The Californian Pasadena Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 120 Bellefontaine Street, Pasadena, California 91105
- CMS Provider Number
- 055480
- Inspections on file
- 33
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Californian Pasadena Healthcare during CMS and state inspections, most recent first.
A resident admitted with a PICC line and multiple complex diagnoses did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident required significant assistance with daily activities and had moderately impaired cognition. Facility staff confirmed that no baseline care plan was created to address the PICC line care, including dressing changes and infection monitoring, resulting in a lack of appropriate care and assessment for this critical area.
A resident with a PICC line did not have their dressing changed and documented according to facility policy, as required every seven days. The DON and ADON confirmed that the dressing change was either not performed or not documented, resulting in a failure to follow professional standards for central line care.
A facility area contained accident hazards and lacked adequate staff supervision to prevent accidents, as observed by surveyors. This deficiency was identified through direct observation and review of facility practices.
A resident with dementia and a history of falls was left unattended in a shower room by a CNA, resulting in a fall and head injury. The resident required maximal assistance for showering, as indicated in their care plan, but was left without adequate supervision. This led to the resident being hospitalized with multiple rib fractures.
The facility failed to maintain the dignity of two residents by not providing a dignity bag for a resident with an indwelling catheter and not assisting another resident with eating, leading to food crumbs on her clothing. These actions were contrary to the facility's policy on dignity, which aims to prevent demeaning practices.
The facility failed to develop discharge care plans for two residents, both of whom had complex medical conditions and were scheduled for discharge with home health services. The Social Service Director admitted responsibility for the oversight, and the Director of Nursing highlighted the importance of discharge care plans to prevent readmissions. The facility's policy requires individualized post-discharge plans, which were not provided for these residents.
The facility failed to document communication records for two residents receiving hemodialysis, missing crucial documentation for multiple sessions. Despite physician orders, there was no evidence of dialysis sessions being recorded, which is essential for monitoring residents' conditions and ensuring appropriate post-dialysis care. The facility's policy requires documented collaboration with the dialysis unit, which was not maintained.
The facility failed to label dry food items with use by dates and discard expired refrigerated foods, as observed by the Dietary Supervisor. Unlabeled sugar-free beverage crystals, expired whole grain bread, and unlabeled jars of jelly were found. Additionally, expired frozen bread and crab cakes without a use by date were identified, contrary to the facility's food storage policy.
The facility failed to properly dispose of garbage, as observed with two uncovered dumpsters, one of which was overflowing. The Infection Prevention Nurse and Administrator acknowledged the risk of pest attraction and infection spread due to this oversight. Facility policy requires garbage containers to have tight-fitting lids and be covered when not in use.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident with pneumonia and COPD struggled to reach a call light on the floor, while another with metabolic encephalopathy and heart disease had a call light under the bed. Staff confirmed the importance of accessible call lights, aligning with facility policies.
A facility failed to maintain the required head elevation for a resident with a gastrostomy tube during feeding, as per physician's orders and facility policy. The resident, who was dependent on staff for positioning and lacked decision-making capacity, had their head of bed elevated at only 20 degrees instead of the required 30 to 45 degrees, increasing the risk of aspiration.
A resident with atrial fibrillation and a history of myocardial infarction did not receive Apixaban for five days due to it being out of stock. The resident expressed concern, and the facility's staff confirmed the omission, noting that the physician was not notified to find an alternative. Facility policies require timely medication administration, which was not followed.
A facility failed to ensure a physician addressed a medication regimen review for a resident on Seroquel, as recommended by a consultant pharmacist. Despite the absence of psychosis indicators, the resident continued on the same dosage without a documented gradual dose reduction (GDR) or clinical rationale for not attempting one. The Assistant Director of Nursing confirmed the lack of physician response, which was required by facility policy.
A facility failed to perform a gradual dose reduction (GDR) for a resident on Seroquel or document a clinical rationale for why a GDR was contraindicated. Despite a consultant pharmacist's recommendation for a dose review, the facility did not ensure a physician's response or any change in dosage. The resident, with Alzheimer's and psychosis, showed no episodes of psychosis for several months, yet remained on the same medication dose, contrary to the facility's policy on medication tapering.
The facility failed to follow infection control practices for two residents. A resident's used urinal was left next to uncovered food, and another resident's catheter drainage bag was touching the floor. Both situations were acknowledged by staff as violations of the facility's infection prevention policies, posing potential infection risks.
A facility failed to implement its norovirus prevention policy by not cohorting staff assignments after a resident tested positive for norovirus. This oversight placed other residents, staff, and visitors at risk of exposure. Despite the policy requiring staff to care for one resident cohort and not move between cohorts, staff assignments included both symptomatic and asymptomatic residents, increasing the risk of spreading the virus.
A resident with multiple health conditions requiring substantial assistance was left unattended on a bedside commode for about 40 minutes in an LTC facility. Despite the care plan indicating a risk for falls and the need for timely response to call lights, the resident's call for assistance went unanswered. The CNA who assisted the resident initially informed the charge nurse but failed to ensure the assigned CNA was aware, leading to a lack of supervision and potential risk for accidents.
A resident with dementia and aphasia reported being fondled by a male CNA during the night. The facility failed to investigate the allegation or suspend the CNA, contrary to its abuse policy, which requires thorough investigation and suspension of accused staff. The DON and Administrator acknowledged the oversight.
A CNA failed to wear an isolation gown when entering a COVID-19 positive resident's room, despite clear precaution signs. The resident had a history of Klebsiella Pneumoniae and required contact and droplet precautions. Staff interviews revealed a lack of communication and awareness of infection control protocols, with the DON and Administrator stressing the need for proper PPE use and staff education.
The facility failed to administer medications safely and timely for two residents. One resident received expired Tobramycin-Dexamethasone and was not given the prescribed Timolol Maleate for glaucoma. Another resident was given Tylenol for pain levels that did not meet the physician's order. These actions were confirmed by the LVN and QA nurse, highlighting a failure to follow medication administration policies.
A facility failed to follow infection prevention procedures during medication administration for a resident. An LVN did not wash hands before administering oral medications and did not perform hand hygiene before wearing gloves and administering eye drops. The resident had multiple medical conditions, and the LVN admitted to not performing hand hygiene as required by the facility's policy.
A resident's call light was repeatedly ignored by staff, including an LVN, CNA, and RN, despite being visible and audible. The resident, admitted with mobility issues, reported waiting up to an hour for assistance, contrary to the facility's policy requiring immediate response.
The facility failed to update care plans and reassess fall risks for two high fall risk residents after falls, leading to repeated incidents and hospital transfers. Despite being identified as high risk, the care plans for these residents were not reviewed or updated with new interventions, and no investigations were conducted following the falls, contrary to facility policies.
Failure to Develop Baseline Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with a peripherally inserted central catheter (PICC line). The resident's admission record indicated diagnoses of obstructive hydrocephalus, type 2 diabetes mellitus without complications, and malignant neoplasm of the brain. Upon admission, the resident had a right antecubital PICC line, which was intact and showed no signs of infection. The Minimum Data Set (MDS) assessment documented that the resident had moderately impaired cognitive skills and required substantial to maximal assistance with daily activities, and was dependent for several self-care tasks. The MDS also confirmed the presence of a central line (PICC) on admission. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that a baseline care plan addressing the resident's PICC line care, including dressing changes, site monitoring for infection, and assessment, was not created within the required 48-hour timeframe. The facility's policy and procedure required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in the resident's case. The absence of a baseline care plan resulted in the resident not receiving appropriate care, monitoring, and assessment specific to the PICC line.
Failure to Document and Perform Timely PICC Line Dressing Change
Penalty
Summary
A deficiency occurred when the facility failed to provide care and dressing changes for a peripherally inserted central catheter (PICC line) in accordance with professional standards and the facility's own policy for one resident. The resident, who had diagnoses including obstructive hydrocephalus, type 2 diabetes mellitus, and malignant neoplasm of the brain, was admitted with a right antecubital PICC line. The facility's policy required that the PICC line dressing be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. However, there was no documentation that the dressing was changed on or before the required date. During interviews and record reviews, the DON confirmed that it was the responsibility of the Treatment Nurse or RN Supervisor to change the dressing and document the procedure. The Assistant DON stated she had changed the dressing but could not recall the date and admitted she did not document the change in the medical record. The DON acknowledged that if the dressing change was not documented, it was considered not done, and confirmed that the facility's policy was not followed in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight by staff to mitigate these risks. The deficiency was identified based on direct observation and review of facility practices related to accident prevention.
Resident Fall Due to Inadequate Supervision in Shower
Penalty
Summary
The facility failed to ensure that a resident, who was assessed at risk for falls and had a diagnosis of dementia, was free from falls and injury in accordance with their care plan. On the day of the incident, a Certified Nurse Assistant (CNA) left the resident unattended in the shower room while turning away to grab a clean towel and chucks. This action resulted in the resident leaning forward and falling from the shower chair, striking her head and sustaining a hematoma. The resident, who had a history of falls and was assessed to require maximal assistance for showering, was left without adequate supervision. The CNA, who was assisted by a student, did not ensure another CNA was present to help, despite the resident's known fall risk and need for constant supervision. The resident's care plan and evaluations by occupational and physical therapists indicated the necessity for maximal assistance and continuous supervision during showers, which was not adhered to during the incident. The fall resulted in the resident being transferred to a hospital, where she was found to have multiple rib fractures and was admitted to the Intensive Care Unit. The Director of Nursing confirmed that the facility's policy on fall risk management was not followed, as the resident was left unattended in a wet environment, increasing the risk of falls. The CNA's failure to maintain supervision directly contributed to the resident's fall and subsequent injuries.
Failure to Maintain Resident Dignity and Provide Necessary Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity according to the facility's policy. Resident 222, who was admitted with diagnoses including pneumonia, COPD, and neurogenic bladder, had an indwelling catheter without a dignity bag to cover the urine drainage bag. This oversight was observed during an interview with the resident, who expressed discomfort at seeing the drains and urine, stating it made him feel weak. A Certified Nursing Assistant confirmed the absence of a dignity bag and acknowledged the importance of using one to promote respect and dignity for residents. Resident 11, admitted with conditions such as cerebrovascular disease, Parkinson's disease, and quadriplegia, was observed in the dining room with food crumbs on her shirt and table while eating without assistance. Despite needing supervision and assistance with eating due to her tremors and difficulty holding a spoon, no staff was present to help her. A Restorative Nursing Assistant confirmed the resident's need for assistance and noted that the presence of food crumbs could affect the resident's dignity and discourage her from eating. The facility's policy on dignity prohibits practices that compromise resident dignity, such as failing to assist residents in maintaining cleanliness and covering urinary catheter bags.
Failure to Develop Discharge Care Plans for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 70 and Resident 71, had a discharge care plan in place, which is a requirement for effective transition to post-discharge care. Resident 70 was admitted with multiple diagnoses, including type 2 diabetes mellitus, muscle weakness, and cognitive communication deficit, and was scheduled for discharge with home health services. Similarly, Resident 71, who had a history of fractures, muscle weakness, and dementia, was also set to be discharged with home health services. However, upon review, it was found that neither resident had a discharge care plan documented, which is essential for outlining their goals and needs post-discharge. The Social Service Director (SSD) acknowledged the absence of discharge care plans for both residents, admitting responsibility for this oversight. The Director of Nursing (DON) emphasized the importance of having discharge care plans to inform residents of their goals and to help meet their needs, thereby preventing potential readmissions. The facility's policy mandates that every resident should have an individualized post-discharge plan, which should be re-evaluated based on any changes in the resident's condition or needs prior to discharge. This policy was not adhered to in the cases of Resident 70 and Resident 71, leading to the identified deficiency.
Failure to Document Dialysis Communication Records
Penalty
Summary
The facility failed to ensure proper communication and documentation for two residents receiving hemodialysis treatment. Resident 122, admitted with chronic kidney disease and other related conditions, did not have Communication Records for Dialysis Residents (CRDR) forms for multiple dialysis sessions. Despite having physician orders for dialysis on specific days, there was no documentation indicating that Resident 122 received dialysis on those dates. The Director of Nursing (DON) confirmed the absence of these records, which are crucial for monitoring the resident's condition and ensuring appropriate post-dialysis care. Similarly, Resident 22, who also depended on renal dialysis, lacked CRDR forms for certain dialysis sessions. The Licensed Vocational Nurse (LVN) acknowledged the missing documentation, which is necessary for communicating the resident's condition and monitoring potential side effects and complications from dialysis. The facility's policy requires documented evidence of collaboration and communication between the facility and the dialysis unit, which was not maintained in these cases. The DON emphasized the importance of having these communication forms to check for new orders, medications, and to document post-dialysis vital signs and complications.
Deficiency in Food Labeling and Expiration Management
Penalty
Summary
The facility failed to ensure that dry food items removed from their original packaging were labeled with a use by date, and refrigerated foods that had expired were discarded. During an observation in the facility's kitchen, the Dietary Supervisor (DS) identified a package of assorted sugar-free beverage crystals that was not labeled with a use by date, indicating it was no longer suitable for human consumption. The DS acknowledged that the package should have been labeled by the staff responsible for labeling packages with delivery, open, and expiration dates. Additionally, a loaf of whole grain bread was found past its expiration date, which the DS stated should have been discarded to prevent potential gastrointestinal issues for residents. Further observations revealed two jars of pear honey and ginger jelly in the dry storage room without a use by date label. In the kitchen, a box of frozen bread with an expired use by date was found in the freezer, which the DS confirmed should have been discarded. Additionally, a box of frozen crab cakes in the freezer lacked a use by date, and the DS was uncertain about its safety for consumption. The facility's policy on food receiving and storage mandates that dry foods stored in bins be labeled and dated with a use by date, and all refrigerated or frozen foods be covered, labeled, and monitored to ensure they are used by their use by date or discarded.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per its policy, which led to a deficiency. During an observation and interview with the Infection Prevention Nurse (IPN), it was noted that two dumpsters located outside the facility by the parking lot were not covered. One dumpster was overflowing with garbage, and both lacked proper covering. The IPN acknowledged that the dumpsters should be covered to prevent the attraction of pests, which could lead to the spread of infection affecting both staff and residents. In a subsequent interview with the Administrator (ADM), it was confirmed that maintaining cleanliness in the garbage area is the responsibility of the maintenance and kitchen staff. The ADM stated that dumpster covers should remain closed and not be filled beyond the full line to prevent pest infestation, which could impact the health of residents and staff. A review of the facility's policies and procedures indicated that all garbage containers should have tight-fitting lids and be kept covered when not in use, especially those containing food waste, to make them inaccessible to pests.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, which is essential for residents to request assistance. Resident 222, who was admitted with pneumonia, COPD, and neurogenic bladder, was observed struggling to reach his call light, which was found on the floor. Certified Nursing Assistant 4 confirmed that the call light should have been on the bed and within reach, emphasizing the importance of accessibility for residents to call for help. The Director of Nursing also stated that call lights on the floor are unacceptable as they prevent residents from reaching out for assistance. Similarly, Resident 126, admitted with metabolic encephalopathy, hypertensive heart disease, atrial fibrillation, and chronic kidney disease, was found unable to reach his call light, which was under the bed. Certified Nursing Assistant 1 acknowledged that the call light was not within reach and should be accessible to ensure timely assistance, especially during emergencies. The facility's policies on accommodating needs and answering call lights both indicate that call lights should be easily accessible to residents at all times.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 54, had the head of their bed elevated at a minimum of 30 degrees during tube feeding infusion, as per the facility's policy and physician's orders. Resident 54 was admitted with a diagnosis of dysphagia and had a gastrostomy tube for nutrition. The resident was dependent on staff for various activities, including positioning, and did not have the capacity to make decisions. The physician's order required the head of the bed to be elevated between 30 to 45 degrees during and one hour after enteral feeding. During an observation, it was noted that the resident's head of bed was elevated at approximately 20 degrees while the tube feeding was infusing, which was below the required minimum. Licensed Vocational Nurse 4 confirmed the inadequate elevation and acknowledged the risk of aspiration due to the resident's need for assistance in turning. The Director of Nursing emphasized the importance of following physician's orders to prevent aspiration, aligning with the facility's policy that mandates a minimum 30-degree elevation during and after feeding.
Failure to Administer Prescribed Anticoagulant
Penalty
Summary
The facility failed to ensure that a resident received Apixaban, a medication prescribed to prevent blood clots, as indicated on the physician's order. The resident, who was admitted with a diagnosis of atrial fibrillation and a history of myocardial infarction, did not receive the medication for five consecutive days due to it being out of stock. This lapse was confirmed during an interview with the resident, who expressed concern about not receiving the medication necessary for her heart condition. The resident's medical records indicated a need for anticoagulant therapy to manage her condition. Licensed Vocational Nurse 3 confirmed that the resident did not receive Apixaban on the specified dates and acknowledged that there was no documentation of the facility physician being notified about the medication's unavailability. The Director of Nursing verified the omission and stated that the licensed nurses should have informed the physician to find an alternative medication. The facility's policies on pharmacy services and medication administration emphasize the importance of having a sufficient supply of prescribed medications and the need for timely administration, which were not adhered to in this case.
Failure to Address Medication Regimen Review for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a physician addressed the medication regimen review (MRR) for a resident, specifically regarding the use of Seroquel, a medication used to treat psychosis. The consultant pharmacist recommended a gradual dose reduction (GDR) for the resident's Seroquel dosage, but there was no documentation indicating that the physician responded to this recommendation or provided a clinical rationale for not attempting a GDR. This oversight was identified during a review of the resident's clinical records and interviews with facility staff. The resident in question, identified as Resident 52, was admitted to the facility with diagnoses including Alzheimer's disease and psychosis. The Minimum Data Set (MDS) for the resident indicated that they had been taking an antipsychotic medication routinely and that a GDR had not been attempted or documented as clinically contraindicated. Despite the absence of psychosis indicators or mood and behavioral symptoms, the resident continued to receive the same dosage of Seroquel since March 2024. Interviews with the Assistant Director of Nursing (ADON) confirmed that the facility did not ensure a physician's response to the pharmacist's recommendation for a GDR. The ADON acknowledged that the physician should have responded within one to two days of the pharmacist's report. The facility's policies and procedures require medication regimen reviews upon admission and at least monthly, with physician responses maintained as part of the permanent medical record. However, in this case, the facility did not adhere to these policies, increasing the risk of adverse effects for the resident.
Failure to Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) for a resident using Seroquel, a medication for treating psychosis, or document a clinical rationale for why a GDR was contraindicated. The resident, who was admitted with Alzheimer's disease and psychosis, had been on a routine dose of Seroquel without any attempts at dose reduction or documentation of contraindications. The Minimum Data Set (MDS) indicated that the resident had severe cognitive impairment but no mood or behavioral symptoms, and no episodes of psychosis were recorded for several months. The Assistant Director of Nursing (ADON) confirmed that the facility did not ensure the physician responded to a consultant pharmacist's recommendation to consider a dose change for the resident's Seroquel. The pharmacist's recommendation, dated several months prior, noted the need for a psychotropic drug regimen review and evaluation for dose reduction. Despite this, there was no documentation of any response from the physician or any change in the medication dosage since March of the same year. The facility's policy on tapering medication and gradual drug dose reduction requires periodic review of medication necessity and appropriate tapering when conditions improve or stabilize. However, the facility did not adhere to this policy, as evidenced by the lack of documentation or action regarding the resident's Seroquel dosage. This oversight increased the risk of adverse effects for the resident, as noted by the ADON during an interview.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to standard infection prevention control practices for two residents, leading to potential infection risks. For Resident 126, a used urinal containing urine was placed next to an uncovered cup of water and a cup of oatmeal on the bedside table. This was observed during an interview with the resident, who mentioned that the CNA was asked to empty the urinal earlier. Both the LVN and the DON confirmed that the urinal should not have been left near the resident's food, as it violates the facility's infection prevention policy, which mandates maintaining hygiene and preventing contamination. For Resident 273, the facility did not ensure proper catheter care, as the resident's urinary catheter drainage bag was observed touching the floor. This was noted during an observation with an RN, who acknowledged that the bag should not be in contact with the floor due to the risk of infection. The DON confirmed that the facility's catheter care policy requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Both instances demonstrate a failure to follow the facility's infection control policies, placing residents at risk for potential infections.
Failure to Cohort Staff During Norovirus Outbreak
Penalty
Summary
The facility failed to implement its policy and procedure for norovirus prevention and control, which resulted in a deficiency. The issue arose when the facility did not cohort staff assignments after receiving a positive norovirus result for a resident. This failure to cohort staff placed all other residents, staff, and visitors at risk of exposure to norovirus. The facility's policy required that staff care for one resident cohort on their unit and not move between resident cohorts, which was not followed. The report details the cases of three residents who exhibited symptoms consistent with norovirus, such as diarrhea, vomiting, and nausea. One resident tested positive for norovirus, while the other two showed symptoms but were not confirmed. Despite the positive test result and symptomatic residents, the facility did not assign separate staff to care for these residents, leading to mixed cohorts of symptomatic and asymptomatic residents. Interviews with facility staff, including the Infection Preventionist, Director of Staff Development, and Assistant Director of Nursing, confirmed that the facility did not follow its policy to cohort staff assignments. The staff acknowledged that the failure to cohort assignments increased the risk of spreading the virus. The facility's policy clearly stated that during an outbreak, staff should care for one resident cohort and not move between cohorts, which was not adhered to in this case.
Resident Left Unattended on Bedside Commode
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was left unattended on a bedside commode for an extended period. The resident, who had been admitted with conditions including acquired deformities of the left lower leg, enterocolitis due to Clostridium difficile, abnormal gait and mobility, and severe protein-calorie malnutrition, required substantial assistance for activities of daily living. Despite being assessed as low risk for falls, the resident's care plan indicated a risk for falls due to medication use and required timely response to call lights and assessment of toileting needs. On the day of the incident, a CNA assisted the resident to the bedside commode and instructed the resident's daughter to use the call light when assistance was needed. However, the CNA left the room and did not return to assist the resident, who was left on the commode for approximately 40 minutes. The resident's daughter eventually had to assist the resident back to bed after the call light went unanswered for an extended period. Interviews with facility staff revealed a lack of communication and follow-up, as the CNA informed the charge nurse but did not ensure the resident's assigned CNA was aware of the situation. The facility's policy on activities of daily living and fall risk management emphasized the need for appropriate support and assistance for residents unable to carry out ADLs independently. However, the failure to provide timely assistance and supervision placed the resident at risk for accidents, such as falls, due to the prolonged period on the commode without staff supervision. The incident highlights a breakdown in communication and adherence to established care protocols within the facility.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure for a resident by not thoroughly investigating an allegation of sexual abuse. The resident, who was admitted with diagnoses of dementia and aphasia, reported being fondled by a male staff member during the nighttime or early morning hours. The facility's records indicated that a male Certified Nursing Assistant (CNA) was assigned to the resident during the relevant shift. However, the facility did not take appropriate action to investigate the allegation or suspend the staff member involved. The Director of Nursing and the Administrator both acknowledged that the facility should have reviewed the staffing records for the shift in question and suspended the CNA pending further investigation. The facility's policy requires that all allegations of abuse be thoroughly investigated and that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow these procedures placed the resident at risk for elder abuse.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, as evidenced by a Certified Nursing Assistant (CNA 3) not wearing an isolation gown while entering the room of a resident who tested positive for COVID-19. The resident, admitted with a diagnosis of Klebsiella Pneumoniae and resistance to multiple antimicrobial drugs, required contact and droplet precautions due to their COVID-19 status. Despite the presence of a precaution sign outside the resident's room, CNA 3 entered without the necessary protective equipment, stating unawareness of the resident's COVID-19 status and neglecting to read the precaution sign. Interviews with staff revealed a lack of communication and awareness regarding the infection control protocols. The Licensed Vocational Nurse (LVN 2) acknowledged the need to inform CNA 3 about residents' COVID-19 status, while the Director of Nursing (DON) emphasized the importance of educating staff on the use of Personal Protective Equipment (PPE). The Administrator also highlighted the necessity for staff to be knowledgeable about residents' isolation precautions and the appropriate PPE required. The facility's policy, revised prior to the incident, mandated the use of gowns for staff entering rooms of residents in isolation, which was not followed in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medication in a safe and timely manner for two residents. Resident 1 did not receive Tobramycin-Dexamethasone ophthalmic suspension within the 30-day period after opening as per the facility's policy. Additionally, Resident 1 was administered Tobramycin-Dexamethasone instead of the prescribed Timolol Maleate for glaucoma, and the medication was not found in the medication cart or refrigerator. This oversight was confirmed by the Licensed Vocational Nurse (LVN) and the Quality Assurance (QA) nurse, who emphasized the importance of verifying medication expiration dates and following physician orders to ensure resident safety and medication efficacy. Resident 2 was administered Tylenol for pain despite reporting a pain level of two to three, which did not meet the physician's order for Tylenol to be given for moderate pain levels of four to six. The LVN acknowledged the discrepancy and the potential risk of medication dependency due to inappropriate administration. The QA nurse reiterated the necessity of adhering to physician orders, including pain parameters, to ensure the efficacy of the medication and reduce the risk of addiction. The facility's policies and procedures for administering medications were reviewed and found to require that medications be administered in a safe and timely manner, as prescribed. The policies also specified that medications should be administered within one hour of their prescribed time unless otherwise specified. The deficiencies observed in the administration of medications to Residents 1 and 2 highlight a failure to comply with these policies, potentially compromising the residents' health and well-being.
Failure to Follow Infection Prevention Procedures During Medication Administration
Penalty
Summary
The facility failed to follow infection prevention procedures during medication administration for one resident. Specifically, a Licensed Vocational Nurse (LVN) did not wash hands before administering oral medications and did not perform hand hygiene before wearing gloves and administering ophthalmic medications. This was observed during a medication administration session where the LVN entered the resident's room without performing hand hygiene and administered several oral medications. The LVN also applied gloves without washing hands and attempted to administer eye drops, touching various surfaces and the resident's face without proper hand hygiene. The resident involved had a history of falling, difficulty in walking, muscle weakness, hypertension, glaucoma, hyperlipidemia, and benign prostatic hyperplasia. The resident's cognitive skills for daily decision-making were moderately impaired, but there was no impairment in the range of motion in the upper and lower extremities. The LVN admitted to not performing hand hygiene before entering the resident's room and administering eye drops. The facility's quality assurance nurse confirmed that staff should sanitize their hands before and after medication administration and wash their hands when administering eye drops, as per the facility's policy on hand hygiene.
Failure to Respond to Call Light Promptly
Penalty
Summary
The facility failed to ensure that the call light device, a critical communication tool for residents to request assistance, was answered promptly for one of the residents. On multiple occasions, staff members, including a Licensed Vocational Nurse (LVN), a Certified Nurse Assistant (CNA), and a Registered Nurse (RN), either ignored or failed to respond to the call light of a resident who had been admitted with conditions such as difficulty in walking and muscle weakness. The resident's care plan emphasized the importance of timely response to the call light to prevent falls and ensure safety. Observations revealed that the call light was left unanswered despite being visible and audible to staff members. Interviews with staff confirmed that the call light should be answered promptly to prevent accidents and maintain resident dignity. The resident reported experiencing delays of 30 minutes to an hour before receiving assistance, particularly during busy shifts, leading to feelings of discouragement. The facility's policy mandates immediate response to call lights, which was not adhered to in this instance.
Failure to Update Care Plans and Assessments for High Fall Risk Residents
Penalty
Summary
The facility failed to ensure the safety and prevent falls for two high fall risk residents, Resident 2 and Resident 3. Resident 2, admitted with diagnoses including muscle weakness and traumatic subarachnoid hemorrhage, was identified as high risk for falls. Despite this, the facility did not update Resident 2's care plan or reassess the fall risk after a fall on April 25, 2024, which resulted in a head injury requiring hospital transfer. The care plan was not reviewed or updated to include new interventions to prevent further falls, leading to another fall on May 4, 2024, where Resident 2 was found unresponsive and required emergency medical attention. Resident 3, admitted with difficulty walking and muscle weakness, was also not adequately protected from falls. After a fall on April 9, 2024, which resulted in a laceration and hospital transfer, the facility failed to initiate a care plan or accurately update the fall risk assessment. The assessment incorrectly indicated no history of falls, which did not reflect the resident's actual condition and needs. This oversight placed Resident 3 at continued risk for falls without appropriate interventions in place. The Director of Nursing acknowledged that no investigations were conducted for the falls involving Resident 2 and Resident 3, as there were no injuries deemed serious. However, this lack of investigation and failure to update care plans and assessments contravened the facility's policies on safety and supervision, which emphasize the importance of identifying fall causes and updating care plans to prevent future incidents.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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