The Canyons Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Colton, California.
- Location
- 1350 Reche Canyon Rd, Colton, California 92324
- CMS Provider Number
- 555435
- Inspections on file
- 63
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Canyons Post-acute during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and documented CRAB/KPC infection was on contact precautions with physician orders and facility policy requiring staff to wear gown and gloves before entering the room and to follow hand hygiene and glove-use protocols. Despite isolation signage on the door, a CNA entered the room and picked up the resident’s call light from the floor without wearing gloves, later stating she had forgotten, while the ADON and DSD confirmed this was unacceptable and contrary to the facility’s isolation procedures.
Surveyors found that staff failed to keep call lights within reach for two residents, one with chronic respiratory failure and another with hemiplegia, hemiparesis, and a tracheostomy. In one case, a CNA located the resident’s call light on the floor while the resident was in bed; in the other, the ADON found the call light wrapped around a bed rail, out of the resident’s reach. These situations did not comply with the facility’s policy requiring call lights to be within easy reach when residents are in bed or confined to a chair, creating the potential for delayed assistance, unmet care needs, and possible injury.
A resident with anxiety disorder, hematuria, and psychosis was transferred to a GACH after intentionally removing a catheter, causing profuse bleeding. Nursing staff documented the transfer and MD notification, and an LVN reported calling the resident’s daughter only to inform her of the hospital transfer. Facility records claimed the daughter was notified of a 7‑day bed‑hold option and declined it, but the form lacked the time of the call and the staff member’s name. The RN Supervisor denied making any bed‑hold notification call, and the daughter reported receiving no verbal or written information about bed‑hold rights. Review of the facility’s Bed‑Holds and Returns policy with the DON and ADON confirmed that required written information about bed‑hold rights at or shortly after transfer was not provided, and the DON acknowledged the policy was not followed.
Two residents with significant medical histories, including repeated falls and a recent fracture, were found unable to access their call lights due to improper placement and obstruction by furniture. Staff interviews and policy review confirmed that call lights were not within reach as required, and facility leadership acknowledged the deficiency.
The facility did not ensure continuous RT coverage for several hours during a night shift, leaving residents without access to a respiratory therapist. A resident reported that nurses were unable to operate respiratory equipment, resulting in the resident remaining off the machine. Staff interviews and timesheet reviews confirmed the absence of RT staff, and the DON acknowledged the facility did not follow its staffing policy.
A resident with end stage renal disease missed two scheduled dialysis treatments after readmission due to the facility's failure to obtain necessary consent and complete required paperwork, resulting in the resident being sent to an acute hospital for treatment. Staff interviews revealed confusion about the process for re-establishing dialysis services and a lack of timely follow-up on required documentation.
A CNA did not perform hand hygiene after removing PPE when leaving the isolation rooms of two residents on contact precautions for MDROs. The CNA stated she did not clean her hands because she believed she had not touched anything, despite facility policy and CDC guidelines requiring hand hygiene after glove removal. The DON confirmed that hand hygiene should have been performed.
Two residents who were clinically compromised and dependent on ventilators were found to be using equipment that was overdue for scheduled preventative maintenance. Staff interviews confirmed that the facility's policy for routine equipment maintenance was not followed, and the process for notifying and arranging service was not effectively implemented.
Three residents with complex medical conditions were found soiled and wet, with their briefs and linens saturated, due to lapses in timely incontinence care. Staff interviews confirmed that residents were not changed as required by the facility's ADL policy, and the DON acknowledged that residents should not have been left in this condition.
A resident's admission MDS assessment was not completed within the required 13-day timeframe after admission, as it was finalized on March 6, 2025, instead of within the allowed period. The MDS Coordinator admitted the delay was due to being busy, and the facility lacked a specific policy for MDS assessments, relying on the RAI Manual instead.
A resident's discharge MDS was inaccurately coded, indicating discharge to a hospital instead of home with hospice services. Facility staff, including the MDS Coordinator and DON, confirmed the error, acknowledging the resident was discharged home with hospice as per family request.
A facility failed to monitor a resident for adverse drug reactions or side effects related to the use of Zyprexa, an antipsychotic medication. Despite facility policy requiring monitoring, the resident's order summary lacked such orders. Interviews with LVNs and the DON confirmed the absence of monitoring orders, which should have been initiated when the medication was prescribed.
A facility failed to disinfect a clipboard between uses for two residents requiring contact precautions due to carbapenem-resistant infections. An LVN moved the clipboard between the residents' beds without cleaning it, contrary to the facility's policy. Interviews with staff confirmed the oversight and the importance of using Clorox wipes for disinfection to prevent cross-contamination.
Three residents experienced prolonged wait times for assistance due to staffing shortages and non-compliance with ADL policies. A resident with chronic respiratory failure waited over an hour for help, while another with necrotizing fasciitis faced similar delays. A third resident with a stage 4 pressure ulcer also experienced care delays. CNAs reported systemic staffing issues, with management aware but not effectively addressing them. The DON acknowledged expectations for prompt response to call lights, but these were not consistently met, risking residents' health.
Two residents reported issues with the shower room, including uneven flooring, fractured tiles, and permanent residue on the walls. The room was described as dirty, with gloves on the floor and inconsistent hot water availability. The Director of Maintenance and Housekeeping confirmed these issues, and the Director of Nursing acknowledged the room's unclean appearance. The facility's maintenance policy was not followed, impacting residents with osteomyelitis, type 2 diabetes, chronic respiratory failure, a tracheostomy, and epilepsy.
A resident in a persistent vegetative state was left unattended during care, leading to a fall and injury. The CNA left to gather supplies, and upon returning, found the resident on the floor with a cut and dislodged G-tube. The resident was transferred to a hospital for evaluation. Known tendencies of the resident to lean forward when coughing were not addressed with appropriate fall precautions.
The facility failed to respond to call lights in a timely manner, affecting three residents with significant medical conditions. One resident reported waiting over 20 minutes for assistance at night, another typically waited an hour, and a third experienced a six-hour delay, leading to discomfort from an unchanged diaper. Staff acknowledged the delays, citing understaffing as a reason, despite a policy requiring responses within 10 to 15 minutes.
A resident with multiple health issues refused wound care for three days, but the facility failed to document these refusals properly or notify the physician. The treatment nurse only observed the wounds without performing necessary treatments, and the TAR was inaccurately marked as completed. This lack of documentation and communication led to the resident's condition worsening, resulting in an infection and hospital stay.
A resident with complex medical needs was admitted to a facility without a comprehensive nursing assessment, leading to a critical error where enteral feeding was connected to a paracentesis drainage tube instead of a gastrostomy tube. This resulted in severe abdominal pain and subsequent death after being transferred to a hospital.
A resident with complex medical needs experienced a fatal incident due to a nurse's error in a LTC facility. The nurse mistakenly infused enteral feeding into a paracentesis drainage tube instead of the gastrostomy tube, leading to severe abdominal pain and hospitalization. Interviews revealed that staff lacked specific training on managing paracentesis drainage tubes, contributing to the error.
Two residents in the facility experienced significant delays in staff responses to call lights, contrary to the facility's policy. One resident, with a self-care deficit due to deconditioning, reported delays of up to two hours, particularly during night shifts, and infrequent repositioning. Another resident, with chronic kidney disease and other health issues, faced delays of 30 minutes or more, affecting their ability to receive timely assistance with daily activities. Both residents' care plans emphasized the need for prompt response to call lights, which was not consistently followed.
A resident developed a stage 4 pressure ulcer due to the facility's failure to follow its policy of repositioning dependent residents every two hours. The resident, who required maximum assistance for bed mobility, reported delayed staff responses and inadequate repositioning, leading to the ulcer's development.
Failure to Follow Contact Precaution PPE Requirements
Penalty
Summary
The facility failed to maintain infection control practices for a resident on contact-precaution isolation when a CNA did not follow required personal protective equipment (PPE) protocols. The resident had chronic respiratory failure and a documented infection with Klebsiella pneumoniae, and a physician’s order dated June 1, 2023, directed contact precautions every shift for CRAB and KPC infection, including wearing a gown and gloves before entering the room or caring for the resident. Facility policy titled “Isolation - Categories of Transmission-Based Precautions,” dated October 2018, required staff and visitors to wear clean, non-sterile gloves when entering the room, to change gloves after contact with infective material, to remove gloves and perform hand hygiene before leaving the room, and to avoid touching potentially contaminated environmental surfaces or items after gloves were removed. On the survey date, signage on the resident’s door indicated the resident was on contact precautions. During observation at 10:45 AM, the CNA was seen in the resident’s room picking up the resident’s call light from the floor without wearing gloves. In a concurrent interview, the CNA acknowledged she had forgotten to wear gloves and stated she understood the importance of wearing gloves to protect herself and the resident. In separate interviews, the ADON and the DSD each stated it was unacceptable for the CNA to be in the contact isolation room without gloves and confirmed that all staff were required to follow the established isolation protocols, including glove use in contact isolation rooms.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure resident call lights were within reach as required by facility policy. For one resident with chronic respiratory failure and Klebsiella pneumoniae, an observation and interview with a CNA in the resident’s room found the resident lying in bed while the call light was located on the floor, out of the resident’s reach. The CNA searched for the call light, located it on the floor, and stated that the call light should be within the resident’s reach. In a separate observation and interview with the ADON involving another resident with hemiplegia and hemiparesis affecting the right dominant side and tracheostomy status, the resident was also lying in bed when the ADON searched for the call light and found it wrapped around the bed rail, not within the resident’s reach. The ADON stated that staff must have neglected to place the call light within reach after attending to the resident and described this as unacceptable. Review of the facility’s undated “Answering the Call Light” policy indicated that when a resident is in bed or confined to a chair, the call light is to be within easy reach of the resident. These observations showed that staff did not follow the facility’s policy for two of four sampled residents, which the report states had the potential to delay their ability to request assistance when needed, increasing the risk of unmet care needs and possible injury.
Failure to Notify Resident Representative of Bed-Hold Rights at Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its Bed-Holds and Returns policy for a resident who was transferred to a general acute care hospital. The resident, who had diagnoses including anxiety disorder, hematuria, and psychosis, was initially admitted on an unspecified date and had his daughter listed as his responsible party. On January 4, 2026, nursing notes documented that at approximately 4:45 a.m. a CNA sitter informed an RN and LVN that the resident had removed his catheter. The charge nurse and RN found the resident in bed with profuse bleeding from the penis. The RN documented that the resident stated he had purposely pulled out his catheter because he wanted to be sent out, and the sitter witnessed the resident pull out the catheter. The MD was notified, an ambulance was called around 5:00 a.m., and the resident left the facility at 5:05 a.m. with ambulance personnel. A review of the facility’s Bed Hold Policy and Notification form for this resident indicated that the resident’s daughter was notified by phone on January 4, 2026, of the right to hold the bed for seven days and that she declined, but the form did not document the time of the call or the identity of the facility representative. In a subsequent interview, the RN Supervisor stated she did not call the resident’s daughter about the bed hold. The LVN reported that she called the daughter to inform her of the transfer to the hospital but did not inform her about the bed hold. The resident’s daughter stated she had not received any call or mail from the facility regarding the right to exercise the bed hold provision since the transfer. Review of the facility’s Bed-Holds and Returns policy, dated March 2022, with the DON and ADON showed that the policy required residents/representatives to be provided written information about bed-hold policies in advance of transfer and at the time of transfer (or within 24 hours for emergencies). The DON acknowledged the policy was not followed.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents. For one resident with chronic kidney disease and a history of repeated falls, the call light was observed wrapped around the left bed rail with the cord hanging down toward the floor, and the bedside table was placed against the left bed rail, obstructing access to the call light. The resident stated he was unaware of the location of the call light and could not recall the last time he experienced a fall in the facility. For the second resident, who had a nondisplaced bimalleolar fracture and a history of repeated falls, the call light was clipped to the top portion of the bed with the cord oriented away from the resident, making it unreachable. During interviews and observations, a CNA confirmed that both residents were unable to reach their call lights when asked. The CNA and LVN both stated that the facility policy requires call lights to be within reach. The DON and ADON reviewed photographic evidence and confirmed that the call lights were not accessible to the residents, acknowledging that this was not acceptable and that staff are responsible for ensuring call lights are within reach after providing care. The facility's policy was reviewed and specifies that call lights must be within easy reach when residents are in bed or confined to a chair.
Failure to Provide Continuous Respiratory Therapy Coverage
Penalty
Summary
The facility failed to provide continuous respiratory therapy coverage for 41 residents when no respiratory therapist (RT) was on duty for approximately seven hours during a night shift. Interviews with a resident and multiple staff members confirmed that the scheduled RTs called off, and no replacement was found. As a result, there was a gap in RT coverage from 10:10 PM until 4:55 AM the following morning. During this period, a resident reported that nurses were unable to operate their respiratory equipment, leading the resident to remain off the machine, although they had been suctioned before the RT left. Review of the respiratory therapist timesheets corroborated the absence of RT staff during the specified hours. The Director of Nursing acknowledged that the facility did not follow its own staffing policy, which requires sufficient numbers of staff with the necessary skills and competency to provide care in accordance with resident care plans and the facility assessment. The lack of RT coverage was confirmed by both the timesheets and staff interviews.
Failure to Ensure Timely Dialysis for Resident After Readmission
Penalty
Summary
A resident with end stage renal disease, dependent on renal dialysis, was admitted to the facility with orders for hemodialysis on specific days. The resident missed two scheduled dialysis treatments due to a failure in obtaining the necessary consent and completing required paperwork for dialysis services following a readmission from an acute hospital stay. The resident was not able to make their own decisions, and consent from the family was required but not obtained in time. As a result, the resident did not receive dialysis as ordered by the physician and was subsequently sent to an acute hospital for treatment. Interviews with facility staff revealed confusion and lack of clarity regarding the process for re-establishing dialysis services after a resident's discharge and readmission. The Admission Coordinator acknowledged not being aware that the resident needed to be treated as a new admission for dialysis purposes and did not complete the necessary paperwork or obtain consent in a timely manner. The DON confirmed that the responsibility for ensuring dialysis authorization and documentation rested with the facility, and the delay in obtaining consent led to the missed treatments.
Failure to Perform Hand Hygiene After PPE Removal in Isolation Rooms
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to perform hand hygiene after removing personal protective equipment (PPE) upon exiting the isolation rooms of two residents who were on contact precautions for multidrug-resistant organisms (MDROs). During an observation, the CNA was seen leaving the isolation room, doffing gloves and gown, but did not clean her hands afterward. The CNA explained that she did not perform hand hygiene because she believed she had not touched the resident or anything in the room. Review of the clinical records confirmed that both residents were on contact precautions due to MDROs. The Director of Nursing (DON) acknowledged that hand hygiene should have been performed after PPE removal. Facility policy and CDC guidelines both require hand hygiene as the final step after removing PPE to prevent the spread of infection.
Overdue Preventative Maintenance on Ventilators
Penalty
Summary
The facility failed to perform timely preventative maintenance on ventilators used by two residents in the Subacute Unit. During an observation, it was noted that the maintenance stickers on both ventilators indicated that their scheduled service dates had already passed—one was due for maintenance in June 2023 and the other in September 2024. Both the Assistant Director of Nursing (ADON) and the respiratory therapist acknowledged that the required maintenance was overdue. The residents involved were clinically compromised and dependent on ventilators for breathing support. Interviews with the ADON, two respiratory therapists, and the administrator revealed that the facility's policy required routinely scheduled maintenance of equipment according to manufacturer guidelines. However, all staff interviewed confirmed that this policy was not being followed. The process described involved respiratory therapists notifying the ADON or Director of Nursing (DON) when maintenance was due, after which the ADON or DON would contact an outside company to perform the service. Despite this process, the required maintenance was not completed as scheduled.
Failure to Provide Timely Incontinence Care per ADL Policy
Penalty
Summary
The facility failed to follow its Activities of Daily Living (ADLs) policy and procedure for three residents who were observed to be left soiled and wet. On April 30, 2025, observations and interviews revealed that one resident with diagnoses including encephalopathy, respiratory failure, tracheostomy status, and hypertension was found with a completely drenched brief, wet linen, and wet gown. The LVN present confirmed the resident's condition and stated that the CNA responsible was at lunch, with the last change occurring around 8 AM after a bowel movement. The CNA interviewed was unsure when the resident was last changed and acknowledged the resident was left wet for too long. The DON confirmed the resident's soiled condition and noted another resident was also found in a similar state. A second resident, with metabolic encephalopathy, chronic respiratory failure, type 2 diabetes, hypertension, and cerebral infarction, was also observed with a drenched brief and wet gown. The LVN confirmed this observation. A third resident, with cerebral infarction, acute respiratory failure, and type 2 diabetes, was found with a moderately wet brief. The CNA responsible stated that the residents were changed earlier in the morning and checked again before lunch, but both were heavy wetters and required frequent changes. The DON acknowledged that residents should be kept dry and repositioned, and that there was sufficient staff to provide care. The facility's ADL policy requires residents to receive necessary services to maintain hygiene, which was not followed in these instances.
Delayed Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment for a resident within the required timeframe of 13 days after admission. The resident was admitted on February 11, 2025, but the MDS assessment was not completed until March 6, 2025, which exceeded the allowed period. The MDS Coordinator acknowledged that the assessment was late due to being busy, and the Director of Nursing confirmed that MDS coordinators are responsible for completing these assessments within the scheduled timeframes. The Administrator and the Director of Nursing both expressed expectations that MDS assessments should be completed timely, in accordance with the guidelines outlined in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. However, the facility did not have a specific policy addressing MDS assessments, relying instead on the RAI Manual. This oversight resulted in the delayed completion of the resident's admission MDS assessment, as confirmed by interviews with facility staff.
Inaccurate MDS Discharge Coding for Resident
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment accurately reflected the location to which a resident was discharged. Specifically, for one resident, the discharge MDS was incorrectly coded to indicate that the resident was discharged to a short-term general hospital, when in fact, the resident was discharged home with hospice services. This discrepancy was identified during a review of the resident's records, which included an Admission Record, Treatment Administration Record, and Progress Notes, all indicating that the resident was discharged home with hospice services as per the family's request. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed the error in the discharge MDS coding. The MDS Coordinator acknowledged that the discharge MDS was completed incorrectly and should have been coded to reflect the resident's actual discharge to home with hospice services. The DON also confirmed the incorrect coding and stated that the MDS coordinators were responsible for completing discharge MDS assessments. The Administrator expressed an expectation for all MDS assessments to be completed accurately.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident was monitored for adverse drug reactions or side effects related to the use of a prescribed antipsychotic medication, Zyprexa. The facility's policy required nursing staff to monitor and report adverse consequences of antipsychotic medications to the attending physician. However, the resident's order summary report did not include orders for monitoring adverse drug reactions or side effects. The care plan directed staff to monitor for side effects and effectiveness each shift, but no monitoring orders were in place. Interviews with nursing staff and the Director of Nursing (DON) revealed that there were expectations for monitoring orders to accompany antipsychotic medication orders. Both Licensed Vocational Nurses (LVNs) confirmed the absence of monitoring orders for the resident's Zyprexa prescription. The DON acknowledged the importance of monitoring for potential side effects and confirmed that monitoring orders should have been initiated when the medication was ordered. The deficiency was identified when it was discovered that the resident had no side effect monitoring orders until the day before the interviews.
Failure to Disinfect Equipment Between Residents
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of supplies between resident uses, as observed during medication administration for two residents. The facility's policy on cleaning and disinfection, revised in 2018, requires that non-critical reusable items, such as clipboards, be cleaned and disinfected between residents. However, during an observation, a Licensed Vocational Nurse (LVN) did not clean or disinfect a clipboard when moving it between the beds of two residents who required contact precautions due to infections with carbapenem-resistant organisms. Resident #72, admitted in November 2022, had a medical history including tracheostomy status, gastrostomy status, and Klebsiella pneumoniae infection. The resident was noted to have a carbapenem-resistant organism and required contact precautions. Similarly, Resident #38, admitted in February 2023, had a medical history including tracheostomy status, gastrostomy status, and a persistent vegetative state, and also required contact precautions for a carbapenem-resistant infection. During the medication administration, the LVN placed a clipboard on both residents' beds without cleaning it between uses, potentially risking cross-contamination. Interviews with the LVN, Nurse Liaison, Assistant Director of Nursing, Director of Nursing, and the Administrator confirmed that the clipboard should have been disinfected between uses. The LVN acknowledged the oversight, and the facility staff reiterated the importance of using Clorox wipes for disinfection to prevent contamination and the spread of infection. The failure to adhere to the facility's disinfection policy was identified as a deficiency in infection prevention and control practices.
Prolonged Wait Times for Resident Assistance Due to Staffing Issues
Penalty
Summary
The facility failed to adhere to its Activities of Daily Living (ADLs) policy and procedure, resulting in prolonged wait times for assistance for three residents. Resident 1, who has chronic respiratory failure and is dependent on a respirator, reported waiting over an hour for assistance after using the call light. The resident also observed a respiratory therapist sleeping at the nurse station, indicating a lack of staff responsiveness. Resident 2, diagnosed with necrotizing fasciitis and acute respiratory failure, experienced similar delays, with staff turning off the call light without providing assistance, leading to waits exceeding an hour. Resident 3, who has a stage 4 pressure ulcer, also faced delays in receiving care, as staff prioritized assigned duties over immediate resident needs. Interviews with Certified Nursing Assistants (CNAs) revealed systemic issues contributing to these deficiencies. CNA1 reported receiving residents in soiled conditions from previous shifts and highlighted the challenge of managing care for 13-14 residents due to staffing shortages. CNA2 corroborated these claims, noting that management was aware of the staffing issues but failed to address them effectively. The CNAs expressed frustration over the lack of support from nurses and management, which hindered their ability to provide timely care. The Director of Nursing (DON) acknowledged the expectation for staff to respond promptly to call lights and to check on residents every two hours. However, the facility's policies on answering call lights and maintaining ADLs were not consistently followed, as evidenced by the residents' experiences and staff testimonies. The facility's failure to ensure adequate staffing and adherence to care protocols placed residents at risk for health complications, such as skin breakdown, due to unmet care needs.
Deficiency in Shower Room Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in the shower room used by two residents. Observations and interviews revealed that the shower room had uneven flooring, fractured tiles, and permanent residue on the walls. Residents reported that the shower room was dirty, with gloves on the floor, and the shower stall was not functioning properly, lacking hot water. The Director of Maintenance acknowledged that the hot water was not checked on some days, and the Director of Housekeeping confirmed the floor's unevenness and the presence of permanent residue that could not be removed. Resident 1, who has osteomyelitis and type 2 diabetes, and Resident 2, who has chronic respiratory failure, a tracheostomy, and epilepsy, both expressed concerns about the cleanliness and condition of the shower room. The Assistant Director of Nursing noted that residents did not wear shoes or slippers when brought to the shower room, and the Director of Nursing admitted that the shower room did not appear clean. The facility's maintenance policy, dated December 2009, requires maintaining the building in compliance with laws and free from hazards, which was not adhered to in this case.
Resident Left Unattended, Resulting in Fall and Injury
Penalty
Summary
The facility failed to adhere to its safety and supervision policy when a resident, who was in a persistent vegetative state, was left unattended during care. The resident was admitted with a diagnosis that included a persistent vegetative state, indicating severe brain damage. During an incident, a CNA left the resident unattended to gather supplies, and upon returning, found the resident on the floor, undressed. This incident resulted in the resident sustaining a cut to the forehead and a dislodged G-tube, necessitating transfer to an acute general hospital for evaluation and treatment. Interviews with staff revealed that the resident had a tendency to lean forward when coughing, which was known to the nursing staff. Despite this, appropriate fall precautions and preventive measures, such as a bed alarm or relocating the resident closer to the nurses' station, were not implemented. The facility's policy on safety and supervision emphasized that resident supervision should be based on individual needs and environmental hazards, which was not adequately followed in this case.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure for timely response to call lights, impacting three residents who were clinically compromised. Observations and interviews revealed that the call lights were not answered promptly, particularly during nighttime hours. Resident 1 reported that it took more than 20 minutes for staff to respond to the call light at night. Resident 2 stated that the response time was typically an hour, with delays being more pronounced at night. Resident 3 experienced an extreme delay, waiting six hours for assistance after activating the call light at 10:30 pm, which resulted in discomfort due to a sore from not having her diaper changed. The facility's staff, including CNAs and the Director of Nursing, acknowledged the delays in responding to call lights, attributing the issue to understaffing. The facility's policy, which was undated, specified that call lights should be answered within 10 to 15 minutes to ensure timely responses to residents' needs. Despite this policy, the facility's failure to provide timely assistance jeopardized the health and safety of the residents, who had significant medical conditions such as chronic kidney disease, sepsis, pulmonary hypertension, and multiple fractures of the pelvis.
Failure to Document and Address Wound Care Refusals
Penalty
Summary
The facility failed to provide proper wound care treatments and assessments for a resident, leading to a health and safety risk. The resident, who was clinically compromised with conditions such as acute kidney failure, heart failure, osteomyelitis, diabetes type II, and hypertension, was admitted with specific wound care orders. These orders included cleansing and dressing various surgical sites and monitoring for infection. However, the treatment nurse reported that the resident refused wound care for three consecutive days, and the nurse only observed the wounds without performing the necessary treatments. The nurse documented the refusals in the care plan but failed to record them in the progress notes or notify the physician properly. The nurse claimed to have informed the nurse practitioner via a message but did not receive a response and continued to monitor the situation without further documentation. The Director of Nursing (DON) was unaware of the refusals until later, and the Treatment Administration Record (TAR) was inaccurately marked as if the treatments were completed, despite the resident's refusals. The facility's policies on wound care and documentation require detailed recording of wound care provided, changes in the resident's condition, and any refusals of treatment. However, these procedures were not followed, as there was no documentation of the refusals in the progress notes, no follow-up assessments, and no proper notification of the physician. This lack of documentation and communication contributed to the resident's condition worsening, resulting in an infection and subsequent hospital stay.
Neglect in Comprehensive Assessment Leads to Resident's Death
Penalty
Summary
The facility failed to protect a resident from neglect when Registered Nurses did not perform a comprehensive nursing assessment upon the resident's initial admission and subsequent readmission from the hospital. This oversight led to a critical error where a Registered Nurse connected the enteral feeding formula to the resident's paracentesis drainage tube instead of the gastrostomy tube. As a result, the resident experienced severe abdominal pain due to the enteral feeding formula being administered into the peritoneal cavity. The resident, who had multiple complex medical conditions including cardiac arrest, end-stage renal disease, liver cirrhosis, and dependence on a tracheostomy and gastrostomy tube, was admitted to the facility without a comprehensive assessment being documented. The lack of a thorough assessment meant that the presence of a paracentesis drainage tube was not noted, leading to the critical error in administering the enteral feeding formula. The error was discovered when the resident's wife reported abdominal pain, prompting an assessment that revealed the feeding formula was incorrectly connected. The resident was transferred to a general acute care hospital, where he was diagnosed with septic shock and peritonitis, ultimately leading to his death. The facility's failure to conduct a comprehensive assessment upon admission and readmission directly contributed to this tragic outcome.
Removal Plan
- In-Service was conducted by the DON and Assistant director of Nursing (ADON) regarding new admissions and readmissions to be assessed by RN upon admission/arrival to include head to toe assessment as soon as practically possible or within the first 2 hours from the time of admissions to assess stability of the resident, with documented evidence of full assessment by the end of the shift and according to the regulatory standards.
- In-Service was conducted by the DON and ADON regarding Licensed staff including RNs will be educated by DON or Designee on the assessment process to ensure compliance prior to starting shifts. Ongoing training will be provided via verbal education and skills-check to existing and new staff, as needed and upon orientation, respectively, to ensure compliance. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties.
- In-Service was conducted by the DON and ADON regarding the policy and procedures of Admission Evaluation / Assessment & Follow-up: Role of Nurse.
Nursing Competency Deficiency Leads to Fatal Tube Misconnection
Penalty
Summary
The facility failed to ensure that licensed nurses were adequately trained and competent in managing paracentesis drainage tubes and gastrostomy tube feeding. This deficiency was highlighted when a registered nurse mistakenly connected and infused enteral feeding formula into a paracentesis drainage tube instead of the gastrostomy tube for a resident. This error resulted in the resident experiencing unnecessary abdominal pain and the retention of enteral feeding formula in the peritoneal cavity, leading to the resident's transfer to a general acute care hospital's intensive care unit, where the resident subsequently died. The resident involved had a complex medical history, including cardiac arrest, end-stage renal disease with hemodialysis, liver cirrhosis, diabetes mellitus type 2, tracheostomy status, and gastrostomy status. The resident was dependent on a ventilator and renal dialysis and had a paracentesis drainage tube and gastrostomy tube. The incident occurred when the resident's wife requested a charge nurse to connect a drainage bag to the paracentesis tube. Upon assessment, it was discovered that the enteral feeding formula was mistakenly infused into the paracentesis drainage tube, which was not properly connected, leading to the resident's severe abdominal pain and subsequent hospitalization. Interviews with nursing staff revealed a lack of specific training and competency in managing paracentesis drainage tubes. Several nurses, including licensed vocational nurses and registered nurses, admitted to receiving general training on drainage tubes but not specifically on paracentesis drainage tubes. The Director of Nursing confirmed that the facility's policy on managing drainage tubes was not followed, and no prior training on paracentesis drainage tubes had been conducted before the incident. This lack of training and competency directly contributed to the misconnection error and the resident's adverse outcome.
Removal Plan
- In-service conducted by Director of Nursing on proper infusion of G-tubes and management of drainage tubes including paracentesis drainage tubes.
- Monitoring of the G-tube feeding by licensed staff per shift to verify pump has been infused properly.
- Observe the status of the resident and ensure resident's needs are met.
- As safety precaution, 2 nurses will check to verify G-tube feedings for accuracy and compliance at the change of shift.
- Ongoing education and competency training to be provided to staff to verify competency of the licensed staff particularly as it relates to proper infusion and monitoring of G-tube feeding and managing paracentesis drainage tubes.
- Onboarding licensed staff and staff who are away will also be oriented of the proper procedures with documented evidence accordingly prior to beginning shift/floor duties.
- In-service conducted by DON and Assistant Director of Nurses regarding identifying the different types of enteral feeding, enteral tube use and maintenance, tube occlusion: prevention/management, G-tube replacement, and patency.
Delayed Response to Call Lights for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing timely responses to call lights, affecting two out of four sampled residents. Resident 1, who was admitted with a diagnosis including unspecified hyperlipidemia, reported that staff responses to call lights were delayed, particularly during the night shift, sometimes taking an hour or two. This resident also mentioned infrequent repositioning, which is crucial given their self-care deficit related to deconditioning. The care plan for Resident 1 emphasized the importance of promptly responding to call lights, yet this was not consistently followed. Similarly, Resident 2, who has multiple health conditions including chronic kidney disease stage 5, hypertension, and obstructive sleep apnea, also experienced delays in call light responses, sometimes waiting 30 minutes or longer. This resident faced challenges in receiving timely assistance with turning, meal requests, and shower schedules. The care plan for Resident 2 also highlighted the need for prompt response to call lights, which was not met. The facility's policy titled 'Answering the Call Lights' was not effectively implemented, as evidenced by the residents' experiences.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for the prevention of pressure ulcers, resulting in a deficiency. A resident, who was admitted with no initial pressure ulcers, developed a stage 4 pressure ulcer on their back while in the facility's care. The resident reported that staff responses to call lights were delayed, particularly during the night shift, and that repositioning was not performed regularly as required. The facility's policy mandates repositioning every two hours for residents dependent on staff for mobility, which was not followed in this case. The resident required maximum assistance for bed mobility, as indicated in the Physical Therapy Discharge Summary. Despite this need, the resident was not repositioned adequately, leading to the development of a severe pressure ulcer. The wound care nurse confirmed that the ulcer was acquired at the facility and was not present during the initial assessment. The failure to reposition the resident as per the facility's policy directly contributed to the development of the pressure ulcer.
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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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