Sunnyview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2000 W Washington Bl, Los Angeles, California 90018
- CMS Provider Number
- 555071
- Inspections on file
- 36
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sunnyview Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic subdural hemorrhage and repeated falls experienced an unwitnessed fall when attempting to get out of bed to go to the bathroom without using the call light, resulting in contact with the floor and minor injury to the nose. Despite a Change of Condition note documenting this event, two MDS assessments indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment, and no significant error assessment was completed to correct the record. The MDS Coordinator acknowledged that the event met the facility’s definition of a fall and should have been coded as such, and the DON confirmed that facility policies requiring accurate, complete documentation of incidents and accidents were not followed.
A resident with a traumatic subdural hemorrhage, repeated falls, severe cognitive impairment, and documented need for extensive assistance with transfers had a physician’s order and care plan for continuous 1:1 sitter supervision due to frequent unassisted attempts to get out of bed. The facility’s own fall risk assessment and policy on Safety and Supervision of Residents identified the need for targeted interventions and adequate supervision. Despite this, the night-shift assignment sheet did not include a 1:1 sitter, progress notes showed no evidence of 1:1 monitoring, and no staff were present at shift change. The resident subsequently got out of bed without using the call light, fell, and sustained a bump and superficial cut to the nose, with the fall unwitnessed and no sitter documented as present.
A resident with ESRD on hemodialysis, hypertension, and a history of falls experienced prolonged waits after dialysis treatments because the facility did not ensure transportation was properly notified of post-dialysis pick-up times. On at least one occasion, dialysis records showed treatment ended mid-afternoon while the resident was not picked up until several hours later, requiring the dialysis center to arrange an Uber ride back. The resident reported that transportation frequently arrived too early, too late, or not at all, and that he had waited for hours feeling tired, weak, hungry, and ignored. Review of the resident’s dialysis/transportation flyer showed it only listed the outbound pick-up time from the facility and omitted a return pick-up time, and the SSD acknowledged this omission despite a policy stating social services must help arrange needed transportation and address transportation concerns.
Licensed nurses did not perform required weekly skin progress reports for a resident with moisture-associated skin damage (MASD), despite the resident's high risk for skin breakdown due to diabetes, immobility, incontinence, and other factors. Facility policy and the care plan called for weekly assessments, but these were not completed, as confirmed by both the treatment nurse and DON.
A resident with cognitive impairment and high fall risk experienced a fall from a wheelchair, but staff did not conduct an IDT review or update the care plan as required. After a subsequent fall from bed, staff returned the resident to bed without notifying the charge nurse or assessing for injuries, resulting in a fractured femur and hospital transfer.
A resident with cognitive impairment and multiple medical conditions was not assessed for pain after a fall when a CNA failed to notify the Charge Nurse, instead returning the resident to bed and monitoring for discomfort. The facility's policy requiring immediate reporting and documentation of incidents was not followed, resulting in a delay in pain assessment and intervention.
Three residents did not have accurate MDS assessments completed, including failure to document the use of an anti-psychotic medication, significant weight loss, and the use of an anti-coagulant. These omissions were confirmed by the MDS nurse and were inconsistent with the residents' medical records and physician orders.
A resident with multiple medical conditions, who was cognitively intact and required substantial assistance with ADLs, was limited to smoking only one cigarette per day at a set time by the DON, rather than being allowed to smoke at her own preference. This restriction, imposed due to the resident's wounds and weakness, was found to violate the resident's rights as outlined in the facility's policy.
A resident with dementia, bipolar disorder, and schizophrenia, who lacked decision-making capacity, was started on Depakote and risperidone without written informed consent or an IDT meeting as required by facility policy. The DON confirmed that the necessary consent forms were not signed and no IDT meeting occurred prior to medication initiation.
A resident with severe cognitive impairment and significant ADL needs was found to have curtains hanging from a bent curtain rod, resulting in a lack of privacy and a potential safety hazard. The resident expressed feeling violated due to visibility from outside, and the Maintenance Supervisor confirmed the poor condition of the curtain and rod, which did not support a homelike environment.
Two residents with limited range of motion did not receive required services: one did not receive timely quarterly joint mobility assessments to monitor changes in ROM, and another did not receive daily passive range of motion exercises as ordered by the physician. These failures were confirmed by staff and documented in facility records, in violation of facility policies and procedures.
A resident with severe cognitive impairment and multiple medical conditions continued to have a peripheral IV catheter in place two days after the completion of IV antibiotic therapy. Facility policy required immediate removal of the catheter after therapy, but this was not done, as confirmed by staff during observation and interview.
A resident with multiple medical conditions was prescribed Lyrica, a controlled medication. The facility failed to maintain accurate documentation and accounting of the drug, with discrepancies found between the destruction log, medication bubble pack, and drug record form. The DON noted that doses were given without proper documentation, and required procedures for shift handoff and medication reconciliation were not followed, resulting in uncertainty about the drug's disposition.
A resident with multiple medical conditions was prescribed Depakote for a mood disorder, and the consultant pharmacist recommended ordering valproic acid and ammonia levels to monitor medication safety. The facility did not inform the physician or act on this recommendation, and no orders for the tests were placed, contrary to facility policy requiring timely follow-up on pharmacy consultant recommendations.
A resident with severe cognitive impairment and multiple diagnoses did not receive monthly ammonia level lab tests as ordered by the physician. Review of records showed that the required tests were not completed for several months, and there was no documentation of results, despite facility policy requiring staff to arrange for such tests.
A resident with a feeding tube, identified as being at moderate risk for infection, did not receive care in accordance with enhanced barrier precautions. An LVN was observed checking the feeding tube while wearing gloves but not a gown, despite facility policy and posted signage requiring both. The LVN later acknowledged the omission and its importance in preventing infection.
A trash dumpster lid was observed open and filled with trash during a walkthrough with the Dietary Supervisor, who confirmed that dumpsters should remain closed according to facility policy. This failure to keep the dumpster lid closed was not in accordance with the facility's waste control procedures.
A resident with a history of cognitive impairment and psychiatric diagnoses, who had been refusing prescribed antipsychotic medication, physically assaulted another resident, causing serious injuries including head trauma and a suspected facial fracture. Staff were aware of the resident's medication non-compliance and escalating paranoia but did not take effective action to prevent the assault, resulting in a violation of the facility's abuse prevention policy.
A resident with schizophrenia and a history of medication non-compliance was not provided with an IDT meeting as required by their care plan. The resident refused Lithium Carbonate on multiple occasions, and the facility failed to notify the physician or document the refusals properly. The DON acknowledged the need for an IDT meeting, which was not conducted, leading to unaddressed medication refusals.
A facility failed to adhere to its infection control policy when an LVN was observed drinking cranberry juice and placing a personal cell phone on a medication cart, both actions contrary to the facility's 'Work Practices' policy. The LVN acknowledged the risk of germ spread and illness from these actions, which violated the policy prohibiting food and drink in areas of possible contamination.
A resident with schizoaffective disorder and mobility issues fell during a shower due to the absence of a specific ADL care plan for showering supervision. Despite requiring supervision, the resident was left unsupervised by a CNA, resulting in a fall. The DON acknowledged the need for a care plan, as per facility policies, to ensure proper supervision during such activities.
A facility failed to protect and account for personal belongings of two residents, leading to a deficiency. One resident's ID, Medi-Cal card, and passport were not documented or accounted for, while another resident's Bible CDs were lost. The facility did not follow its policy on inventorying and documenting personal property, nor did it investigate the complaints of missing items.
A resident with complex medical conditions received oxygen without a physician's order, leading to low oxygen saturation levels. The LVN failed to notify the physician as required by the care plan, resulting in a delay in appropriate interventions and the resident's transfer to a hospital. The facility did not adhere to its policies on changes in condition and oxygen administration.
A resident with multiple diagnoses had discrepancies in their cognitive assessment records and experienced a change in condition that was not thoroughly documented. The facility failed to maintain complete clinical records, as vital signs and a detailed account of the resident's condition change were missing from the progress notes, contrary to the facility's policy.
The facility failed to ensure call lights were within reach for three residents, potentially delaying necessary care. A resident was found unable to reach his call light, tied to a nightstand, while two others had their call lights clipped to an overhead light cord. Staff acknowledged the oversight, and the DON confirmed the importance of accessible call lights, as per facility policy.
The facility did not perform yearly competency assessments for three CNAs, as required by policy. The DSD acknowledged the oversight, which could jeopardize resident safety by not ensuring staff have the necessary skills. The DON confirmed the importance of these assessments for maintaining care standards.
The facility failed to label three tubs of ice cream with received-by and delivery dates in Freezer #5, risking the use of expired food. Additionally, a dirty apron bin was improperly placed in the dry storage area, potentially contaminating food items. These actions were against the facility's policies, as confirmed by dietary staff and the supervisor.
The facility failed to implement proper infection control measures for two residents on Enhanced Standard Precautions due to their use of gastrostomy tubes. Staff did not wear the required PPE, specifically gowns, when administering medication via g-tube, which could lead to cross-contamination and infection spread. Both residents had significant medical conditions and were dependent on staff for daily activities, necessitating strict adherence to infection control protocols.
A resident with Alzheimer's and a seizure disorder was observed using a lap buddy restraint in a wheelchair without regular evaluations or attempts to use less restrictive measures. Staff acknowledged the lack of ongoing assessments, contrary to facility policy, which required frequent reassessment and reduction of restraints.
A facility failed to resubmit a PASRR Level I screening for a resident with epilepsy, anxiety disorder, and schizophrenia after a hospital exemption, despite the resident staying over 30 days. The MDS coordinator admitted the oversight, which was against the facility's policy requiring a new PASRR submission if a resident remains longer than 30 days. This failure potentially impacted the resident's psychiatric treatment and evaluation.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizophrenia, resulting in the omission of a necessary Level 2 evaluation. The resident's records indicated a diagnosis of schizophrenia and dementia, but the screening did not reflect this, leading to the case being closed without further evaluation. The MDS coordinator acknowledged the error, which potentially prevented the resident from receiving appropriate treatment recommendations.
A facility failed to implement a bed alarm for a resident at high risk for falls, despite it being part of the care plan. The resident, with Alzheimer's and a seizure disorder, was found trying to get out of bed without the alarm. Interviews revealed staff were unaware of the care plan requirement, contrary to facility policy.
A resident's nasal cannula for oxygen therapy was found undated and improperly stored, risking contamination. The resident also lacked a physician's order for oxygen, which is required for safe administration. The facility's policy did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
A resident with cerebral infarction and contracture of the left hand was observed without prescribed splints, and the facility failed to document the resident's refusal to wear them. The RNA admitted to not documenting the refusal, and the LVN was unaware of the situation. The DON confirmed that documentation and reporting were required per facility policy.
Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment related to a resident’s health conditions, specifically falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. An H&P dated 1/10/2026 documented that the resident had the mental capacity to understand but could not make medical decisions. An MDS dated 1/14/2026 indicated severe cognitive impairment, no acute change in mental status, no hallucinations or delusions, and that the resident required maximal assistance for bed mobility, transfers, and walking ten feet in the room. This MDS also indicated the resident had not experienced any falls since admission, reentry, or the prior assessment. On 1/16/2026, a Change of Condition (COC) documented that at 8:30 a.m. the resident got out of bed without using the call light to go to the bathroom, their knees buckled, and they made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. A subsequent MDS again documented that the resident had not had any falls since admission, entry, reentry, or the prior assessment, despite the documented fall on 1/16/2026. During interviews, the MDS Coordinator acknowledged that the 1/16/2026 event met the facility’s definition of a fall (any unintentional contact with the ground), that it was unwitnessed, and that it should have been coded as a fall on the MDS and as a fall since the prior assessment, but was not. The MDS Coordinator also confirmed that no significant error assessment was completed to correct the inaccuracy. The DON stated that facility policy requires assessments and documentation to be accurate, complete, and to include events, incidents, and accidents, and that this policy was not followed when the MDS failed to reflect the resident’s fall.
Failure to Provide Ordered 1:1 Sitter Supervision Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Safety and Supervision of Residents policy, as well as the physician’s order and care plan, to provide continuous 1:1 sitter supervision for a resident at high risk for falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. A Rehab Fall Risk Assessment dated 1/9/2026 documented that the resident required extensive assistance for bed mobility and transfers, used a wheelchair without proper safety, did not use the call bell properly, did not demonstrate safety techniques during transfers, and lacked sufficient strength and posture in sitting or standing. The H&P dated 1/10/2026 indicated the resident had the mental capacity to understand but could not make medical decisions. A physician’s order dated 1/13/2026 required 1:1 monitoring every shift because the resident constantly attempted to get out of bed unassisted. The MDS dated 1/14/2026 showed severe cognitive impairment and a need for maximal assistance for transfers and ambulation in the room. The resident’s care plan, also dated 1/14/2026, identified non-compliance with unassisted transfers and risk of falls/injuries, and directed CNAs to provide a 1:1 sitter. Despite this, the nursing assignment sheet for the 11:00 p.m.–7:00 a.m. shift on 1/15/2026 did not list a 1:1 sitter for the resident’s room, and progress notes from 1/15/2026 at 11:00 p.m. through 1/16/2026 at 7:00 a.m. contained no indication that 1:1 supervision was provided. On the 7:00 a.m.–3:00 p.m. shift on 1/16/2026, the nursing assignment indicated that a CNA was assigned as a 1:1 sitter for the resident’s room. However, a Change of Condition note dated 1/16/2026 documented that at 8:30 a.m. the resident got out of bed to go to the bathroom without using the call light, his knees buckled, and he made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. The COC did not indicate that a 1:1 sitter was present or that the fall was witnessed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the resident had an order for continuous 1:1 monitoring, that no sitter was present at the end of the night shift, that the fall was unwitnessed, and that the physician’s orders and care plan for 1:1 supervision were not followed. The facility’s policy required targeted interventions, including adequate supervision, to be implemented correctly and consistently, which did not occur in this case.
Failure to Coordinate Dialysis Transportation Leading to Prolonged Post-Treatment Waits
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate coordination of transportation for a resident who required thrice-weekly hemodialysis. The resident, who had end stage renal disease requiring dialysis, hypertension, and a history of repeated falls, was admitted and re-admitted to the facility and was cognitively able to express needs and understand information. The resident used a walker or wheelchair and required substantial/maximal assistance with several ADLs. Documentation from the hemodialysis flowsheet showed that on 1/7/2026, the resident’s dialysis treatment ran from 10:48 a.m. to 2:56 p.m., but an Uber receipt from the hemodialysis center indicated the resident was not picked up until 5:29 p.m. and did not arrive back at the facility until 6 p.m. A hemodialysis social worker note stated that on that date the resident experienced long wait times after treatment, was not picked up by the arranged transportation, and the hemodialysis administrator had to assist with arranging Uber transportation back to the facility. Interviews and record review showed that the facility’s social services did not ensure that transportation pick-up times from the hemodialysis center were properly arranged or communicated. The Social Services Director (SSD) reported that the resident had ongoing problems with dialysis transportation related to insurance, including transportation arriving too early while the resident was still receiving treatment, but the SSD could not provide documentation of follow-up with the transportation agency. The resident reported that transportation during dialysis days often arrived too early, too late, or not at all, and stated he had waited three hours after dialysis for pick-up, feeling tired, weak, hungry, and ignored. The hemodialysis social worker indicated the problem could be that the facility did not inform transportation to arrange a pick-up time aligned with the end of treatment. Review of a document containing the resident’s insurance, dialysis schedule, and transportation information showed it listed only the pick-up time from the facility to the dialysis center and did not include a return pick-up time from the dialysis center. The SSD acknowledged that the flyer lacked a return pick-up time and that waiting for late or unarranged transportation would not make the resident feel good. The facility’s transportation policy stated that social services should help residents arrange needed transportation and that transportation concerns should be referred to social services.
Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
The facility failed to follow its policy and procedure regarding skin breakdown by not performing weekly skin progress reports for a resident with moisture-associated skin damage (MASD). The resident had multiple risk factors, including diabetes mellitus, generalized muscle weakness, immobility, incontinence, and a history of candidiasis, all of which increased the likelihood of skin breakdown and infection. Documentation showed that the resident was dependent for personal hygiene and had documented skin impairment, with a care plan in place to resolve skin damage and reduce infection risk through regular skin assessments and weekly body checks. Despite these interventions being outlined in the care plan and facility policies, licensed nurses did not complete the required weekly skin assessments or progress reports for the resident during the specified month. Interviews with the treatment nurse and DON confirmed that weekly assessments were not performed, and the facility's policies required such monitoring and documentation. The lack of weekly assessments meant that the resident's MASD was not regularly evaluated for changes or response to treatment, as required by facility policy.
Failure to Implement Post-Fall Care Plan and IDT Review
Penalty
Summary
The facility failed to implement its policy and procedure for comprehensive, person-centered care planning following a resident's fall. After a non-verbal, bedbound resident with multiple diagnoses, including right knee osteoarthritis, hypertension, and ataxia, slid out of a wheelchair and onto the floor, the facility did not conduct an Interdisciplinary Team (IDT) meeting or document a post-fall care plan. The resident was identified as high risk for falls, and the facility's policy required measurable objectives and timetables to be developed and implemented after such incidents. However, there was no evidence of an IDT meeting or updated care plan in the resident's records after the initial fall. Subsequently, the same resident experienced another fall, sliding out of bed and onto the floor. Staff returned the resident to bed without notifying the charge nurse or supervisor and without a qualified staff member assessing for injuries. This resulted in the resident sustaining a fractured femur, enduring hours of pain, and requiring transfer to a general acute care hospital. Interviews with facility staff confirmed that required documentation and care planning were not completed after the initial fall, and the lack of these actions may have jeopardized the resident's safety.
Failure to Assess Pain After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with right knee osteoarthritis, hypertension, and ataxia was not assessed for pain following a fall. The resident, who had cognitive impairment and required substantial assistance with daily activities, was found on the floor by a CNA after a loud noise was heard. The CNA, noting the resident was nonverbal but nodded to indicate she was okay, did not notify the Charge Nurse of the fall due to nervousness and the presence of a recertification survey. Instead, the CNA returned the resident to bed and monitored for pain or discomfort without further assessment. A review of the resident's records indicated that, during a change of condition assessment, the resident exhibited facial grimacing and right leg pain when moved, but was unable to verbalize pain. The facility's policy required that all incidents or accidents be reported to the Charge Nurse and documented immediately, with the Charge Nurse responsible for the completeness and accuracy of the report. However, this protocol was not followed, resulting in a delay in pain assessment and intervention for the resident.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with diagnoses including paranoid schizophrenia and psychosis, the MDS did not reflect the administration of risperidone, an anti-psychotic medication, despite physician orders and documentation indicating its use. The MDS nurse confirmed that the anti-psychotic drug section was not properly marked, which was inconsistent with the resident's medication records. Another resident, diagnosed with congestive heart failure, anemia, and psychosis, experienced significant weight loss over a one-month period, as documented in the weights and vitals summary. However, the MDS assessment failed to code this weight loss under the appropriate section, despite clear evidence from the resident's records. The MDS nurse acknowledged the error, noting that the assessment should have indicated the resident was on a physician-prescribed weight-loss regimen due to the documented weight loss. A third resident, with diagnoses including hypertension, schizoaffective disorder, and atrial fibrillation, was prescribed Dabigatran Etexilate Mesylate, an anti-coagulant, as indicated in the order summary and care plan. The MDS assessment, however, did not document the use of this anti-coagulant. The MDS nurse confirmed that the medication should have been coded accordingly. Facility policies reviewed indicated that staff completing any portion of the MDS are required to certify the accuracy of the information provided.
Resident's Right to Smoke Restricted Against Policy
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to self-determination regarding smoking preferences. The resident, who was admitted with cellulitis of the right lower limb, sepsis, bacteremia, and an open wound to the right thigh, was found to be cognitively intact and required substantial assistance with activities of daily living. Despite this, the resident reported being limited to smoking only one cigarette per day at a designated time, as directed by the DON, rather than being allowed to smoke at her own preference. The resident expressed frustration and anger over this restriction. The DON confirmed that the limitation was imposed due to the resident's medical condition upon admission, specifically her weakness and wounds, and stated that the restriction would remain until her wounds began to heal. The facility's policy on resident rights, however, guarantees the right to exercise personal preferences, including smoking. The survey found that this practice resulted in a violation of the resident's rights as outlined in the facility's policy and federal and state regulations.
Failure to Obtain Informed Consent and IDT Review Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain written informed consent and conduct an interdisciplinary team (IDT) meeting prior to initiating psychotropic medications for a resident diagnosed with dementia, bipolar disorder, and schizophrenia. The resident was determined to lack capacity to make decisions, as documented in the history and physical and the Minimum Data Assessment, which indicated severely impaired cognitive skills and total dependence on staff for daily care. Despite this, the resident was started on Depakote and risperidone based on physician telephone orders, and these medications were administered as documented in the medication administration records. During review, the Director of Nursing confirmed that informed consent forms for the psychotropic medications were not signed by the IDT and that no IDT meeting minutes were completed before the medications were initiated. The facility's policy required an IDT review and a bioethics meeting involving the resident's physician, another physician, and the IDT prior to administering psychoactive medications to residents lacking capacity, except in emergencies. These steps were not followed in this case.
Broken Curtain Rod Compromises Resident Privacy and Safety
Penalty
Summary
A deficiency was identified when a resident's room was found to have curtains hanging from a bent curtain rod, which had been in disrepair for some time. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported feeling violated due to the lack of privacy, as people outside could see into the room. The observation was made during a concurrent interview and inspection, confirming the ongoing issue with the room's curtains and curtain rod. The Maintenance Supervisor acknowledged responsibility for repairing equipment and furnishings and confirmed that the curtain and curtain rod in the resident's room were not in good condition and did not promote a homelike environment. The facility's policy on maintaining a homelike environment was reviewed, which emphasized the importance of staff and management maximizing characteristics that reflect a personalized, homelike setting. The deficiency resulted in a violation of the resident's right to privacy and a potential safety hazard.
Failure to Provide Timely ROM Assessments and Daily PROM Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. For one resident with diagnoses including bipolar disorder, dementia, and mobility abnormalities, the facility did not complete timely quarterly Joint Mobility Screenings/Assessments as required. The last assessment was completed at admission, and subsequent quarterly screenings were missed, which are necessary to monitor changes in ROM and determine if therapy services are needed. This omission was confirmed by both the Minimum Data Set Nurse and the Director of Rehab, who acknowledged that the screenings were not performed according to schedule. For another resident with diagnoses including dysphagia, seizures, and hemiplegia, the facility failed to ensure that passive range of motion (PROM) exercises were provided daily as ordered by the physician. Review of the RNA task forms showed that PROM was not performed every day, despite a physician's order for daily exercises. Both the Licensed Vocational Nurse and the Restorative Nurse Assistant confirmed that PROM was not completed as required, and acknowledged the importance of these exercises in preventing contractures and maintaining function. Facility policies and procedures reviewed indicated that residents with limited ROM should receive regular assessments and services to prevent further decline. The job description for the Restorative Nurse Assistant also specified the responsibility to assist residents with ROM exercises as ordered. The failure to follow these protocols resulted in missed opportunities to monitor and maintain the residents' joint mobility.
Failure to Remove Peripheral IV Catheter After Completion of Therapy
Penalty
Summary
A peripheral intravenous (IV) catheter was not removed from a resident after the completion of IV antibiotic therapy. The resident, who had diagnoses including urinary tract infection, dementia, and type 2 diabetes mellitus, was severely cognitively impaired and totally dependent on staff for daily care. According to the resident's medication administration records, the last dose of IV ceftriaxone was administered on 6/1/2025 at 4:30 p.m. On 6/3/2025, during an observation and interview, it was noted that the resident still had an IV line in place on the left hand, despite the antibiotic therapy having ended two days prior. The Minimum Data Set Nurse confirmed that the IV should have been removed immediately after the last dose, as per facility policy, which states that peripheral catheters are to be removed at the completion of therapy.
Failure to Accurately Account for and Document Controlled Drug
Penalty
Summary
The facility failed to ensure accurate accounting and documentation of a controlled drug, Lyrica, for one resident. The resident, who had diagnoses including hypertension, seizure disorder, and hemiplegia, was admitted with the capacity to make decisions and required moderate assistance with daily activities. Upon review, discrepancies were found in the documentation and physical count of Lyrica pills. The Controlled Medication Destruction Log indicated that 28 pills were turned in for destruction, but there was no signature to confirm receipt. The Director of Nursing (DON) did not sign the form due to an incorrect drug count, and the medication bubble pack showed 28 pills remaining, while the controlled drug record form indicated 30 pills. The DON stated that the nurse administered doses without documenting them and that proper handoff and drug count procedures during shift changes were not followed. Further review and interviews confirmed that the documentation did not accurately reflect the location or disposition of the controlled drug, and the process for destruction and reconciliation was incomplete. Facility policies required that controlled substances be reconciled at various points, including administration and shift changes, and that both the administering nurse and a witness sign off on the destruction of medications. The Licensed Vocational Nurse job description also required timely and accurate documentation of medication administration, which was not adhered to in this instance.
Failure to Act on Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to ensure that a consultant pharmacist's recommendation to consider ordering valproic acid and ammonia levels for a resident was acknowledged and acted upon. The resident in question had diagnoses including congestive heart failure, anemia, and psychosis, and was prescribed Depakote Delayed Release for mood disorder. The consultant pharmacist documented a recommendation in the Medication Regimen Review for the physician to consider ordering these laboratory tests to monitor the therapeutic blood level of the medication. However, the facility did not inform the resident's physician of this recommendation, and no orders for the tests were placed. The Director of Nursing confirmed that the facility's policy requires pharmacy consultant recommendations to be addressed within 14 days and that the purpose of the recommended tests was to ensure the medication was safe to administer. The facility's policy also states that recommendations should be acted upon and documented by staff or the prescriber, with the physician either accepting and acting on the suggestion or providing an explanation for disagreement. In this case, there was no documentation of action or physician response regarding the pharmacist's recommendation.
Failure to Complete Ordered Monthly Ammonia Level Lab Tests
Penalty
Summary
The facility failed to ensure that a laboratory test to check ammonia levels was completed monthly as ordered by the physician for one resident. The resident, who was admitted with diagnoses including bipolar disorder, dementia, and gait abnormalities, was determined to lack the mental capacity to make decisions and had severely impaired cognitive skills, requiring substantial assistance with daily activities. A physician's telephone order was placed for monthly ammonia level checks, but a review of the clinical records revealed that these tests were not completed for the months of March, April, and May. There was no documentation of the laboratory results for these months, and the Minimum Data Set Nurse confirmed that the tests had not been performed and results were unavailable. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician. However, the required monthly ammonia level tests were not conducted, and there was no evidence in the records to indicate that the orders were followed. The Minimum Data Set Nurse acknowledged the omission and stated the importance of monitoring ammonia levels for the resident's medical management.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
A deficiency occurred when staff failed to implement enhanced barrier precautions (EBP) during the care of a resident with a feeding tube. The resident, who had diagnoses including hypertension, dysphagia, and malnutrition, was dependent on staff for activities of daily living and was identified as being at moderate risk for infection related to his feeding tube. The resident's care plan and facility policy both required the use of gloves and a gown when providing care involving the feeding tube. During an observation, a Licensed Vocational Nurse (LVN) was seen applying gloves but not a gown while checking the resident's feeding tube residual. The EBP signage at the resident's room and bed clearly indicated the need for both gloves and a gown. In an interview, the LVN acknowledged that EBP should have been followed and admitted to forgetting to wear a gown, which she recognized put the resident at risk for infection. The facility's policy confirmed that gown and gloves are required for such care activities.
Failure to Keep Dumpster Lids Closed
Penalty
Summary
During an observation with the Dietary Supervisor, one of two trash dumpster lids was found open and filled with trash. The Dietary Supervisor confirmed that all dumpsters were supposed to remain closed and acknowledged that leaving the lid open could lead to pest and vermin infestation. A review of the facility's waste control and disposal policy indicated that trash bins should be covered at all times.
Failure to Prevent Resident-on-Resident Physical Abuse Due to Inadequate Implementation of Abuse Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding the identification and prevention of abuse, resulting in a serious incident involving two residents. One resident, with a history of hypertension, bilateral hearing loss, type 2 diabetes, and hypercalcemia, and who was cognitively intact but required assistance with activities of daily living, was physically assaulted by another resident. The assault occurred after staff heard a loud noise and discovered the resident on the floor, being kicked and stomped on the head by another resident. The injured resident sustained significant injuries, including swelling to the forehead, a suspected zygomatic arch fracture, traumatic injury to the right ear and temple, temporary unconsciousness, and bleeding, necessitating transfer to an acute care hospital for treatment and subsequent readmission to the facility. The resident who committed the assault had diagnoses including paranoid schizophrenia, mood affective disorder, hypertension, and type 2 diabetes, and was noted to have severely impaired cognitive skills but was independent with activities of daily living. This resident had a care plan addressing non-compliance with treatment, specifically refusal of prescribed antipsychotic medication (Haldol), which was documented as refused daily for over two weeks prior to the incident. Staff interviews confirmed that the resident's refusal of medication was known and that the risk of aggression due to non-compliance was recognized, yet the facility did not take effective action to mitigate this risk or prevent the assault. The facility's policy, which strictly prohibits any form of resident abuse, was not effectively implemented in this case. Staff were aware of the resident's escalating paranoia, delusions, and refusal of antipsychotic medication, but failed to prevent the resulting physical abuse. The incident was directly observed by multiple staff members, who confirmed the sequence of events and the severity of the injuries sustained by the assaulted resident.
Failure to Implement Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to implement a care plan for a resident who was non-compliant with medication, specifically Lithium Carbonate prescribed for paranoid schizophrenia. The resident had a history of refusing medications for two months, and the care plan required an Interdisciplinary Team (IDT) meeting to address this non-compliance. Despite the care plan's directive, the facility did not conduct an IDT meeting, nor did they document the resident's response to non-compliance or notify the physician of the medication refusals on specific dates. The resident, diagnosed with schizophrenia, suicidal ideations, and restlessness, was admitted to the facility with a history of non-compliance. The resident refused medication on multiple occasions, and progress notes indicated episodes of distress and refusal to take psychiatric medications. The Director of Nursing acknowledged that an IDT meeting should have been conducted due to the resident's non-compliance. The facility's policy required IDT involvement to address refusals, but this was not followed, resulting in the resident's continued refusal of medication not being addressed.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Work Practices,' which indicated that drinks should not be stored in areas of possible contamination. During an observation, a Licensed Vocational Nurse (LVN) was seen reviewing the computer screen on the medication cart while drinking cranberry juice. In a subsequent observation and interview, the same LVN was observed with a cup of cranberry juice and her personal cell phone ringing on top of the medication cart. The LVN acknowledged that both the juice and cell phone belonged to her and admitted awareness that she should not be drinking cranberry juice or placing her personal cell phone on the medication cart due to the risk of germ spread and potential illness. The facility's policy, dated April 2023, clearly stated that food and drink should not be stored in areas with possible contamination.
Lack of ADL Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident had a care plan for Activities of Daily Living (ADL) specific to showering, which included necessary interventions. This deficiency was identified during a review of the resident's records and interviews with staff. The resident, who was admitted with diagnoses including schizoaffective disorder, restlessness, lack of coordination, and abnormalities of gait/mobility, required supervision for showers, dressing, and personal hygiene as indicated in the Minimum Data Set (MDS). However, on a shower day, a Certified Nursing Assistant (CNA) allowed the resident to shower without direct supervision, resulting in the resident falling and sustaining an injury. The Director of Nursing (DON) confirmed that the resident should have had a care plan detailing the required supervision during showering. The facility's policies and procedures mandate the development of a comprehensive person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a specific care plan for showering supervision led to the resident not receiving the necessary care, contributing to the fall incident.
Failure to Protect and Account for Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure the protection and accountability of personal belongings for two residents, leading to a deficiency in maintaining a safe and homelike environment. Resident 1's identification card, Medi-Cal card, and passport were not documented on the resident's Inventory List, despite being submitted to the Social Services Director (SSD) by the resident's brother. The Business Office Manager (BOM) claimed not to have received these items, and the SSD admitted to not updating the Inventory List. This oversight resulted in the resident's personal documents being unaccounted for when the resident's representative received an envelope missing these items. Additionally, the facility did not prevent the loss or theft of Resident 3's personal belongings, specifically 20 Compact Discs (CDs) and a CD player. Resident 3, who is blind, reported the loss of her Bible CDs to the SSD and an unnamed supervisor, but the issue was not addressed. The Director of Nursing (DON) was unaware of the missing CDs and acknowledged the importance of these items for Resident 3's well-being due to her visual impairment. The facility's Policy and Procedure on Personal Property, which mandates the inventory and documentation of residents' belongings upon admission and as necessary, was not followed. The policy also requires prompt investigation of any complaints regarding misappropriation or mistreatment of resident property, which was not conducted in these cases. This failure to adhere to established procedures contributed to the deficiency in safeguarding residents' personal belongings.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for oxygen administration, which led to the resident receiving oxygen without proper authorization. The resident, who had a history of complex medical conditions including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive, was admitted without an order for oxygen. On a specific date, the resident experienced low oxygen saturation levels of 79%-81% while on 2 liters of oxygen per minute, yet the physician was not notified to obtain the necessary orders for oxygen administration. The Licensed Vocational Nurse (LVN) on duty did not follow the facility's policy to notify the physician of the resident's change in condition, as indicated in the care plan. The Director of Nursing (DON) confirmed that the care plan required prompt notification of the medical doctor for respiratory distress symptoms, which was not done. The facility's policy and procedure for changes in a resident's condition and oxygen administration were not adhered to, resulting in a delay in receiving appropriate interventions from the physician, ultimately leading to the resident's transfer to a general acute care hospital.
Incomplete Clinical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, which is necessary for providing appropriate care. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive. A discrepancy was noted between the resident's History and Physical (H&P) and the Minimum Data Set (MDS) regarding the resident's cognitive ability and decision-making capacity. The H&P did not indicate the resident's capacity to understand and make decisions, while the MDS showed impaired cognitive ability and dependence on staff for activities of daily living and mobility. On a specific date, the resident experienced shortness of breath, and vital signs were taken but not documented in the progress notes by the Licensed Vocational Nurse (LVN). The Director of Nursing (DON) confirmed that the progress notes were incomplete, lacking a thorough account of the assessment, interventions, and physician notification of the change in the resident's condition. The facility's policy and procedure for changes in a resident's condition or status required detailed observations and documentation, which were not followed in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three residents, leading to a potential delay in obtaining necessary care. Resident 65 was observed in his room, unable to reach his call light, which was tied to the nightstand. Despite being awake and alert, Resident 65 had to resort to pressing the TV remote control and shouting for help. The resident's medical history included cerebral infarction, contracture of the left hand, and major depression, and he was dependent on staff for activities of daily living. A CNA admitted to forgetting to check the call light during rounds, acknowledging the risk of falls if the call light was not accessible. In another instance, the call lights for two residents, Resident 43 and Resident 72, were found clipped to a string on the overhead light above their beds, out of reach. Resident 43 had a history of type 2 diabetes, anxiety disorder, and schizophrenia, and required supervision for daily activities. Resident 72 had dementia, anxiety disorder, and chronic kidney disease, and also required assistance for daily living activities. A CNA confirmed that the call lights should not have been placed on the overhead light cord and emphasized the importance of having them within reach for emergencies. The Director of Nursing confirmed that call lights should always be within reach to prevent potential harm to residents. The facility's policy on call lights stated that staff should ensure call lights are accessible to residents in their rooms or when on the toilet. The failure to adhere to this policy resulted in a deficiency that could have delayed necessary care and services for the affected residents.
Failure to Conduct Yearly Competency Assessments for CNAs
Penalty
Summary
The facility failed to ensure that competency assessment skills were performed yearly for three out of five randomly selected Certified Nursing Assistants (CNAs). During an interview and record review with the Director of Staff Development (DSD), it was found that CNAs 2, 3, and 5 did not have their competency assessments completed on an annual basis. The DSD acknowledged that these assessments should be conducted upon hire and then yearly, and she was responsible for completing them. The lack of these assessments could potentially jeopardize resident health and safety, as it would prevent the facility from assessing the necessary skills to provide nursing services. The Director of Nursing (DON) confirmed that all nursing staff should have current competency assessments to ensure they can provide the standard of care and practice within regulations. The facility's policy and procedure, titled 'Sufficient and Competent Nursing Staffing,' revised in August 2022, indicated that the facility is required to provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to care for all residents in accordance with their care plans and the facility assessment. The failure to perform these assessments as per policy could lead to a deficiency in providing adequate care to residents.
Deficiencies in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as maintaining cleanliness in the kitchen area. During an observation, three tubs of ice cream in Freezer #5 were found without received-by and delivery dates. This oversight was confirmed by Dietary staff, who acknowledged that the tubs should have been dated to prevent the risk of serving expired food, which could potentially cause illness among residents. The Dietary Supervisor also confirmed that all food items should be labeled with appropriate dates to avoid possible contamination and foodborne illnesses. Additionally, a dirty apron bin was observed in the dry storage area of the kitchen, which is against the facility's policy. The presence of the dirty apron bin in the dry storage area was acknowledged by the Dietary staff and the Dietary Supervisor, who stated that it could lead to contamination of food items stored in that area. The facility's policy requires that storage areas be clean, dry, and well-ventilated, and that all items in refrigerators and freezers be properly covered, dated, and labeled.
Failure to Implement Infection Control Measures for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, identified as Residents 15 and 24, who were on Enhanced Standard Precautions (ESP) due to their use of gastrostomy tubes (g-tubes). Staff did not wear the required Personal Protective Equipment (PPE), specifically gowns, when administering medication via g-tube to these residents. This oversight was observed during a survey, and it was noted that the lack of PPE use could lead to cross-contamination and the spread of infections, putting other residents at risk. Resident 15 had a history of peripheral vascular disease, type 2 diabetes mellitus, and heart failure, and was assessed to rarely or never understand others, being dependent on staff for activities of daily living. Similarly, Resident 24 had diagnoses including cerebral infarction, acute kidney failure, and type 2 diabetes mellitus, and was also assessed to rarely or never understand others, requiring staff assistance for daily activities. Both residents were on ESP due to their g-tubes, and the facility's policy required the use of gowns and gloves during high-contact care activities, which was not adhered to by the staff.
Failure to Regularly Evaluate and Reduce Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 69, was free from the use of physical restraints unless necessary for medical treatment. Resident 69, who was admitted with Alzheimer's disease and a seizure disorder, was observed using a lap buddy restraint in a wheelchair. The resident's cognitive skills were severely impaired, and the restraint was reportedly used for safety due to involuntary movements. However, the facility did not conduct regular evaluations or attempt less restrictive measures as required. The last physical restraint assessment for Resident 69 was conducted several months prior, and no ongoing quarterly assessments were performed. During interviews, staff members, including an LVN and the MDS coordinator, acknowledged the lack of regular assessments and attempts to use less restrictive devices. The facility's policy required the interdisciplinary team to evaluate restraint measures and make recommendations, but this process was not followed. The Director of Nursing confirmed that physical restraints should not be permanent and should be reassessed frequently. The failure to conduct regular evaluations and explore less restrictive options placed Resident 69 at risk for unnecessary prolonged use of restraints.
Failure to Resubmit PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I screening was re-submitted for a resident after a hospital exemption, despite the resident staying in the facility for more than 30 days. This oversight was identified during an interview and record review, where it was noted that the resident, who had diagnoses including epilepsy, anxiety disorder, and schizophrenia, did not have the necessary PASRR Level II evaluation and determination completed. The resident was dependent on staff for activities of daily living, and the lack of a timely PASRR submission had the potential to impact the psychiatric level of treatment and evaluation the resident received. The Minimum Data Set (MDS) coordinator acknowledged that the PASRR should have been resubmitted on the 31st day of the resident's stay, as per the Department of Health Care Services Letter. The facility's policy indicated that a new Level I PASRR should be submitted if the pre-admission screening was exempted for fewer than 30 days and the resident remained at the facility longer than 30 days. The Director of Nursing confirmed that the PASRR is essential for assessing the services a resident may need. The failure to resubmit the PASRR was a deviation from the facility's policy and procedure, potentially affecting the resident's access to necessary services.
Failure to Accurately Complete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident diagnosed with schizophrenia. The resident, who was originally admitted and later readmitted to the facility, had a documented diagnosis of schizophrenia and dementia. Despite this, the PASRR Level 1 screening did not reflect the resident's schizophrenia diagnosis, leading to the case being closed without a Level 2 evaluation. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set (MDS) coordinator, who acknowledged the error in the screening process. The resident's medical records, including the History and Physical (H&P) and Minimum Data Set (MDS), indicated significant cognitive and functional impairments, such as total dependence in personal care activities. The facility's policy required a new Level 1 PASRR to be submitted in case of any discrepancies, but this was not done. The failure to correctly identify the resident's mental disorder in the PASRR Level 1 screening potentially prevented the resident from receiving appropriate treatment recommendations for schizophrenia.
Failure to Implement Bed Alarm for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as high risk for falls. The resident, who was admitted with Alzheimer's disease and a seizure disorder, had severely impaired cognitive skills and required maximum assistance for daily activities. The care plan for this resident included the use of a bed alarm to alert staff when the resident attempted to get up unassisted. However, during an observation, the resident was found trying to get out of bed without a bed alarm in place, despite being on a low bed with side rails and a floor mat. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the bed alarm intervention was not implemented. The DON was unaware of the care plan requirement for a bed alarm, and the LVN confirmed that the resident was found on the floor mat without the alarm. The facility's policy on personal alarms and managing falls indicated that sensor pads should be used to alert staff to potential falls, but this was not followed for the resident in question.
Improper Storage and Use of Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident by not dating and properly storing a nasal cannula used for oxygen therapy. During an observation, an oxygen concentrator and nasal cannula were found at the resident's bedside, with the concentrator turned off and the nasal cannula undated and uncovered, exposing it to potential contamination. The Licensed Vocational Nurse (LVN) confirmed that the nasal cannula was not dated and lacked a protective covering, which is necessary to prevent contamination from room air. Additionally, the resident did not have a physician's order for oxygen therapy, which is required to administer oxygen safely. The Director of Nursing (DON) confirmed that a physician's order is necessary and that oxygen tubing should be dated and stored in a plastic bag with a label when not in use. The facility's policy on oxygen administration did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
Failure to Document Resident's Refusal of Splints
Penalty
Summary
The facility failed to document a resident's refusal to wear prescribed splints, which are external devices used to support and immobilize injuries or joints. This deficiency was identified through observation, interview, and record review. The resident, who was admitted with diagnoses including cerebral infarction and contracture of the left hand, was observed without the splints on multiple occasions. The resident's Minimum Data Set indicated dependency on staff for various activities and noted the provision of passive range of motion and splint assistance. However, the Restorative Nurse Assistant (RNA) admitted to not documenting the resident's refusal to wear the splints, which was a requirement per the facility's policy. The RNA stated that the splints were stored in the resident's drawer and acknowledged forgetting to document the refusal weekly. The Licensed Vocational Nurse (LVN) was unaware of the resident's refusal, and the Director of Nursing (DON) confirmed that the RNA should have documented the refusal and reported it to the charge nurse. A review of the facility's policy on charting and documentation emphasized the need for complete and accurate records, including details of procedures and treatments. The lack of documentation regarding the resident's refusal to wear the splints was a clear deviation from these standards.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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