Temecula Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Temecula, California.
- Location
- 44280 Campanula Way, Temecula, California 92592
- CMS Provider Number
- 555923
- Inspections on file
- 29
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Temecula Healthcare Center during CMS and state inspections, most recent first.
A resident with hypertensive heart disease, heart failure, and morbid obesity, who required partial/moderate assistance with multiple ADLs and mobility, was planned for discharge home with support from informal caregivers. The care team, including the CM and DOR, identified the need for home health, a caregiver, and equipment such as a bariatric FWW, wheelchair, and oxygen, and the physician ordered discharge home. However, there was no documented evidence that caregiver training on required care and ADLs was completed for the responsible party or any designated caregiver, nor that missed training was rescheduled. On the planned discharge day, staff confirmed the resident still needed assistance with daily activities, and the responsible party expressed uncertainty about being able to provide the necessary care, contrary to facility policy requiring verification of caregiver capacity for a safe discharge.
A resident with hypertensive heart disease with HF and morbid obesity was initially scheduled for discharge home, and a written Notice of Proposed Transfer/Discharge was issued reflecting that plan. Later, a physician order and discharge summary documented a change in the discharge destination to a board and care facility, but the facility did not issue a new written notice reflecting this change to the resident, the resident representative, or the Ombudsman. Interviews with the CM and DON confirmed that the process requires a new notice when the discharge plan changes and that the SSD or CM should provide and review the notice and send a copy to the Ombudsman, but there was no documentation that this occurred, contrary to facility policy requiring a new notice for significant changes such as a change in discharge destination.
Two residents were involved in a hallway altercation in which one resident alleged being choked and the other admitted to pushing the complainant away after a verbal dispute involving an LVN. Staff intervened, assessed the alleged victim, and documented the incident, including that the alleged victim reported choking and the alleged aggressor denied choking but admitted pushing. Despite staff knowledge that resident physical altercations must be reported within two hours, the incident was not reported to the SSA until the following morning, well beyond the facility policy’s definition of “immediately” (within two hours for abuse allegations), resulting in a failure to comply with required abuse reporting timeframes.
A resident with surgical aftercare needs and mental health diagnoses developed persistent loose, watery diarrhea after a clinician recommended a stool culture for C-diff, but staff instead processed only a generic stool culture and never completed the specific C-diff test. Over the following week, documentation showed ongoing diarrhea without evidence that the physician was informed the ordered C-diff test was not done or that treatment for the diarrhea was initiated. Later, the resident experienced significant weight loss and a critically elevated WBC, which was received by staff but communicated to the physician only by text, with no documented follow-up or new orders despite facility policy calling for immediate, direct notification for critical results. The resident’s condition deteriorated overnight, with hypotension, respiratory distress, and altered mental status, leading to a 911 call and transfer, after which the resident died in transit; the physician later reported not being told that the C-diff culture had not been performed and was unaware of any delay in transfer.
A nurse used a wound cleanser containing sorbitol to clean the peristomal skin of a resident with a colostomy, contrary to facility protocols and professional guidelines that require gentle cleansing with normal saline or water. The resident experienced severe pain and burning during the procedure, and staff interviews confirmed that wound cleansers should not be used for ostomy care.
A physical therapist transferred a resident with hemiplegia and Parkinson's disease using a Hoyer lift without a second staff member, contrary to facility policy and the resident's care plan, which required two-person assistance for safe transfers.
A resident with a history of stroke-related monoplegia was involved in a verbal altercation after being moved to a new room, displaying agitated behaviors and making threatening statements. The incident caused emotional distress to the new roommate, who was subsequently relocated. Despite facility policy requiring documentation of such events, staff interviews and record reviews confirmed that the incident was not documented in the resident's medical record.
A resident with multiple medical conditions was found by staff with a bleeding head wound, severe pain, and confusion, with no explanation for the injury. Staff discovered the incident in the early morning, observed significant blood loss and an overturned walker, and transferred the resident to the hospital, where serious head injuries were diagnosed. Despite policy requiring notification within two hours, the DON reported the incident to the SSA more than twelve hours later.
A resident who was alert and oriented was discharged after their health improved, but the facility did not send the discharge notice to the LTC Ombudsman at the same time it was provided to the resident and their representative, as required by policy. The notice to the Ombudsman was sent several days later, contrary to facility procedures.
Surveyors found that the internal release mechanisms on the walk-in refrigerator and freezer doors were not functioning, preventing staff from being able to open the doors from the inside. The Director of Maintenance was unaware of the issue until it was identified during the inspection.
Surveyors found that the generator enclosure, which houses the diesel fuel storage area, lacked a portable fire extinguisher within the required travel distance. The closest extinguisher was located inside the facility, across a courtyard, rather than within 30 or 50 feet of the enclosure as required by NFPA 10. This deficiency affected all residents and smoke compartments.
Two kitchen staff members were found to be unaware of proper response protocols for grease fires and reported not having received training on this topic. This deficiency was observed during a facility tour and interview with the DOM and Kitchen Lead Staff, affecting one of four smoke compartments.
Multiple lapses in food safety and sanitation were observed, including an expired sandwich left in the refrigerator, a dispensing scoop stored in direct contact with mashed potato powder, a kitchen door left open near the garbage area for an extended period, and uncovered dumpsters. These deficiencies were confirmed by dietary staff and were not in accordance with facility policy or professional standards.
The facility did not ensure that residents or their representatives were provided with follow-up information or documentation regarding Advance Directives (ADs). Multiple residents, including those with intact and moderately impaired cognition, were unsure if they had an AD or if information was offered. Record reviews showed missing documentation of education or follow-up about ADs, despite facility policy requiring this. The deficiency was confirmed through interviews and record reviews, with the Social Service Director acknowledging the lack of required documentation.
Two residents received improper respiratory care when one was given oxygen at a higher flow rate than ordered without proper assessment or documentation, and another used unlabeled oxygen tubing, contrary to facility policy. Staff interviews and record reviews confirmed that oxygen administration and equipment labeling protocols were not followed.
A dietary aide did not follow the manufacturer's instructions when testing the Quat sanitizer solution, dipping the test strip for only four seconds instead of the required ten. This deviation from procedure was acknowledged by the aide and confirmed by the RD, with facility policy also requiring adherence to manufacturer guidelines.
A resident with a right below knee amputation and moderate cognitive impairment was found with their call light on the floor and out of reach, despite care plan and facility policy requiring accessibility. Staff interviews confirmed the call light should have been within reach to allow the resident to request assistance as needed.
A resident with dementia was exposed to a chemical hazard when a housekeeper left a cup containing toilet cleaning solution and a brush on the bedside table near the resident's drinking cup. The cleaning solution was accessible to the resident, and staff interviews confirmed that such chemicals should be secured away from resident areas according to facility policy.
The facility did not effectively use its QAPI program to resolve an ongoing issue with missing covers on all three dumpsters. Despite identifying the problem and making multiple attempts to contact the waste management company, the bins remained uncovered, and no interim solutions were implemented. The daily supervisor rounds checklist consistently showed the task for closing and cleaning trash lids was not completed.
A nurse did not follow manufacturer instructions for disinfecting a shared blood pressure cuff, failing to keep the surface wet with a disposable wipe for the required one-minute contact time after use on a resident. Interviews with the IP and ADON confirmed staff are expected to follow these instructions, and facility policy requires equipment to be cleaned per manufacturer guidelines.
A resident's legal representative requested medical records, but the facility failed to provide them within the specified two working days. The Medical Records Director forwarded the request to the legal team, causing a delay. The facility's policy requires records to be provided within two days for current residents or 15 days for discharged residents, which was not adhered to in this case.
A resident with atrial flutter was transferred to a hospital without a physician order after becoming unresponsive. Despite the facility's policy requiring physician notification and an order for hospital transfers, staff failed to follow this protocol, as confirmed by interviews with the RN and ADON.
A facility failed to maintain accurate medical records for a resident, resulting in inconsistencies in the timeline of an alleged financial abuse incident. The resident's daughter reported the abuse to the Case Manager, but the eINTERACT SBAR Summary inaccurately documented the incident time. The RN who documented the note was not present during the incident and was instructed by the DON to create a late entry, leading to confusion and inaccuracies. The facility lacked a specific policy on late charting, although standard practice discouraged documentation by staff not on duty.
A resident with a history of falls and severe cognitive impairment was observed without a bed alarm, despite it being a recommended intervention. The care plan was not implemented, and the fall risk assessment was not updated. Staff interviews revealed a lack of communication and adherence to the care plan, leading to potential fall risks.
A resident with Bipolar Disorder alleged physical abuse by a CNA during a shower, reporting pain from hair pulling. The incident was not reported to CDPH within the required two-hour timeframe, as confirmed by interviews with facility staff. The report was delayed by 14 hours, contrary to the facility's policy for immediate reporting of abuse allegations.
The facility failed to notify the Ombudsman prior to the discharges of two residents, as required by policy. One resident with hemiplegia and another with multiple health issues were discharged without timely notification to the Ombudsman, which is necessary for advocacy support. The facility's practice of sending discharge notices monthly resulted in delays, contrary to the policy requiring simultaneous notification to the Ombudsman and the resident.
A resident, identified as a fall risk, did not have bilateral floor mats in place as ordered, posing a potential injury risk. Observations revealed only one mat was present, despite orders for mats on both sides of the bed. Interviews with a CNA and the ADON confirmed the deficiency, highlighting a lapse in following the facility's fall prevention protocol.
A facility failed to provide medical records within two business days after receiving a request from an attorney for a resident with severe cognitive impairment. The request, received on August 20, 2024, was sent to the corporate office, which instructed not to respond, indicating the facility's attorney would handle it. As of the survey date, seven business days had passed without fulfilling the request, violating the facility's policy for timely provision of protected health information.
The facility failed to provide adequate supervision for two residents, resulting in separate elopement incidents. Both residents, identified as elopement risks, managed to leave the facility undetected despite having personal alarms. Staff interviews and care plan reviews confirmed that the residents were not properly monitored.
The facility failed to maintain an infection prevention and control program during a COVID-19 outbreak by not conducting contact tracing and testing for staff and residents, believing that N95 respirators negated the need for such measures. This led to the spread of COVID-19 among residents and staff, affecting all four units.
The facility failed to thaw chicken safely for 106 of 113 sampled residents. The chicken was found in a sink without a continuous flow of cold water, contrary to the facility's policy. Cook #33 admitted to using hot water to thaw the chicken more quickly. The Dietary Supervisor instructed the chicken to be discarded, and interviews confirmed the expectation for staff to follow food safety guidelines.
The facility failed to follow up with the local authority for a Level II PASARR evaluation for a resident with schizophrenia and anxiety disorder. Despite a positive Level I screen, the ADON did not ensure the evaluation was completed, leading to the resident not receiving necessary services.
The facility failed to submit a Level I PASARR for a resident with bipolar disorder and anxiety disorder who remained in the facility longer than 30 days. Staff interviews revealed a lack of awareness and understanding of the requirement to resubmit the Level I evaluation, leading to non-compliance with the facility's policy and state instructions.
The facility failed to schedule physician-ordered follow-up appointments for two residents, leading to a deficiency in meeting professional standards of quality. Despite documented orders, the necessary appointments were not scheduled, as confirmed by staff interviews.
The facility failed to ensure that a pharmacy recommendation for a resident with heart failure and dementia was reviewed by the physician. The recommendation for a primidone level was not documented as reviewed or responded to by the physician, leading to a lack of evidence of follow-up. The DON and a quality assurance nurse were involved in the process, but documentation was incomplete.
Failure to Provide Caregiver Training Prior to Planned Home Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective discharge planning and caregiver training prior to a planned discharge home. The resident was admitted with hypertensive heart disease with heart failure and morbid obesity, and MDS assessments showed the resident was cognitively intact but required partial/moderate assistance for toileting hygiene, bathing, dressing, footwear, bed mobility, and toilet transfers. Case management notes documented that the resident and the designated DPOA agreed the resident would return home, with assistance from a family member and a close friend for ADLs, mobility, personal care, meals, and supervision. A physician order set a discharge date to the resident’s home, and the physical therapist recommended home health, a caregiver, bariatric front wheel walker, wheelchair, and oxygen upon discharge. Despite these identified needs and the plan for home discharge with caregiver support, there was no documented evidence that caregiver training was provided to the responsible party or any designated caregiver prior to the planned discharge date. There was also no documentation that caregiver training was rescheduled when it was not completed before the planned discharge. On the planned discharge day, the CNA confirmed the resident required assistance with daily activities, and the responsible party reported uncertainty about being able to provide the necessary care after discharge. The DOR confirmed there was no documentation of caregiver training or appointments to coordinate such training, and the CM stated caregiver training had been offered but not completed. The DON stated that rehab was responsible for caregiver training for ADLs and that the caregiver or any designated caregiver should have been trained to ensure a safe discharge home, and that without completed caregiver training, discharge home would not be considered safe. The facility’s discharge policy required discharge planning to ensure a safe transition and to determine if appropriate and adequate support, including caregiver capacity, was in place.
Failure to Issue Revised Transfer/Discharge Notice After Change in Discharge Destination
Penalty
Summary
The facility failed to provide a new written notice of proposed transfer or discharge when a resident’s discharge destination changed from home to a board and care facility. The resident, admitted with hypertensive heart disease with heart failure and morbid obesity, had an initial physician order dated February 4, 2026, indicating Medicare benefit exhaustion on February 6 and discharge on February 7 to the resident’s home address. A corresponding Notice of Proposed Transfer/Discharge dated February 4 documented an effective discharge date of February 7 and listed the home address as the transfer/discharge destination. Subsequently, a physician order dated February 13 changed the discharge plan to a board and care facility, and the Discharge/Transfer Summary dated February 13 documented that the resident was discharged to a board and care. Despite this change in discharge destination, there was no documented evidence that a new written notice of proposed transfer/discharge reflecting the board and care destination was provided to the resident, the resident representative, or the Ombudsman. During interviews, the Case Manager stated that she provides a new written notice when there are changes in the discharge plan but acknowledged she did not provide a new copy to the Ombudsman for this resident. The DON stated that the SSD or Case Manager should review the notice with the resident and/or representative, complete the written notice, and fax it to the Ombudsman, and confirmed that a new notice should have been prepared for the revised discharge date and destination but there was no documentation that this occurred. The facility’s policy on Transfer or Discharge Notices required written notification to residents or representatives, a copy to the State Long-Term Care Ombudsman, and issuance of a new notice for significant changes such as a change in discharge destination, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Physical Abuse Allegation to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged incident of physical abuse between two residents to the state survey agency (SSA) within the required two-hour timeframe. On January 4, 2026, at approximately 6:30 p.m., a physical altercation occurred in the hallway of Station 3 between Resident 1 and Resident 2. Resident 2 reported that Resident 1 choked him, stating, "He choked me, but I managed to get out," while Resident 1 stated that Resident 2 came very close to his face, prompting him to push Resident 2 away. Staff, including an LVN, intervened to separate the residents and assessed Resident 2 for skin issues or injuries, and the physician was notified. Resident 1’s medical record showed admission with multiple diagnoses including peripheral vascular disease, anxiety disorder, right below-knee amputation, type 2 diabetes mellitus, orthopedic aftercare following amputation, osteomyelitis, cellulitis of the left lower limb, and MRSA infection. A history and physical dated January 1, 2026, indicated no neuro focal deficits. Resident 2’s record indicated admission with diagnoses including opioid use, anxiety disorder, a displaced bicondylar fracture of the left tibia status post ORIF, and injuries from a pedestrian–vehicle collision, with a history and physical dated January 5, 2026, documenting that Resident 2 was oriented to person, place, and time. Progress notes and eINTERACT SBAR summaries documented that Resident 2 admitted to using profanity toward an LVN related to a prior incident, that Resident 1 witnessed this verbal altercation, intervened, and that Resident 2 alleged choking while Resident 1 denied choking and reported only pushing Resident 2 away. Interviews with staff confirmed both the occurrence of the altercation and the delay in reporting it to the SSA. LVN 1 stated that when two residents have a physical altercation, the RN should be notified immediately and that such altercations should be reported within two hours. The Social Services Director and the Director of Nursing both confirmed that the altercation occurred at 6:30 p.m. on January 4, 2026, and that the SSA was not notified until 9:15 a.m. on January 5, 2026. The DON acknowledged that the altercation was considered abuse and should have been reported immediately. Review of the facility’s abuse, neglect, exploitation, and misappropriation reporting policy, revised September 2022, showed that suspected abuse must be reported immediately to the administrator and appropriate agencies, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. The facility did not adhere to this policy or the regulatory requirement for timely reporting.
Failure to Perform Ordered C-diff Test and Respond to Critical Lab Result for Resident With Persistent Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered laboratory test was correctly carried out and that critical results and ongoing symptoms were appropriately communicated and addressed. A resident was admitted with diagnoses including encounter for surgical aftercare following digestive system surgery, major depressive disorder, and bipolar disorder, and had a POLST specifying comfort-focused treatment and transfer to the hospital only if comfort needs could not be met in the facility. On December 25, 2025, an SBAR form documented a change in condition with the onset of diarrhea and a primary clinician recommendation for a stool culture for C-diff. However, the order summary for that date showed only a generic stool culture was sent, and the facility did not complete the specific C-diff test that had been recommended. From December 26 through December 31, 2025, bowel continence/movement records showed the resident repeatedly had loose and watery stools, with multiple entries documenting incontinence or continent episodes with large, medium, or small amounts of loose or watery stool. A stool culture result dated December 28, 2025, showed no salmonella or shigella, but there was no documentation that the physician was notified that the ordered C-diff culture had not been performed, nor that the resident continued to have loose stool over this seven-day period. Progress notes did not indicate any treatment for the resident’s ongoing loose stool. Facility staff, including an LVN and the ADON, later confirmed that a stool culture for C-diff is a different test from a routine stool culture and that the physician should have been notified when the wrong laboratory test was completed. On December 31, 2025, an SBAR documented that the resident had significant weight loss over one week and drowsiness, with a recommendation for CBC and CMP. Laboratory results showed the resident’s WBC increased from 8.44 on December 23, 2025, to a critically elevated 36.91 on December 31, 2025. An SBAR at 11:39 p.m. recorded receipt of the critical WBC result but did not document any recommendations or interventions from the physician. RN 1 reported that she texted the physician with the critical value, received a question about the admission date, provided that information, and received no further response, and she endorsed the critical value to LVN 3. LVN 3 stated that a critical lab value is considered an emergency requiring an immediate phone call to the physician rather than a text message. The ADON confirmed that a WBC of 36.91 is a critical value, that the physician should have been notified, and that RN 1 should have followed up with the physician after the initial text response. During the night shift spanning December 31, 2025, to January 1, 2026, LVN 3 monitored the resident every 30 minutes due to the critical lab value, performed a bladder scan, and noted the resident was easily aroused and not in distress around midnight. Later, he observed that the resident’s breathing became fast and labored, and he notified RN 1 and a CNA. An SBAR dated January 1, 2026, at 2:05 a.m. documented hypotension, bradycardia, tachypnea, and low oxygen saturation, with staff noting that the resident was initially without shortness of breath or distress around 12:45 a.m., but by around 2:00 a.m. had fast and labored breathing, prompting immediate RN assessment and a 911 call. Progress notes from January 1, 2026, described initiation of oxygen via non-rebreather mask, altered mental status, and the call to 911 at approximately 2:12 a.m., with transfer to the hospital and subsequent notification that the resident died in the ambulance at 2:38 a.m. The physician later stated he was not informed that the C-diff culture ordered on December 25, 2025, had not been performed and that, if the resident continued to have loose watery stool, a C-diff culture would have been important because a positive result would have led to antibiotic orders. The physician also stated he ordered the resident’s transfer to the hospital but was unaware of any delay in the transfer. The facility’s own policies required correct processing of lab orders, prompt physician notification of significant condition changes and critical lab results, and direct voice communication for results requiring immediate notification, which were not followed in this case.
Improper Use of Wound Cleanser During Ostomy Care Causes Resident Pain
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow professional standards of practice for ostomy care by using a wound cleanser containing sorbitol to clean the peristomal skin of a resident with a colostomy. The resident, who had multiple diagnoses including surgical aftercare following digestive system surgery, pneumonitis, pressure ulcer, and type 2 diabetes, experienced severe pain during the procedure. The LVN used the wound cleanser after the resident's colostomy bag was found leaking, despite facility practice and physician orders indicating that the peristomal area should be cleansed with normal saline or warm water and not with harsh chemicals or alcohol-based products. Interviews with facility staff, including the Director of Nursing, Registered Nurse, and Treatment Nurse, confirmed that wound cleansers are not appropriate for peristomal skin due to the risk of burning and irritation. The resident reported significant pain and burning sensation when the cleanser was applied, describing the spray as smelling strong and feeling like alcohol. Documentation in the resident's medical record and facility guidelines further supported that only gentle cleansing agents should be used for ostomy care, and the use of the wound cleanser was inconsistent with established protocols.
Failure to Use Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a physical therapist (PT) operated a Hoyer lift to transfer a resident from bed to wheelchair without the assistance of a second staff member. Observation confirmed that the PT performed the transfer alone, despite the resident being in the lift and requiring maximum assistance for bed transfers. Interviews with both a CNA and the PT confirmed that facility policy requires two staff members to operate the Hoyer lift for safety during transfers. The resident involved had a history of hemiplegia and Parkinson's disease, resulting in substantial to maximal assistance needs for mobility and transfers. The resident's care plan and functional assessment documented these needs, and the facility's policy, revised in July 2017, specified that at least two nursing assistants are required for safe use of a mechanical lift. The PT acknowledged operating the lift alone, which was inconsistent with both the resident's care requirements and facility policy.
Failure to Document Resident Altercation and Related Behaviors
Penalty
Summary
The facility failed to ensure accurate documentation of an incident involving a verbal altercation and related behaviors between two residents. One resident, who had a history of monoplegia following a stroke, was moved to a new room after a previous altercation. Upon being placed with a new roommate, the resident was observed by staff and the new roommate to be agitated, bumping her wheelchair into objects, and making threatening statements over the phone. The new roommate became emotionally distressed, activated her call light, and was subsequently moved to another room by staff. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed that the incident was not documented in the medical record of the resident who made the threatening statements. The facility's policy requires that all changes in a resident's condition, as well as events, incidents, or accidents, be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no evidence of documentation in the medical record regarding the incident involving the verbal altercation and the resident's behaviors. Record reviews showed that while some documentation existed in the new roommate's records, including an SBAR summary and an IDT note describing the emotional distress and the events that occurred, there was a lack of corresponding documentation in the record of the resident who was the source of the altercation. This omission was confirmed by the DON during a review of the progress notes, indicating a failure to comply with the facility's documentation policy.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Survey Agency (SSA) within the required two-hour timeframe. The incident occurred when a resident, who had a history of intertrochanteric femur fracture, arterial aneurysm, and rheumatoid arthritis, was found by staff in the early morning hours with a bleeding wound on the right posterior scalp. The resident was visibly distressed, in severe pain, and unable to explain the cause of the injury. Staff observed a large pool of blood on the floor, the resident's walker overturned, and the resident using her bedside table for support. The resident was transferred to an acute care hospital, where she was diagnosed with trace pneumocephalus, subarachnoid hemorrhage, and subdural hematoma, and admitted to the ICU for further monitoring. Interviews with facility staff revealed that the injury was discovered at approximately 3 a.m., but the SSA was not notified until 4:38 p.m., more than twelve hours after the incident. The facility's policy requires that injuries of unknown origin, especially those resulting in serious bodily injury, be reported to the SSA, Ombudsman, and law enforcement within two hours. Staff acknowledged awareness of this policy and the reporting requirements, but the notification was delayed significantly beyond the mandated timeframe. Record reviews confirmed the timeline of events, including the initial discovery of the injury, the resident's transfer to the hospital, and the late reporting to authorities. Documentation showed that the required SOC 341 form was sent to the appropriate agencies and law enforcement was notified, but only after a substantial delay. The failure to report the injury promptly constituted a breach of the facility's own policy and regulatory requirements regarding timely reporting of suspected abuse, neglect, or injuries of unknown origin.
Failure to Timely Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a copy of the discharge notice for a resident was sent to the Long-Term Care (LTC) Ombudsman at the same time it was provided to the resident and their representative. According to interviews and record review, the discharge notice was given to the resident and their family member on April 22, 2025, but was not sent to the LTC Ombudsman until April 25, 2025. Facility policy requires that the notice be sent to the Ombudsman simultaneously with the notice to the resident and representative. The resident involved was alert and oriented to person, place, and time, and was being discharged because their health had improved sufficiently to no longer require services from the facility. Documentation confirmed the discharge process and the timing of notifications, as well as the facility's policy on transfer or discharge notices. The delay in notifying the LTC Ombudsman was confirmed through staff interviews and review of the discharge notice and progress notes.
Non-Functioning Internal Door Releases on Walk-In Refrigerator and Freezer
Penalty
Summary
Surveyors observed that the facility failed to maintain proper means of egress as required by NFPA 101, Life Safety Code. During a tour, it was found that both the walk-in refrigerator and freezer, located towards the back of the walk-in refrigerator, were equipped with deadbolt locks and internal release knobs intended to allow individuals to open the doors from the inside. However, when the Director of Maintenance (DOM) attempted to operate the internal release mechanisms from inside both units, the mechanisms failed to function. The deficiency was identified through direct observation and interview with the DOM, who stated he was unaware that the internal release knobs were not working. This issue was present in one of four smoke compartments within the facility. The report specifically notes that the non-functioning internal door release mechanisms could result in staff becoming trapped inside the walk-in units. No information was provided in the report regarding any residents being directly involved or affected at the time of the deficiency. The findings were limited to the staff's ability to exit the walk-in refrigerator and freezer in the event of an emergency, as observed during the facility tour.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The facility immediately addressed the non-functioning internal door release mechanism in the walk-in refrigerator and freezer doors. The doors were repaired to function properly so that no potential entrapment could occur. 2. How the facility will identify other residents having the potential to be affected. Staff who utilize the walk-in refrigerator and freezers have the potential to be affected. No residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the dietary staffs were in-serviced by the Environmental Service Director regarding "Means of Egress requirements." The Dietary Supervisor will monitor the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress weekly. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with members of the Safety Committee the weekly monitor in place for the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress. The findings will be reported to the QA/QAPI Committee at least quarterly for analysis, review, modification and/or correction. The utilization of portable fire extinguishers and their locations to hazardous areas. The Environmental Services Director and/or designee will verify monthly that the portable fire extinguishers within the building are in compliance and within the appropriate distance of hazardous areas. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor at least quarterly the monthly monitoring conducted by the Environmental Services Director that the portable fire extinguishers within the building comply and are within the appropriate distance of hazardous areas. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. K711. 1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The Environmental Services Director immediately discussed with the two staff who were unaware of the protocols for addressing a grease fire and made them aware of the appropriate procedures to address such an occurrence.
Failure to Provide Fire Extinguisher in Generator Enclosure
Penalty
Summary
The facility failed to properly equip the generator enclosure with the required fire safety equipment, specifically a portable fire extinguisher. During a tour and interview with the Director of Maintenance, it was observed that the diesel fuel storage area, located in an external concrete enclosure with the generator, did not have a fire extinguisher installed within the minimum required travel distance. The closest fire extinguisher was found to be inside the facility, across a courtyard, rather than within 30 or 50 feet of the diesel fuel storage enclosure as required by NFPA 10 standards for Class B hazards. This deficiency was identified during an inspection and affected all 114 residents and four smoke compartments in the facility. The absence of a fire extinguisher in the specified location was directly observed, and the Director of Maintenance confirmed the lack of appropriate fire safety equipment in the generator enclosure area.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. A fire extinguisher was put in place within the diesel fuel storage area. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and Environmental Service Director. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and/or Maintenance Director regarding "The protocols for addressing a grease fire and the appropriate procedures to address such an occurrence." The DSD and/or Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction.
Kitchen Staff Lacked Training on Grease Fire Response
Penalty
Summary
During a facility tour and interview with the Director of Maintenance, it was observed that kitchen staff were not aware of the proper response protocols for addressing a grease fire in the cooking facilities. Two kitchen staff members were specifically asked about the procedures to follow if a grease fire were to occur on the griddle or stove top. Both staff members stated that they did not know the appropriate response protocols and confirmed that they had not received training on how to respond to a grease fire. The deficiency was identified in one of four smoke compartments and was witnessed by the Director of Maintenance and the Kitchen Lead Staff during the interview. The lack of staff knowledge and training regarding grease fire response was cited as a failure to maintain the cooking facilities in accordance with NFPA 101: Life Safety Code, which requires employees to be instructed in life safety procedures and devices.
Deficient Food Safety and Sanitation Practices in Kitchen Operations
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices as evidenced by several observed deficiencies. One expired peanut butter and jelly sandwich was found in the snacks refrigerator, despite facility policy requiring items to be clearly marked with a use-by date and discarded accordingly. Both the Assistant Dietary Supervisor (ADS) and the Registered Dietician (RD) confirmed that the sandwich was past its expiration date and should not have been available for consumption. Additionally, a dispensing scoop was observed stored inside a container of mashed potato powder, in direct contact with the food product, contrary to professional standards and FDA Food Code, which require utensils to be stored with handles above the food to prevent cross-contamination. Further observations revealed that the kitchen door near the garbage area was left open for approximately 20 minutes, which the ADS acknowledged could allow insects and dust to enter, increasing the risk of cross-contamination. Three large dumpsters were also found without tight-fitting covers, a violation of facility policy and food safety standards, as this could attract insects and rodents. These lapses in food safety and sanitation practices were observed in a facility serving 112 out of 115 residents who received food prepared in the kitchen.
Failure to Provide and Document Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that a copy of each resident's Advance Directive (AD) was available and that residents or their representatives were provided with follow-up information regarding the formulation of an AD. This deficiency was identified in 11 out of 14 residents reviewed for ADs. Multiple residents, during interviews, expressed uncertainty about whether they had an AD, whether they had been asked about creating one, or whether they had received information or follow-up on the topic. Record reviews for these residents consistently showed either the absence of an executed AD or lack of documentation that information or education about ADs was provided or followed up. For each resident cited, the admission records, Advance Directive Acknowledgment forms, POLST forms, and care conference documentation were reviewed. In all cases, the documentation either indicated that the resident had not executed an AD or did not mention an AD at all. Care conference records typically had a check mark for "Advance Directive/POLST/code status order," but there was no evidence that residents or their representatives were given information or education about their right to formulate an AD, nor was there documentation of follow-up discussions. Interviews with the Social Service Director confirmed that such documentation was missing and should have been present. Residents involved in the deficiency included those with both intact and moderately impaired cognitive function, as indicated by their BIMS scores. Several residents stated they would like to have an AD or wanted more information, while others were unsure if the facility had followed up with them. The facility's policy required that residents or their representatives be provided with written information about ADs and that staff document offers of assistance and the resident's decision. However, the required documentation and follow-up were not found in the records reviewed for the cited residents.
Failure to Follow Oxygen Administration Policies for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following established policies and procedures for oxygen administration. One resident with a diagnosis of COPD was observed receiving continuous oxygen at six liters per minute via nasal cannula, which exceeded the physician's order of 2-4 liters per minute as needed to maintain oxygen saturation above 90%. There was no documentation or assessment of the resident's oxygen use that morning, and staff did not report the increased oxygen level or assess the resident's condition as required. Facility staff, including an LVN and RN Supervisor, acknowledged that the oxygen was set incorrectly and that the resident's condition and oxygen use had not been properly monitored or documented. Another resident, admitted with acute respiratory failure and pleural effusion, was observed using an unlabeled nasal cannula for oxygen delivery. The tubing was not labeled with the date as required by facility policy, which mandates that oxygen tubing be changed and labeled every seven days and as needed. Staff confirmed that the tubing should have been labeled to prevent infection, and the physician's order specified regular changes and labeling of the oxygen equipment. These failures were directly observed and confirmed through staff interviews and record reviews.
Dietary Staff Failed to Follow Manufacturer's Instructions for Sanitizer Testing
Penalty
Summary
A deficiency was identified when a dietary aide (DA) failed to follow the manufacturer's instructions for testing the Quaternary ammonium compound (Quat) sanitizer solution in the facility's three-compartment sink. During observation, the DA dipped the Quat test strip into the sanitizing solution for only four seconds before comparing it to the color chart, instead of the required ten seconds as specified by the manufacturer's directions. The DA acknowledged during an interview that the correct procedure was not followed and that this could result in inaccurate readings of the sanitizer concentration. The facility's policy and procedure manual also indicated that the manufacturer's instructions should be followed for proper sanitation.
Call Light Not Accessible to Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with a right below knee amputation and moderate cognitive impairment was observed with their call light button on the floor and not within reach. The resident stated they could not reach the call light and needed it to be closer in order to call for assistance. The resident's care plan specifically indicated that the call light should be within reach to encourage its use for assistance with activities of daily living. During interviews, a Licensed Vocational Nurse, the Director of Staff Development, and the Assistant Director of Nursing all confirmed that the call light should not have been on the floor and should have been accessible to the resident. Facility policy also requires that call lights be accessible to residents in various locations, including in bed. The failure to ensure the call light was within reach constituted a lack of reasonable accommodation for the resident's needs and preferences.
Resident Exposed to Chemical Hazard Due to Improper Storage of Cleaning Solution
Penalty
Summary
A housekeeper left a cup containing a pink toilet cleaning solution and a brush on the bedside table of a resident diagnosed with dementia and unable to make medical decisions. The cleaning solution was placed near the resident's drinking cup, making it accessible to the resident. The family member discovered the cleaning solution and reported it to the nurse, who confirmed the substance was a toilet cleaner. Interviews with staff, including a Licensed Vocational Nurse and the Housekeeping Supervisor, confirmed that cleaning chemicals should not be left in resident areas and should be properly secured. The facility's policy requires that cleaning supplies be maintained in a safe manner and stored away from resident areas. The housekeeper admitted to leaving the cleaning solution in the resident's room and acknowledged that it should have been stored in the proper storage area. This incident resulted in the resident being exposed to a chemical hazard, contrary to facility policy and expectations for resident safety.
Failure to Address Missing Dumpster Covers Through QAPI
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to address an ongoing issue with missing covers on all three dumpsters. Review of the Food & Nutrition Services: Daily Supervisor Rounds Checklist showed that the task 'Trash Lids closed and clean' was not checked off on any day between March 2, 2025, and April 17, 2025. During an interview and record review, the Administrator confirmed that replacing the dumpster covers was a current QAPI project, but the bins remained uncovered due to repeated cancellations by the waste management company. Although temporary measures were considered, no interim solutions were implemented to prevent animal access or potential contamination. The facility's QAPI policy requires ongoing monitoring and problem resolution, but the issue persisted without effective action.
Improper Disinfection of Shared Blood Pressure Cuff
Penalty
Summary
A licensed nurse failed to properly disinfect a shared manual blood pressure cuff after use on a resident. During a medication pass observation, the nurse was seen wiping the cuff with a disposable disinfectant wipe but did not allow the surface to remain wet for the full one-minute contact time required by the manufacturer's instructions. The nurse initially stated the cuff should have air dried for three minutes, but upon reviewing the manufacturer's instructions, acknowledged that the required contact time was one minute. Interviews with the Infection Preventionist and the Assistant Director of Nursing confirmed that the facility's expectation was for staff to clean and disinfect shared resident equipment, such as blood pressure cuffs, according to the manufacturer's instructions. The facility's policy also required reusable resident care equipment to be decontaminated between residents per manufacturer guidelines. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide access to personal and medical records within two working days upon request by a resident's legal representative. Resident 1 was admitted to the facility and later discharged on January 29, 2025. A request for the release of Resident 1's medical records was made on February 11, 2025, by the resident's legal representative, specifying that the records be made available within two working days. However, the Medical Records Director (MRD) forwarded the request to the facility's legal team, which delayed the process. The MRD received the request on February 11, 2025, and forwarded it to the legal team, but the records were not released within the requested timeframe. On February 14, 2025, the legal representative followed up, but the MRD had not provided an update or followed up with the legal team since then. The facility's policy states that records should be provided within two days for current residents or within 15 days for discharged residents. The failure to release the records within the specified time frame was a deviation from the facility's policy and resulted in a deficiency.
Failure to Obtain Physician Order Before Hospital Transfer
Penalty
Summary
The facility failed to ensure that a physician order was obtained prior to the hospital transfer of a resident, identified as Resident 2. On February 19, 2025, Resident 2, who had been admitted with a diagnosis of atrial flutter, experienced a medical emergency while using the bathroom. The resident became unresponsive, prompting the staff to call American Medical Response (AMR), which resulted in the resident being transported to a hospital for further assessment. However, the transfer was conducted without obtaining a necessary physician order, as confirmed by the review of Resident 2's medical records and interviews with the facility's staff. During interviews conducted on March 3, 2025, both a Registered Nurse (RN) and the Assistant Director of Nursing (ADON) acknowledged that the standard procedure for a change in a resident's condition includes notifying the physician and obtaining a transfer order before hospital transfer. The facility's policy, dated 2001, also mandates that the attending physician or physician on call be notified when a transfer is needed. The failure to secure a physician's order before transferring Resident 2 to the hospital was a deviation from these established protocols, potentially impacting the resident's safety and appropriateness of care.
Inaccurate Documentation of Financial Abuse Incident
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, leading to inconsistencies in the reporting timeline of an alleged financial abuse incident. The resident, who had moderate cognitive impairment, was involved in an allegation against his wife for financial abuse. The incident was reported by the resident's daughter to the Case Manager at 2 p.m. on February 18, 2025. However, the eINTERACT SBAR Summary for Providers inaccurately documented the time of the incident as 7:49 a.m., which was not consistent with the actual time of reporting. The Registered Nurse (RN) who documented the note was not present at the facility when the incident occurred and was instructed by the Director of Nursing (DON) to create a late entry note. The RN admitted to documenting the incident without firsthand knowledge, which led to confusion and inaccuracies in the resident's medical records. The DON acknowledged the mistake and stated that the facility lacked a specific policy on late charting, although it was standard practice for staff not to document in a resident's medical record if they were not scheduled to work. The facility's policy on charting and documentation emphasized the need for objective, complete, and accurate documentation.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident who was at risk for falls. The resident, who had a history of repeated falls and severe cognitive impairment, was observed without a bed alarm, which was a recommended intervention following a fall. The resident's care plan, which included the use of a bed alarm as a fall prevention measure, was not implemented, and the fall risk assessment was not updated to reflect newly identified risks discussed during an interdisciplinary team meeting. Interviews with facility staff, including a CNA and RN Supervisor, revealed that the bed alarm was not in place, and the CNA was not informed of the need for it. The RN Supervisor acknowledged that the care plan should have been implemented and updated to reflect the current fall risks. The Director of Nursing confirmed that the post-fall evaluation was not conducted as per facility policy, which required updating the fall evaluation after a resident experiences a fall to determine current risks and needs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the California Department of Public Health (CDPH) after being made aware of the incident involving a resident. The resident, who was cognitively intact and diagnosed with Bipolar Disorder, reported that during a scheduled shower, a Certified Nurse Assistant (CNA) pulled her hair hard, causing pain. The resident informed a Licensed Vocational Nurse (LVN) about the incident, but the LVN did not take immediate action to report the abuse allegation. The incident occurred in the late afternoon, but the report to CDPH was not made until the following morning, approximately 14 hours later. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the involved LVN, confirmed that the abuse allegation should have been reported within two hours to ensure the resident's safety and prevent further abuse. The facility's policy mandates immediate reporting of abuse allegations to local, state, and federal agencies, which was not adhered to in this case.
Failure to Notify Ombudsman Prior to Resident Discharges
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding the discharge of two residents, which is a requirement to provide advocacy support for residents being transferred or discharged. Resident 4, who was admitted with hemiplegia and hemiparesis following a stroke, was discharged on October 9, 2024, without the Ombudsman being notified prior to the discharge. The Social Service Designee (SSD) 1 stated that discharge notices are sent to the Ombudsman by email on the first of the month, indicating a delay in notification. This practice resulted in Resident 4's discharge notice not being sent to the Ombudsman office before the discharge occurred. Similarly, Resident 5, who had diagnoses including aftercare cervical decompression, type 2 diabetes mellitus, dementia, and multiple rib fractures, was discharged on September 11, 2024. The discharge notice for Resident 5 was also sent to the Ombudsman on October 1, 2024, after the discharge had already taken place. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, which was not adhered to in these cases. This failure to follow protocol potentially deprived the residents of advocacy support prior to their discharges.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident had bilateral floor mats in place as ordered, which had the potential to result in an injury due to a fall. During an unannounced visit, it was observed that the resident, who was identified as a fall risk, only had a floor mat on the right side of her bed, despite the order specifying that floor mats should be placed on both sides. The resident's medical records indicated she was admitted with multiple diagnoses, including dementia, hemiplegia, and hemiparesis following a stroke, which affected her ability to make decisions. Interviews conducted with the resident, a CNA, and the ADON confirmed the deficiency. The CNA, responsible for the resident's care, acknowledged that the resident was a fall risk and confirmed that there should be a floor mat on each side of the bed. The ADON also stated that if there was an order for bilateral floor mats, they should be in place on both sides of the bed. The facility's policy on falls indicated that staff and physicians should identify interventions to prevent falls and address the risks of significant consequences from falling.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of medical records upon request and within two business days after receiving a request from an attorney on behalf of a resident, identified as Resident 3. This deficiency was identified during an unannounced visit to investigate a complaint allegation. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Medical Records (MR) personnel, revealed that the facility's standard procedure was to fulfill medical record requests within 24 to 48 hours. However, the request for Resident 3's records, which was received on August 20, 2024, was not fulfilled within this timeframe. The MR personnel stated that the request for Resident 3's records was sent to the corporate office on the same day it was received, and the corporate office instructed not to respond to the request, indicating that the facility's attorney would handle it. The Administrator confirmed that the facility's legal department dealt with requests from attorneys, but he was unsure of the timeline for fulfilling such requests. As of the date of the survey, it had been seven business days since the request was received, and the records had not been provided. Resident 3 had been admitted to the facility with diagnoses including a fracture of the left thigh and diabetes mellitus and had severe cognitive impairment. The resident was transferred to a general acute care hospital and did not return to the facility. The request for records was made by the resident's attorney, with an authorization signed by a family member, requesting all writings related to the resident for legal matters. The facility's policy required timely provision of requested protected health information, which was not adhered to in this case.
Inadequate Supervision Leading to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for two residents, resulting in separate elopement incidents. Resident 1, who was admitted with diagnoses including cerebral infarction and cognitive communication deficit, eloped on March 26, 2024. Despite having a Wanderguard, Resident 1 was able to leave the facility undetected and was found outside by a family member. Interviews with staff revealed that Resident 1 was not properly monitored, despite being identified as an elopement risk in her care plan and elopement risk assessment. Similarly, Resident 2, who was admitted with diagnoses including psychosis, anxiety, and depression, eloped on March 22, 2024. Resident 2 also had a personal alarm due to her elopement risk but managed to leave the facility and was later found outside. Staff interviews indicated that Resident 2 was not adequately supervised, and her alarm was not responded to in a timely manner. Both residents' care plans and elopement risk assessments indicated they were at risk for elopement and should not leave the facility unattended. The Director of Nursing confirmed that the elopement episodes were due to inadequate monitoring for safety.
Failure to Conduct Contact Tracing and Testing During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of COVID-19 to staff and residents on all four units. Specifically, the facility did not conduct contact tracing for staff during a COVID-19 outbreak, believing that the use of N95 respirators negated the need for testing individuals exposed to COVID-19. This led to the failure to test all residents and staff who had been in close contact with others who had COVID-19, and the facility did not conduct broad-based COVID-19 testing when contact tracing failed to halt transmission. This deficiency had the potential to affect all 111 residents in the facility, with eight residents and two staff testing positive for COVID-19 as of the report date. The issue began when a resident tested positive for COVID-19, and the facility did not perform appropriate contact tracing and testing of everyone who had contact with the infected resident. Subsequently, several other residents across different units tested positive for COVID-19. The facility's policy required immediate investigation and contact tracing when a COVID-19 positive individual was identified, but this was not followed. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and other staff revealed a misunderstanding that the use of N95 respirators by staff prevented the need for further testing and contact tracing. Further review of the facility's COVID-19 Outbreak Log and interviews with staff indicated that the facility did not test any residents or staff who had been in contact with COVID-19 positive individuals, relying instead on the use of N95 respirators as a protective measure. This approach was contrary to CDC guidelines, which recommend testing and contact tracing regardless of the use of source control measures like N95 respirators. The facility's failure to follow these guidelines and its own policies led to the spread of COVID-19 among residents and staff, resulting in an Immediate Jeopardy situation that required immediate corrective action.
Removal Plan
- Immediate testing of staff and residents and reaching out to unscheduled staff for testing and in-service.
- Review and update of care plans based on residents' needs.
- In-service and instruction on updated facility mitigation plan and general infection control.
- In-service of all staff on revised mitigation plan and guidelines, including contact tracing and testing procedures.
- QAPI Committee meeting to review and approve QAPI plan addressing the issue.
- COVID-19 testing of all residents and staff using antigen testing/POC.
- Random assessment of staff competency in screening visitors and wearing PPE.
- In-service of all staff on new mitigation plan and infection control procedures.
- Daily rounds to ensure compliance with infection control procedures.
- Monitoring and review of compliance by QAPI Committee until significant compliance is demonstrated for three consecutive months.
Improper Thawing of Chicken in Kitchen
Penalty
Summary
The facility failed to thaw chicken in a safe manner for 106 of 113 sampled residents who received food from the kitchen. The facility's policy on safe thawing practices, as outlined in their General HACCP Guidelines for Food Safety, requires meat, fish, and poultry to be thawed in a refrigerator in a drip-proof container, under clean running water, in a microwave if cooked immediately, or as part of the cooking process. However, during an observation, four bags of chicken were found in a sink without a continuous flow of cold water. The Dietary Aide/Assistant Supervisor (DA/AS) #35 confirmed that the chicken was placed in the sink by Cook #33, who admitted to using hot water to thaw the chicken more quickly, contrary to the facility's policy. The Dietary Supervisor was informed of the improper thawing method and instructed DA/AS #35 to discard the chicken. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator confirmed that the expectation was for kitchen staff to follow the facility's food safety guidelines. Despite this, Cook #33 did not adhere to the proper thawing procedures, leading to a potential risk of cross-contamination and foodborne illness for the residents receiving food from the kitchen.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to follow up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) for one resident. The facility's policy required a Level II Full Evaluation by a state-designated authority when a Level I screen identified a resident with mental illness or intellectual disability. Resident #93, who was admitted with diagnoses including schizophrenia and anxiety disorder, had a positive Level I screen necessitating a Level II evaluation. Despite this, the facility did not ensure the completion of the Level II evaluation, as evidenced by a letter from the State Department of Health Care Services indicating the resident was unable to participate in the evaluation and subsequent interviews with facility staff confirming the lack of follow-up. Interviews with the Director of Medical Records, the Assistant Director of Nursing (ADON), the MDS Registered Nurse (RN), and the Director of Nursing (DON) revealed a breakdown in communication and responsibility. The ADON, who was responsible for the PASARR process, did not notify the local authority to reschedule the Level II evaluation for Resident #93. The MDS RN was unaware of the missed evaluation, and the DON confirmed that the ADON should have taken immediate action to ensure the resident received the appropriate treatment services. This failure resulted in the resident not receiving the necessary evaluation and potentially appropriate services for their mental health conditions.
Failure to Submit Level I PASARR for Resident with Mental Disorders
Penalty
Summary
The facility failed to submit a Level I Preadmission Screening and Resident Review (PASARR) for a resident with mental disorders or intellectual disabilities. The resident, who had diagnoses including bipolar disorder and anxiety disorder, was originally admitted on 07/26/2023 and readmitted on 12/19/2023. Despite the resident's active diagnosis of bipolar disorder and the requirement to submit a new Level I screening if the resident remained in the facility longer than 30 days, the facility did not comply with this requirement. The facility's policy indicated that a Resident Review should be submitted by the 40th calendar day after admission for cases exceeding the 30-day exempted hospital discharge, but this was not done for the resident in question. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to resubmit a Level I evaluation. The Assistant Director of Nursing (ADON) acknowledged that a new Level I screening was not submitted because she was unaware of the instructions in the letter from the State of California-Health and Human Services Agency Department of Health Care Services. The MDS Registered Nurse (RN) also admitted to not being aware of the letter specifying the need for a new Level I evaluation on the 31st day. The Director of Nursing confirmed that the ADON was responsible for the submission of the Level I screening, and the Administrator stated that the facility should have ensured the completion of the Level I screening on the 31st day.
Failure to Schedule Physician-Ordered Follow-Up Appointments
Penalty
Summary
The facility failed to schedule physician-ordered follow-up appointments for two residents, leading to a deficiency in meeting professional standards of quality. Resident #111, admitted with a displaced fracture of the left clavicle and a dislocation of the right ulnohumeral joint, had an order for a post-operation follow-up with an orthopedic surgeon. Despite the order being placed in the electronic medical record and the case manager's slot, the appointment was not scheduled. Interviews with the Administrative Assistant/Case Manager Assistant (AA/CMA) and the Director of Nursing (DON) confirmed that the appointment was missed and should have been scheduled upon the resident's admission to the facility. Similarly, Resident #188, admitted with diagnoses including acute kidney failure and hydronephrosis, had multiple follow-up appointments ordered, including with an internal medical doctor, oncologist, urologist, and hematologist/oncologist. Despite these orders being documented, the resident reported that no follow-up appointments had been scheduled. The AA/CMA stated that he had not received any instructions from the case manager to schedule these appointments. The Administrator confirmed that staff were expected to handle appointments according to the facility policy, which was not followed in these cases.
Failure to Document Physician Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation was reviewed by the physician for a resident with heart failure and dementia. The resident was admitted on 01/15/2024, and a medication regimen review (MRR) conducted between 02/01/2024 and 02/07/2024 included a recommendation for a primidone level. However, there was no documentation to indicate that the physician reviewed or responded to this recommendation. The Director of Nursing (DON) delegated the follow-up of pharmacy recommendations to a quality assurance nurse, who in turn sent the recommendations via text message to the physician. The nurse only documented responses when the physician agreed with the recommendations and made changes, but did not document when the physician disagreed or did not respond. This led to a lack of evidence that the physician reviewed the pharmacist's recommendation for the resident's laboratory request. Interviews with the DON and the quality assurance nurse revealed that the nurse did not recall if the physician responded to the recommendation for the resident's laboratory request and acknowledged the absence of documentation. The DON stated that the physician addressed the recommendation but failed to document it, and the nurse followed up but did not document the outcome. The Administrator expected accurate and complete documentation of pharmacy recommendations and physician responses, including whether the physician agreed or disagreed with the pharmacist's recommendation, in the resident's progress notes.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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