For Resident 92, the facility improperly stored custom jewelry in a narcotic box within a medication cart. The jewelry, made by the resident and given to staff as gifts, was not accepted by the staff and was intended to be returned to the resident's family. However, the items were stored inappropriately in the narcotic box, which is meant for controlled substances. Interviews with staff revealed that the items had been stored there for several days, contrary to the facility's policy, which requires such items to be submitted to social services in a timely manner.
Failure to Provide Communication Aids and Baseline Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to provide adequate communication support for Resident 254, who had a language barrier and was unable to speak English. Despite being admitted with conditions such as cerebral infarction, hemiplegia, hemiparesis, and dysphagia, the resident's preferred language was not accommodated. Observations and interviews revealed that no communication aids were provided to the resident since admission, and staff did not utilize any aids to facilitate communication. The facility's policy required language assistance for individuals with limited English proficiency, but this was not implemented for Resident 254. Additionally, the facility did not develop a baseline care plan addressing the language barrier for Resident 254 within the required timeframe. The activities director confirmed that the baseline care plan was not developed and should have been implemented within 24 hours of admission. The responsibility for providing communication aids was shared between activities staff and nurses, but neither group ensured that the necessary aids were available to the resident. The facility's policy mandated a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not adhered to in the case of Resident 254.
Failure to Update Fall Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to update the fall care plan and provide new interventions for a resident who was at high risk of falling. This resident, identified as Resident 6, had multiple diagnoses including polyneuropathy, COPD, pulmonary fibrosis, and unspecified asthma, which contributed to their high fall risk. Despite being assessed as high risk for falls, the facility did not revise the care plan or implement new interventions after each of the resident's four falls since admission. The resident's falls were documented in the clinical records, with the first fall occurring when the resident slipped on a piece of food while attempting to walk to the bathroom. Subsequent falls involved the resident sliding down from a wheelchair or bed, with one incident resulting in a skin tear. The interdisciplinary team (IDT) noted generalized weakness and the resident's diagnoses as contributing factors but did not identify any new contributing factors or develop new interventions to prevent future falls. Observations and interviews revealed that the resident was often left unsupervised, such as being seated in front of a medication cart without footwear, and the facility's director of nursing confirmed that the fall care plan was not updated or revised after each incident. The facility's policy required that care plans be revised when a resident's condition changes or when desired outcomes are not met, but this was not adhered to in the case of Resident 6.
Failure to Monitor Resident's Unplanned Weight Gain
Penalty
Summary
The facility failed to implement a comprehensive and systematic approach to effectively monitor a resident who experienced a severe unplanned weight gain of 9.78% over three months. The resident, who had a history of morbid obesity, type 2 diabetes, and cellulitis, was not adequately assessed or monitored for nutritional intake and weight changes. Despite being on a cardiac diet with no added sodium, the resident's weight increased significantly, and there was no evidence of a care plan addressing this unintentional weight gain. Interviews with the resident and staff revealed gaps in communication and follow-up. The resident was unaware of the significant weight gain and had not discussed dietary concerns with the dietitian. The Registered Dietitian (RD) acknowledged not interviewing the resident about his weight gain or food intake, including snacks from outside the facility. The Director of Nursing (DON) confirmed that the resident was not on a physician-ordered weight gain program and that the care plan should have addressed the weight gain and external food sources. The facility's policies on weight intervention and nutrition assessment were not followed. The RD had recommended protein supplementation and a comprehensive metabolic panel (CMP) lab assessment, but there was no follow-up to ensure these recommendations were implemented. The physician was unaware of the resident's BMI exceeding 35 and had not ordered the necessary labs, which could have aided in assessing the resident's nutritional status and preventing further weight gain.
Deficiencies in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in oxygen administration. For Resident 6, who was admitted with conditions such as COPD, pulmonary fibrosis, and asthma, the oxygen was not turned on after being transferred to an E-tank. This oversight occurred when a restorative nursing assistant moved the resident to a wheelchair and connected the oxygen tubing to the E-tank, but did not ensure the oxygen was flowing at the prescribed rate of 3 liters per minute. The resident reported not receiving air for 15 minutes, and this was confirmed by RN F during an observation. Additionally, the facility did not develop a care plan for Resident 6's oxygen use, despite the resident's need for oxygen therapy due to their medical conditions. The Director of Nursing confirmed the absence of a care plan and acknowledged that it should have been developed to address the resident's oxygen needs. For Resident 10, who had diagnoses including Parkinsonism, chronic bronchitis, and COPD, the facility failed to post an 'Oxygen in Use/No Smoking' sign at the room entrance, as required by facility policy. The resident was on oxygen therapy at 2 liters per minute, but the necessary signage was missing. The Director of Nursing confirmed the oversight and also noted that a care plan for Resident 10's oxygen use was not developed, which should have included the oxygen rate ordered by the physician.
Nurse Staffing Information Not Clearly Posted
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a clearly visible and prominent place accessible to residents and visitors. During observations on multiple occasions, it was noted that nurse staffing information was not posted at nurse stations AA, BB, and CC. Additionally, the staffing information was found behind the receptionist desk in the lobby area, making it not easily visible to family members, visitors, or residents. The front desk receptionist confirmed that the information was not visible and acknowledged that it should be posted in an area visible to all. The staffing coordinator also confirmed that the information was placed behind the receptionist desk and agreed it should be more visible.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs. The resident, who was admitted with diagnoses of depression and Alzheimer's disease, had a physician order for Lorazepam to be administered as needed for anxiety. However, the order did not limit the use of Lorazepam to 14 days, as required by the facility's policy on psychotropic medication use. During an interview and record review, the Director of Nursing confirmed that the Lorazepam order for the resident was not appropriately limited to a 14-day duration, and there was no documented rationale for extending the order beyond this period.
Failure to Post Staffing Waiver Approval Letter
Penalty
Summary
The facility failed to comply with Federal and State laws and regulations by not posting the approval letter for a staffing waiver where visitors and residents could easily read it. During an observation on October 14, 2024, at 8:30 a.m., it was noted that the approval letter was not displayed on the facility's glass-covered cork board. In an interview on October 15, 2024, at 1:34 p.m., the staffing coordinator confirmed the existence of a staffing waiver. Further review and interviews with the director of nursing and the clinical consultant confirmed that the approval letter, dated July 12, 2024, was not posted as required. The letter specified that it should be posted immediately adjacent to the facility's license and that residents should be provided with a true copy of the approval letter prior to the execution of an admission agreement.
Misappropriation of Resident's Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a housekeeper cashed out the resident's check without permission. The resident, who was admitted with a diagnosis of major depressive disorder, was alerted by her bank about unauthorized check cashing. The resident kept her checks in her purse and informed the facility administrator immediately upon receiving the bank's notification. The facility was notified by the resident's daughter about the unauthorized transactions, prompting an investigation. The facility reported the issue to the police, who advised waiting for more evidence. Upon obtaining copies of the checks, the facility identified them as matching an employee's information, leading to the housekeeper's arrest. The housekeeper was not allowed to work in the facility after the issue was discovered. The facility's social service director stated that the resident was offered the option to store valuables in a secure safe at the business office, which the resident declined. No other secure storage options were provided, such as a locked cabinet at the resident's bedside. The facility's policy emphasized the right of residents to be free from exploitation and the implementation of measures to safeguard resident valuables, which were not adequately followed in this case.
Failure to Conduct Thorough Investigations and Document Outcomes
Penalty
Summary
The facility failed to conduct thorough investigations and provide conclusive reports for several alleged altercations involving residents. Specifically, the investigation summaries for altercations between Residents 7 and 8, 9 and 10, 11 and 12, and 1 and 10 did not include outcomes or conclusions about whether the facility determined if the altercations occurred. This lack of conclusive documentation was confirmed during a review with the Administrator, who acknowledged that the investigation reports lacked conclusions. Additionally, the facility did not document an interview with a witness, Resident 14, who was present during an alleged altercation between Residents 3 and 4. The Case Manager confirmed that although Resident 14 was interviewed, the interview was not documented. The facility's policy requires that witnesses to incidents be interviewed and documented, and that follow-up investigation reports provide sufficient information to describe the results of the investigation.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the appropriate agencies, including the State Survey Agency. The incident involved a resident allegedly throwing a fan at their roommate, which was reported by the family member of the affected resident to the charge nurse on duty. Despite the report, the facility did not notify the State agency, potentially compromising the safety of the residents and violating mandated reporting requirements. The incident occurred when a resident's family member reported that another resident had thrown a fan at their relative. The affected resident had a severe cognitive impairment, while the alleged perpetrator had intact cognition but was diagnosed with acute transverse myelitis, PTSD, and an unspecified mood disorder. The facility's social services director and the DON were informed of the incident, but they decided it was not reportable because the alleged perpetrator denied the action, claiming the fan fell accidentally. The facility conducted an internal investigation, which included interviews with staff and both residents. The investigation concluded that the fan was not intentionally thrown, as the alleged perpetrator was asleep and not physically capable of throwing objects. The facility's administrator, who also serves as the abuse coordinator, decided not to report the incident to the State agency, as they believed no actual abuse occurred and no harm resulted from the incident. This decision was contrary to the facility's policy and state regulations, which require reporting any suspected or alleged abuse.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
