The Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 12332 Garden Grove Blvd., Garden Grove, California 92843
- CMS Provider Number
- 555021
- Inspections on file
- 23
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at The Grove Post Acute during CMS and state inspections, most recent first.
A resident who preferred to remain in LTC and required extensive to total assistance with ADLs and transfers was transferred to a hospital for slurred speech, and a bed hold was documented for the resident’s room. When the hospital case manager requested readmission, the facility refused because the resident had tested positive for Candida auris and required EBP/contact precautions, despite facility policies allowing for management of Candida auris with isolation and PPE and the availability of a room without roommates. The refusal occurred during the active seven-day bed hold period and was not supported by documented transfer/discharge criteria in the facility’s own bed hold and readmission policy.
Surveyors found that the facility did not follow its own transfer, discharge, and bed-hold policies when several residents were transferred or discharged. One resident’s Notice of Transfer/Discharge showed that the copy intended for the resident remained in the chart instead of being given to the resident, and the associated bed-hold form had required confirmation sections left blank. For three different residents, their transfer/discharge notices lacked any documentation that the LTC Ombudsman was notified, despite facility policy and staff statements that such notifications should be made and supported by fax confirmations. The SSD and DON acknowledged that the Ombudsman notification sections and bed-hold confirmations should have been completed and that, without this documentation, the notifications could not be verified.
A resident with severe cognitive impairment and total dependence on staff for ADL care was found to have a non-functional call light system, resulting in an extended wait for incontinence care. The issue was confirmed by an LVN, who noted that staff should have checked the call light before leaving the room. Facility policy required reporting of such issues, and the DON and Administrator acknowledged the deficiency.
The facility did not maintain current inspection and testing records for its automatic sprinkler system, with the last documented 5-year inspection being overdue. Additionally, storage items were found placed too close to a sprinkler deflector in the kitchen storage closet, contrary to fire safety regulations. These deficiencies affected all residents in the facility.
Surveyors found that the facility did not perform the required 30-minute monthly load test on the emergency generator, instead conducting only 20-minute tests. This deficiency was identified through record review and staff interviews, affecting all residents in the facility.
The facility did not have annual inspection, maintenance, and testing records for its kitchen cooking equipment, including burners, ovens, and a griddle. Instead, equipment was only inspected when broken, and there was no established program for annual inspection, affecting 24 residents in one smoke compartment.
A portable oxygen tank was found freestanding and not properly secured in a resident's room, in violation of NFPA 99 requirements for gas cylinder storage. The Maintenance Director indicated that a nurse likely left the tank unsecured while replacing it. This deficiency affected two residents in one smoke compartment.
The facility did not consistently follow prescribed menus, resulting in residents not receiving correct diets, portion sizes, or culturally preferred meals. Several residents on pureed diets did not receive menu-specified items or received incorrect portions, and residents with preferences for Korean food were served American menu items instead. Additionally, a resident was served a food item not listed on the menu, which she could not tolerate. Staff acknowledged these errors were due to mistakes and lack of tray accuracy checks.
Surveyors found that the facility failed to properly label and date food items, maintain clean and undamaged kitchen utensils and equipment, and post required handwashing signage. Additionally, a resident with impaired decision-making capacity had perishable food at bedside that was not labeled or dated, and the refrigerator for outside food was not clean. Staff confirmed these lapses, which were not in accordance with facility policy and food safety standards.
A resident who lacked capacity to make medical decisions was admitted with an executed advance directive, but the facility did not maintain a copy in the medical record or document any follow-up to obtain it. The POLST form was incomplete, and staff interviews confirmed the absence of required documentation and follow-up regarding the advance directive.
A resident reported sustaining a skin abrasion and alleged rough handling by a CNA during care. The facility failed to fully document and address the resident's specific grievance, did not determine or record whether the resident was satisfied with the investigation or outcome, and omitted a response to the allegation in follow-up documentation, resulting in the grievance not being thoroughly resolved.
A resident was given temazepam for insomnia without documented evidence that nonpharmacological interventions were attempted beforehand, as required by facility policy and the care plan. The MAR and progress notes lacked documentation of these interventions, and a nurse could not clarify chart markings or provide supporting records, resulting in a deficiency related to unnecessary use of psychotropic medication.
Three residents did not have care plans reflecting their individual needs: two residents who preferred Korean food were served American food without care plans addressing their preferences, and a resident with a shrimp allergy did not have a care plan problem developed for the allergy. These deficiencies were confirmed through record reviews, observations, and staff interviews.
A resident with an indwelling urinary catheter and a history of recurrent UTIs was observed with their urinary drainage bag lying on the floor on multiple occasions. Staff confirmed that the bag should not touch the floor to prevent infection, but failed to maintain proper positioning, increasing the risk for CAUTI.
A resident with an order for continuous oxygen therapy was observed not receiving oxygen as prescribed, with the oxygen tank turned off and the nasal cannula not in use. The resident reported turning off the oxygen most of the day, and staff confirmed the resident was not receiving oxygen as ordered. The RN did not provide education about the risks and benefits of oxygen therapy during the interaction.
A resident with moderate cognitive impairment did not receive proper pain management, as staff failed to assess and document pain levels before administering pain medication and did not provide non-pharmacological interventions prior to medication on several occasions. Facility policy required these steps, but records and staff interviews confirmed they were not consistently followed.
Nursing staff did not consistently rotate subcutaneous insulin injection sites for several residents, resulting in repeated injections at the same anatomical locations. Additionally, emergency medication kits were not replaced within the required timeframe after use, contrary to facility policy. These deficiencies were confirmed through record reviews and staff interviews.
Surveyors found that medication cabinets were not kept clean, a bottle of geri-tussin had an illegible expiration date, and multiple packets of Dermaseptin ointment and Dermarite Boarder Gauzes in a treatment cart were not labeled with expiration dates after removal from original packaging. Staff confirmed these lapses, which were not in accordance with facility policy.
Several residents with documented preferences for Korean pureed meals were served American pureed menu items instead, and a resident who disliked carrots was served a meal containing carrots. Staff interviews and record reviews confirmed that meal tickets reflected these preferences and dislikes, but they were not followed during meal service. The deficiency was acknowledged by dietary and nursing leadership.
A resident with severe cognitive impairment and a physician-ordered soft and bite-sized (SB6) diet was served a regular texture slice of bread during a meal, despite staff checks and clear dietary orders. The SLP confirmed that the resident was not cleared for regular bread at the time, and the error posed a risk of aspiration and unmet nutritional needs.
The facility's Facility Assessment was found deficient for not involving direct care staff, residents, or their representatives in its development, and for failing to address necessary staffing resources for weekends, recruitment and retention plans for direct care staff, and a contingency plan for staffing needs. The Administrator confirmed these omissions and acknowledged the assessment was not updated per the latest CMS guidance.
Staff failed to follow infection control protocols, including not performing hand hygiene between glove changes during medication administration for a resident with a G-tube, not wearing a gown as required for enhanced barrier precautions when assisting a resident with a urostomy, and storing personal items next to clean linens in the laundry area, increasing the risk of infection transmission.
A resident who had previously received the PPSV23 vaccine was not offered the PCV15 or PCV20 pneumococcal vaccination as required by facility policy and CDC guidelines. Medical records and the state immunization registry confirmed the absence of the required vaccine offer or administration, and the Infection Preventionist verified this deficiency during review.
Two residents were found without their bed remote controls within reach, despite facility staff confirming that remotes should be accessible. One resident, unable to make decisions, had the remote at the foot of the bed, while another cognitively intact resident had the remote hanging out of reach and expressed a preference for it to be accessible. Staff interviews confirmed the expectation that remotes be within reach, but this was not consistently followed.
A resident's MDS assessment was not coded to reflect ongoing hemodialysis treatment, despite a physician's order for regular dialysis sessions. The MDS Coordinator confirmed the error during a review, and the DON acknowledged the findings. This failure meant the assessment did not accurately represent the resident's current status.
A resident's medical record contained vital signs documented as obtained after the individual had already been transferred to an acute care hospital. The DON confirmed the resident was not present in the facility when these measurements were recorded, resulting in inaccurate medical documentation.
Two residents in a LTC facility did not receive proper denture care, as their dentures were not cleaned or stored according to facility policy. One resident with severe cognitive impairment and another requiring moderate assistance were both found with improperly stored dentures. Interviews with staff revealed non-compliance with the facility's denture care policy, and there was no care plan for a resident's refusal to wear dentures.
A resident with a history of hypothyroidism was admitted to the facility without the continuation of their prescribed levothyroxine medication, despite it being listed in the hospital's discharge medication list. The medication was not ordered until six days after admission due to a failure in reconciling discharge medications, resulting in a gap in treatment.
A facility failed to conduct an initial fall risk assessment for a resident admitted after a fall resulting in a hip fracture. The fall risk form was signed by an LVN but left blank, contrary to the facility's policy. This was confirmed by the ADON during a review.
The facility failed to assess a bolster mattress as a potential restraint for a resident with multiple diagnoses and a history of falls. Staff confirmed the mattress restricted the resident's movement, but no assessment was conducted to determine if it was a restraint, violating facility policy.
Failure to Readmit Hospitalized Resident During Bed Hold Due to Candida auris Status
Penalty
Summary
The deficiency involves the facility’s failure to readmit a resident during an active seven-day bed hold period following a hospital transfer, resulting in a potential inappropriate discharge. The facility’s own Bed Hold Notice Upon Transfer policy, revised 12/2022, states that residents must be permitted to remain in the facility and not be transferred or discharged unless specific criteria are met, such as the resident’s needs not being met in the facility, sufficient improvement in health, safety concerns, non-payment, or facility closure. The resident had a Social Services Assessment indicating a preference to remain in LTC, no assistance available at home, and a need for extensive to total assistance with ADLs and transfers, supporting ongoing LTC appropriateness. The resident was transferred to an acute care hospital for slurred speech, with documentation showing an eINTERACT Transfer Form and a progress note describing the event and subsequent hospital transfer. The facility’s Daily Census documented a bed hold for the resident’s room from 11/18–11/20, with no other roommates assigned during that period. However, the Order Summary Report for November did not contain a physician’s order for the transfer or for a bed hold. During the hospitalization, the hospital case manager requested readmission the day after transfer, but the facility informed the hospital that the resident would not be readmitted, despite the active seven-day bed hold. The facility’s refusal to readmit was based on the resident’s hospital diagnosis of Candida auris, an MDRO fungal infection, and the need for enhanced standard or contact precautions. This decision conflicted with the facility’s Management of Candida Auris policy, which allows for placement on transmission-based precautions, use of PPE, and either a single room or cohorting with another resident with the same organism. Interviews with the DON and RN indicated that residents on isolation or enhanced barrier precautions, including those with Candida auris, could be accommodated, and that the resident’s room was unoccupied by other residents during the relevant days, meaning the resident could have been placed alone. The administrator acknowledged that the facility had not accepted residents with Candida auris in the past and confirmed that the resident was not readmitted during the bed hold period, leading to the appeal for readmission.
Failure to Provide Required Transfer Notices and Ombudsman Notifications
Penalty
Summary
The deficiency involves the facility’s failure to follow required transfer and discharge procedures, including providing written notices to residents and notifying the LTC Ombudsman. Facility policies titled "Transfer and Discharge" and "Bed Hold Notice Upon Transfer" required that, for non-emergency transfers or discharges initiated by the facility, written transfer/discharge notices be provided to the resident or representative and to the Ombudsman, and that for emergency transfers, a notice of transfer and the facility’s bed-hold policy be provided to the resident and representative, with copies of emergency transfer notices sent to the Ombudsman. The bed-hold policy further required that, at the time of transfer for hospitalization or therapeutic leave, the resident and/or representative receive written notice specifying the duration of the bed-hold policy and information about return to the next available bed, or within 24 hours in the case of an emergency transfer. For one resident, surveyors found that the written Notice of Transfer/Discharge dated 11/17/25 showed both the white and yellow carbon copies remained in the closed medical record, indicating the yellow copy had not been given to the resident at the time of transfer to an acute care facility. RN 1 and the DON both stated that the process for a transfer included completing the Notice of Transfer/Discharge form and providing the yellow copy to the resident, and the DON confirmed that the notice in this case had not been provided to the resident. Review of the same resident’s Bed Hold Notification dated 9/18/25 showed blank entries for the Confirmation of Transfer and Bed Hold Provision and the 24-Hour Confirmation section, and the DON verified these sections should have been completed but were left blank. Surveyors also identified that the facility failed to document notification of the LTC Ombudsman for three residents who were transferred or discharged. For the first resident, the Notice of Transfer/Discharge dated 11/17/25 did not show that the Ombudsman was notified. For a second resident, admitted and later discharged from the facility, the Notice of Transfer/Discharge dated 10/23/25 similarly lacked documentation of Ombudsman notification. For a third resident transferred to an acute care facility, the Notice of Transfer/Discharge dated 1/22/26 also failed to show Ombudsman notification. The SSD stated that nurses are responsible for notifying the Ombudsman when a resident is transferred to acute care, and that she notifies the Ombudsman when residents are transferred to another facility or home, retaining fax confirmation sheets and attaching them to the notice; however, the Notices of Transfer/Discharge for all three residents had blank entries in the section "copy to LTC Ombudsman Office-date." The SSD and DON both acknowledged that these sections should have been completed and that, without documentation, it could not be verified that the Ombudsman had been notified.
Non-Functional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional during an observation and interview. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living (ADL) care, reported waiting for almost an hour for incontinence care and stated that he had pressed the call light several times without receiving assistance. The call light was observed to be within reach but did not function when pressed. A licensed vocational nurse (LVN) confirmed that the call light was not working and acknowledged that staff should have ensured its functionality before leaving the room. The facility's policy and procedure required staff to report any problems with the call light system to the supervisor or maintenance director. The Director of Nursing (DON) and the Administrator were informed of the findings and acknowledged that the call light system should be functional for residents.
Outdated Sprinkler System Inspection Records and Improper Storage Near Sprinkler Deflector
Penalty
Summary
The facility failed to maintain up-to-date inspection and testing records for its automatic sprinkler system as required by NFPA 25. During a record review and interview with the Administrator and Maintenance Director, it was found that the most recent 5-year inspection and testing documentation was dated 7/18/2019, making the records past due. The Maintenance Director confirmed that no more current records were available. This deficiency affected all 93 residents across four smoke compartments in the facility. Additionally, during an inspection of the physical environment, storage items were observed in the kitchen storage closet placed within 8 inches of a sprinkler deflector. This placement does not comply with NFPA 13 requirements, which prohibit obstructions within 18 inches of a sprinkler deflector that could prevent the sprinkler discharge pattern from fully developing. The Maintenance Director stated they were unaware of this regulation.
Plan Of Correction
K353 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. 5-year fire sprinkler inspection, main drain test on all systems, inspectors test/water flow test, back flush on all fire department connections, visual inspection of all fire heads and components, shutdown/reinstatement was performed 6/26/25 by GNA Firebrook Protection certified technician. 2. Boxes were removed from the kitchen storage room 6/25/25. • 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 patients have the ability to be affected by this 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 recur: 1. Maintenance director has put together an annual list of required testing, required to bring to January QA for review by all department heads/governing body. 2. Maintenance director is required to audit storage spaces for ceiling clearance once per week until reaching compliance for 3 months. • How the facility plans to monitor its performance to make sure that solutions are sustained: 1. Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. All inspections and planned schedule will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. 2. Environmental services director will bring his storage room ceiling clearance audit results to monthly QA until 3 consecutive months with no findings. • Include dates when corrective action will be completed: 1. Inspection completed 6/26/25. 2. Compliance for ceiling clearance on 6/25/25. How the facility plans to monitor its performance to make sure that solutions are sustained: 1. Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. All inspections and planned schedule will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. 2. Environmental services director will bring his storage room ceiling clearance audit results to monthly QA until 3 consecutive months with no findings. • Include dates when corrective action will be completed: 1. Inspection completed 6/26/25. 2. Compliance for ceiling clearance on 6/25/25.
Failure to Complete Required 30-Minute Generator Load Testing
Penalty
Summary
The facility failed to maintain compliance with essential electrical system maintenance and testing requirements as specified by NFPA 101 and related standards. During a review of records and interviews with the Administrator and Maintenance Director, it was found that the emergency generator was not exercised under load for the required 30 minutes each month. Instead, the generator was only tested under load for 20 minutes monthly, as indicated by the facility's "Emergency Generator Log." The Maintenance Director stated during the interview that they were unaware of the 30-minute requirement for the monthly load test. This deficiency affected all 93 residents in four smoke compartments, as the generator's operability during an emergency situation or fire could not be assured based on the incomplete testing. The findings were based solely on documentation and staff interviews, with no mention of any specific resident medical history or condition at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Environmental services director held a 30-minute load test on 6/26/25 with no negative findings. 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 patients have the ability to be affected by this 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 recur: Environmental services director is required to test the generator backup system for 30 minutes each month, was given a 1:1 by the administrator on 6/26/25 explaining the 30-minute monthly requirement, and has agreed to perform the test each month for the full, required 30 minutes. How the facility plans to monitor its performance to make sure that solutions are sustained: Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. Maintenance generator load testing log sheet will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. Include dates when corrective action will be completed: Inspection completed 6/26/25.
Failure to Maintain Annual Inspection and Maintenance of Kitchen Cooking Equipment
Penalty
Summary
The facility failed to maintain proper inspection, maintenance, and testing of its kitchen cooking equipment as required by NFPA 96 and NFPA 101 standards. During a record review and interview with the Administrator and Maintenance Director, it was found that the facility did not have annual inspection, maintenance, and testing records for the kitchen equipment, which included six burners, two ovens, and one griddle. Instead, the equipment was only inspected when it was already broken, and there was no established program for annual inspection of the kitchen cooking equipment. This deficiency affected 24 out of 93 residents in one of the smoke compartments. The absence of required documentation and a preventive maintenance program for the kitchen equipment was directly observed and confirmed during the survey process. The Administrator acknowledged that no program was in place for annual inspection of the kitchen cooking equipment.
Plan Of Correction
K324 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Stove and oven maintenance was inspected and verified by Maintenance Director under the supervision of regional director for environmental services. Condition of all equipment, connections, and burners passed inspection. • 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 patients have the ability to be affected by this 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 recur: Maintenance director has been put on a quarterly inspection of stove and oven components, required to fill out the log documenting all inspections and any findings to be brought to QA for review. • How the facility plans to monitor its performance to make sure that solutions are sustained: Environmental services director will be responsible for bringing the log to each quarterly QA meeting until reaching 3 consecutive quarters with no findings. • Include dates when corrective action will be completed: Inspection completed 7/2/25
Improper Storage of Portable Oxygen Cylinder
Penalty
Summary
A deficiency was identified when a portable oxygen tank was observed freestanding and not properly secured in Bedroom 18. This observation was made during a facility tour and interview with the Administrator and Maintenance Director. The oxygen tank was not chained or supported in a proper cylinder stand or cart, as required by NFPA 99, Health Care Facilities Code, 2012 Edition, section 11.6.2.3. The Maintenance Director stated that a nurse was likely replacing the oxygen tank and left the old one in the room. This incident affected two of 93 residents in one of four smoke compartments. The report specifically notes that the portable oxygen tank was not properly secured, which is a violation of the regulations for gas equipment cylinder and container storage. No additional details about the residents' medical history or condition at the time of the deficiency are provided in the report.
Plan Of Correction
K923 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Oxygen tank was removed from room 18 on 6/25/25 and replaced with an oxygen tank that was fully secured. • 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: DON and DSD audited all rooms within the facility and found no other freestanding oxygen tanks, no other residents were affected. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Administrator gave 1:1 inservice with Central supply coordinator (CSC) on 6/26/25. CSC will be auditing all rooms 2 x week to verify all oxygen tanks are properly stored in resident rooms and oxygen storage rooms. • How the facility plans to monitor its performance to make sure that solutions are sustained: Central supply coordinator will bring audit findings to monthly QA meeting until 3 consecutive months with no findings. • Include dates when corrective action will be completed: Completed 6/26/25
Failure to Follow Menus and Dietary Preferences for Residents
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals in accordance with their prescribed diets, preferences, and portion sizes. Observations revealed that a resident on a pureed diet did not receive pureed green beans as specified on the menu, and only received them after staff intervention. Additionally, kitchen staff did not serve the correct portion sizes for certain menu items, as evidenced by the use of incorrect scoop sizes for Korean menu items. The facility also failed to prepare and serve the Korean pureed menu for residents who had documented preferences for Korean food, instead providing them with American pureed menu items. Multiple residents who preferred Korean food and required pureed diets were served American menu pureed items rather than the Korean menu purees indicated in their care plans and nutrition progress notes. In one instance, a resident who preferred the American menu was served pureed kimchi instead of pureed bread, contrary to the menu and her preferences. The dietary staff acknowledged these errors, attributing them to mistakes made by the cook and a lack of awareness regarding the preparation of specific menu items. Further, a resident was served carrots that were not included on the menu for the day, despite her stating she did not like carrots due to an adverse reaction. Staff confirmed that the carrots were not part of the planned menu and that food trays were not checked for accuracy before being distributed. These failures affected the majority of residents receiving food from the kitchen and had the potential to result in unmet nutritional needs.
Plan Of Correction
F803 Menus Meet Resident Needs/Prep in Advance/Followed Corrective action for residents found to have been affected by this deficiency: - DS provided Resident 65 with the pureed green beans that were found missing from the meal tray, immediately on 6/16/25. - DS in-serviced dietary staff on 6/17/25, including the Lead Cook and Cook 2, on P&P "Standardized Menus" and "Food Preparation Guidelines," emphasizing the importance of following recipes, using proper measuring utensils, and correct portion sizes according to the menu spreadsheets, to ensure residents receive adequate nutrition by providing all food items on the menu, including both the American and cultural Korean menus. - DS conducted resident satisfaction surveys and visited all residents on a puree textured diet, or who were not served the correct food items, initiated on 6/17/25 and completed on 7/7/25, including Residents 79 and 40, and residents who preferred the Korean menu, including Residents 27 and 96, to ensure residents are content with the meals provided. Corrective action for residents that may be affected by this deficiency: - DS, RD, or trained designee will conduct daily round audits during food preparation 3 times per week for 3 months to ensure all standardized menus and spreadsheets are followed. - DS, RD, or trained designee will conduct test tray and tray line audits, 3 times per week for 3 months, ensuring both the American and Korean menus and spreadsheets are followed, including all pureed foods and cultural food preferences. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - DS or RD will report their findings regarding standardized menus and food preparation compliance to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 7/7/25
Deficiencies in Food Safety, Sanitation, and Labeling Practices
Penalty
Summary
Surveyors identified multiple failures in food safety and sanitation practices within the facility's kitchen and food storage areas. During an initial kitchen tour, several food items were found to be improperly labeled and dated, including containers of dry pasta and kimchi with incorrect or expired dates, and an opened bottle of oyster sauce with inconsistent labeling. The facility's policy required clear date marking and timely disposal of expired items, but these procedures were not followed. The Dietary Services Supervisor (DSS) acknowledged that some labels were incorrect and that the kimchi had not been prepared on the date indicated. Further observations revealed that kitchen utensils and equipment were not maintained in a sanitary condition. Two rubber spatulas had corroded edges, another had a melted handle with a brown coating, and a small pitcher had a melted bottom. Additionally, two cutting boards were heavily marred and chipped, making them difficult to clean and sanitize. The DSS confirmed these findings. The residents' refrigerator, used to store food brought in from outside, was found to have brown food residue on one of the shelves, and this was verified by a registered nurse. The facility also failed to post required handwashing signage at the kitchen handwashing station on multiple occasions, as required by the USDA Food Code. The DSS admitted that the signage was not posted as it should have been. In a resident's room, two pieces of bananas brought in by a visitor were found in a clear plastic bag without proper labeling or dating, contrary to facility policy. Staff members, including a CNA and an LVN, were unable to determine when the bananas had been brought in and confirmed that perishable foods should be dated. The resident involved had no capacity to make decisions and was on a specialized diet, as documented in their medical record.
Plan Of Correction
F812 Food Procurement, Store/Prepare/Serve-Sanitary Corrective action for residents found to have been affected by this deficiency: -The licensed nurse (LVN 2) discarded the unlabeled pieces of banana immediately found by Resident 22's bedside table. Corrective action for residents that may be affected by this deficiency: -Cook 1 discarded the expired container of dry pasta immediately on 6/16/25. The DS discarded the opened mislabeled bottle of oyster sauce and kimchi immediately on 6/16/25. -The multiple pieces of equipment found damaged were discarded immediately by the DS on 6/16/25, including the rubber spatulas, pitcher, and cutting boards. -DS ensured the resident refrigerator was cleaned immediately, with the brown food residue removed on 6/16/25. -DS posted proper handwashing signage immediately at the handwashing station on 6/17/25. -DS in-serviced dietary staff initiated on 6/16/25 and completed for all dietary staff on 6/17/25, utilizing P&Ps "Date Marking for Food Safety" and "Sanitation Inspection", emphasizing the importance of proper labeling and dating and cleaning of equipment. -The DON, Director of Staff Development (DSD) and DS conducted an in-service with all the dietary and nursing staff initiated on 6/16/25 and completed on 7/9/25, utilizing the P&P "Use and Storage of Food Brought in by Family or Visitors" on proper labeling and dating of outside food, and ensuring food is discarded if not properly labeled and that the resident refrigerator is cleaned following the cleaning schedule. Measures that will be put into place to ensure that this deficiency does not recur: -DS, RD, or trained designee will complete daily kitchen rounds, 5 times per week X 3 months, and the RD will complete their monthly sanitation audit, ensuring proper labeling & dating in all areas, including the resident refrigerator and bedside tables, and compliant equipment cleaning, discarding any damaged equipment. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: -DS or RD will report their findings regarding proper labeling & dating, cleaning of equipment and outside food for residents to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 7/9/25
Failure to Maintain and Document Advance Directive in Resident Record
Penalty
Summary
The facility failed to obtain and/or maintain a copy of an executed advance directive in the medical record for a resident who was admitted without capacity to make medical decisions. Upon admission, documentation showed that the resident had executed an advance directive, and the facility's policy required that copies of such documents be placed in the resident's chart and communicated to staff. However, a review of the resident's medical record did not show a copy of the advance directive, nor was there evidence of any follow-up attempts to obtain or document the advance directive. Further review revealed that the Physician Orders for Life-Sustaining Treatment (POLST) form for the resident had the section for advance directive information left blank. Interviews with facility staff indicated that prior to a departmental change, the admissions team handled advance directive forms, but the Social Services department, now responsible, did not have documentation or records of the resident's advance directive or any follow-up. The Administrator, Director of Social Services, and Director of Nursing acknowledged these findings during the survey.
Plan Of Correction
F - 578 Request/Refuse/Dscntnue Trmnt; Fornite Adv Dir Corrective Action Initiated For Resident/s Resident 52's advance directive status was immediately reviewed on 6/20/25 by SSD. Social Services obtained a copy of the advance directive and placed it into the resident's medical record. Resident 52's POLST form was reviewed and updated to accurately reflect the advance directive information on 6/23. How Potential Other Residents Were Identified and Corrective Action Taken Other residents are at risk for this noted practice. Starting on 6/23 through 7/7/25, the Social Services Director (SSD) initiated an audit of all current resident medical records to ensure advance directives were accurately documented, present in charts, and consistent with resident or representative decisions. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 6/25/25, all admissions and Social Services staff were re-educated by the DON regarding facility policy and procedures for obtaining, maintaining, and documenting advance directives upon admission, including immediate follow-up processes. A standardized admission checklist was implemented to verify the presence and accurate documentation of advance directives during each admission. Findings will be reported at daily stand-up for follow-up. Social Services will check new admits for follow-up documentation and the maintenance of advance directive copies on a weekly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/7/25 A standardized admission checklist was implemented to verify the presence and accurate documentation of advance directives during each admission. Findings will be reported at daily stand-up for follow-up. Social Services will check new admits for follow-up documentation and the maintenance of advance directive copies on a weekly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/7/25
Failure to Properly Address and Resolve Resident Grievance
Penalty
Summary
A deficiency occurred when the facility failed to properly address and resolve a resident's grievance in accordance with its own policies and procedures. The resident reported sustaining a skin abrasion to her thigh after a CNA changed her soiled adult brief, alleging that the CNA was too rough and hard with the towel during cleaning. The resident initially reported this incident to facility staff and later reiterated her concern during a resident council meeting, stating that the facility had not followed up with her or addressed her specific concern. The facility's grievance official, the Social Services Designee (SSD), documented the initial grievance on the facility's grievance form but failed to include the resident's specific allegation that the CNA was not gentle and cleaned her hard. The SSD acknowledged that this information should have been documented and addressed, and that a determination should have been made as to whether the resident was satisfied with the investigation and outcomes. The grievance form sections regarding the resident's satisfaction and the date the grievance was resolved were left blank. Further, when the resident raised her concern again during a resident council meeting, the facility documented the concern but the department's written response only addressed whether the resident would be compensated for the skin tear, not the allegation of rough handling. The section on the form indicating whether the allegation was resolved to the resident's satisfaction was also left blank. These failures resulted in the resident's grievance not being thoroughly addressed, investigated, documented, or resolved as required by facility policy.
Plan Of Correction
F-585 Grievance Corrective Action Initiated For Resident/s On 6/18/25, the Social Services Director (SSD) met with Resident 53 to follow up on her grievance, documented her concerns in full, and ensured her satisfaction with the facility's investigation and action. On 6/18/25, Resident 53's grievance form was immediately updated to include the omitted allegation regarding the CNA being too rough and a documented resolution, including whether the resident was satisfied. How Potential Other Residents Were Identified and Corrective Action Taken On 6/25/25, the SSD initiated a review of all active grievance logs from the past 30 days to ensure complete documentation, follow-up, and resident satisfaction were recorded appropriately. No other unresolved grievances were identified. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 7/10/25, the DON/designee re-educated facility staff - IDT (Social services, activities, and DSD), including CNAs and Licensed nurses, on the grievance reporting process, emphasizing the importance of thorough documentation and prompt follow-up per the facility's P&P. The grievance tracking tool will be checked by the social services director to ensure all grievances include: Full resident concern details, steps taken to investigate, final determination and corrective actions, confirmation of resident satisfaction, and resolution date. The Administrator will review all grievances on a weekly basis for follow-up and resolution on a timely basis. Resident Council agendas will now include a follow-up item to verify that concerns voiced are addressed and documented thoroughly by department heads and verified by the administrator on a monthly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved, as determined by the committee. Date of Compliance: 6/25/25 The Administrator will review all grievances weekly for follow-up and resolution on a timely basis. Resident Council agendas will include a follow-up item to verify that concerns voiced are addressed and documented thoroughly by department heads and verified by the administrator on a monthly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved, as determined by the committee. Date of Compliance: 6/25/25
Failure to Document Nonpharmacological Interventions Prior to Psychotropic Medication Administration
Penalty
Summary
A deficiency was identified when a resident was administered temazepam, a sedative medication, for insomnia without documented evidence that nonpharmacological interventions were attempted prior to its use. The facility's policy requires that such interventions be implemented unless clinically contraindicated, and that psychotropic medications should only be used to treat medical symptoms, not for staff convenience or discipline. The resident's care plan specifically included interventions to address potential environmental and behavioral causes of insomnia before initiating hypnotic therapy, as well as the use of nonpharmacological approaches to improve sleep. Medical record review showed that the resident had ongoing orders for temazepam and monitoring for side effects, as well as instructions to document hours of sleep and to evaluate other factors contributing to insomnia. However, the Medication Administration Record (MAR) for the relevant period did not contain documentation that nonpharmacological interventions were provided prior to administering temazepam. The MAR included chart codes and prompt legends, but there was no indication that these interventions were attempted or documented, and the progress notes also lacked this information. During an interview, a registered nurse was unable to explain the meaning of certain chart markings related to nonpharmacological interventions and could not provide documentation that such interventions were implemented before administering the medication. This failure to document or implement required nonpharmacological interventions prior to the use of a psychotropic medication constituted a violation of the resident's right to be free from unnecessary chemical restraints.
Plan Of Correction
F605 - Right to be free from chemical restraint. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The facility will ensure that non-pharmacological interventions will be attempted prior to administration of hypnotic medication. For resident 1, documentation of non-pharmacological interventions used will be documented in the medication administration record (MAR) starting on 6/17/25. 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. An audit of residents using hypnotic medication was completed on 7/2/25. No other resident uses hypnotic medication. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. The medical records department/designee will audit the medical records of the residents on hypnotic medication weekly to identify if non-pharmacological interventions were provided prior to administration. Findings will be reported to DON for follow-up. Inservice to licensed nurses initiated on 6/23/25 regarding psychotropic medication including providing non-pharmacological interventions. Completion date by 7/10/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25
Failure to Develop Comprehensive Care Plans for Food Preferences and Allergies
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by federal regulations. Specifically, two residents who expressed a preference for Korean food at lunch and dinner did not have care plans reflecting these preferences. Instead, both residents were observed receiving pureed American food items, despite their nutrition progress notes and lunch tickets indicating a preference for Korean cuisine. The Director of Social Services (DSS) confirmed that the care plans for these residents did not address their food preferences. Additionally, another resident with a documented food allergy to shrimp did not have a care plan problem developed to address this allergy. The resident's admission record clearly indicated the shrimp allergy, but a review of the care plan showed no documentation or interventions related to this allergy. This was verified by an LVN, who acknowledged the absence of a care plan addressing the allergy. These deficiencies were confirmed through medical record reviews, direct observations of meal service, and staff interviews. The Director of Nursing (DON) was informed of these findings and acknowledged the lack of appropriate care planning for the residents involved.
Plan Of Correction
Date of compliance: 7/2/2025 F656 Develop/Implement Comprehensive Care Plan Corrective action for residents found to have been affected by this deficiency: - Residents 40, 27, and 96 nutrition care plans were updated by the Dietary Supervisor (DS) and Assistant Director of Nursing (ADON) on 6/18/25. Specifically, Resident 40's care plan addresses the shrimp food allergy, and for Residents 27 and 96, their dietary preference for Korean food. Corrective action for residents that may be affected by this deficiency: - The DS and ADON audited the nutrition care plans on 6/18/25 and completed on 7/9/25, to ensure all care plans capture food allergies and preferences for Korean food. - The Director of Nursing (DON) and ADON in-serviced nursing, the RD and DS utilizing P&P "Comprehensive Care Plans" initiated on 6/23/25 and completed on 7/9/25, emphasizing the importance of ensuring all nutrition care plans address food allergies and cultural food preferences. Measures that will be put into place to ensure that this deficiency does not recur: - The RD, DS, ADON, or trained designee will conduct nutrition care plan audits weekly X 3 months to ensure care plans address food allergies and food preferences. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - The DS, RD, or ADON will report their findings regarding Comprehensive Care Plans to the QA committee for discussion and further recommendations. The QA will continue monitoring for at least 3 months or until substantial compliance is achieved. Date of compliance: 7/9/25 Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - The DS, RD, or ADON will report their findings regarding Comprehensive Care Plans to the QA committee for discussion and further recommendations. The QA will continue monitoring for at least 3 months or until substantial compliance is achieved.
Failure to Maintain Proper Positioning of Urinary Drainage Bag
Penalty
Summary
A facility failed to provide appropriate care and services to prevent urinary tract infection (UTI) for a resident with an indwelling urinary catheter and a history of recurrent UTIs. The resident was readmitted with a physician's order for an indwelling urinary catheter due to neurogenic bladder. Medical records indicated the resident had a recent change in condition, including increased sleepiness, and was subsequently treated for a UTI with IV antibiotics as ordered by the physician. During observations on two separate days, the resident's urinary drainage bag was found lying on the floor while the resident was in bed. Staff interviews confirmed that the drainage bag should not be in contact with the floor for infection prevention, and staff acknowledged the improper positioning of the bag. The failure to keep the urinary drainage bag off the floor was not in accordance with CDC guidelines for catheter maintenance and posed a risk for catheter-associated urinary tract infection (CAUTI).
Plan Of Correction
F690 Bowel/Bladder Incontinence, Catheter, UTI How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident's indwelling catheter bag was checked on 6/19/25 by the ADON for proper positioning and the bag was not touching the floor at the time. 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: An audit of residents with indwelling urinary catheters was completed on 6/23/25 by the infection prevention and control nurse. One other resident was identified with an indwelling urinary catheter. Positioning for the collection bags was checked. The collection bags were not touching the floor. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: In-service was initiated on 6/23/25 provided by DSD to the staff regarding catheter care. In-service will be completed by 7/11/25 regarding proper positioning and catheter care. I.P. will observe residents with indwelling catheters 3 times per week for 3 months if the collection bags are touching the floor and for proper positioning. Findings will be addressed immediately. How the facility plans to monitor its performance to make sure that solutions are sustained: The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/11/25
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow the physician's order for oxygen therapy for a resident who required respiratory care. The resident had an order to receive oxygen via nasal cannula at 2 liters per minute, with the option to titrate up to 4 liters per minute if oxygen saturation dropped below 92%, and to monitor oxygen saturation in room air every shift. Medical records showed the resident's oxygen saturation ranged from 84% to 97%. During observation, the resident was found sitting on the patio with the portable oxygen tank turned off and the nasal cannula not in use, despite the order for continuous oxygen administration. The resident stated he turned off his oxygen most of the day and felt fine without it. Staff, including an RN and the DON, verified the physician's order for continuous oxygen and acknowledged that the resident was not receiving oxygen as ordered. The RN checked the resident's oxygen saturation, which was 92% at the time, and assisted the resident in resuming oxygen administration. However, the RN did not provide education to the resident about the risks and benefits of oxygen therapy during the interaction. The facility's policy required oxygen to be administered per physician order, except in emergencies, but this was not followed in the resident's case.
Plan Of Correction
F 695 Respiratory/Tracheostomy Care and Suctioning • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. A change of condition assessment was initiated on 6/18/25 regarding resident's non-compliance with oxygen therapy by the charge nurse. A care plan for residents' non-compliance with oxygen therapy was put in place on 6/18/25 by the charge nurse. The resident was asked to keep the nasal cannula; however, he insisted on taking it off when he feels "fine." The order for the continuous oxygen was changed to as needed on 6/18/25 per resident preference. His oxygen saturation level was checked on 6/18/25 at 1710 and it was 93% on supplemental oxygen via nasal cannula. His oxygen saturation level will continue to be checked every shift. • 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. An audit of the residents on oxygen therapy was done on 6/30/25 by the IP nurse. Three other residents were identified with orders for continuous oxygen therapy. The residents were checked for compliance to oxygen therapy, and there was no other issue identified. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. IP nurse/designee will monitor residents on continuous oxygen therapy for compliance 3 times/week for 3 months. Findings will be addressed immediately and reported to the DON for follow-up. In-service to licensed nurses on respiratory care and oxygen management was initiated on 6/23/25 by the DON/designee and will be completed by 7/11/25. • How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The IP/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/11/25 F 695
Failure to Assess Pain and Provide Non-Pharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident with moderate cognitive impairment who required such services. Specifically, staff did not ensure an accurate pain level was assessed and documented prior to administering pain medication on at least one occasion, as evidenced by the administration of tramadol when the pain level was documented as "0". Additionally, the medical record did not show that non-pharmacological interventions were provided prior to administering pain medication on multiple occasions when the resident reported moderate to severe pain levels. Review of the facility's pain management policy indicated that staff should use appropriate pain assessment tools and implement non-pharmacological interventions before administering medication. However, documentation for the resident showed repeated instances where these steps were not followed. Both the RN and DON confirmed that pain assessments and non-pharmacological interventions should have been completed and documented prior to medication administration, but this was not consistently done for the resident in question.
Plan Of Correction
F 697 Pain management • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Pain assessment on resident 49 was done on 6/23/25 by ADON. The resident had a pain level of 7/10 on 6/22/25 at 1535 and she was given Tramadol which was effective. Follow-up pain level was 0/10. Documentation of non-pharmacological intervention was initiated on 6/17/25 by the charge nurse. 1:1 training with LVN who made the error was done on 6/23/25 by ADON on pain management and providing non-pharmacological interventions prior to administration of medication. Inservice with licensed nurses on pain management and providing non-pharmacological interventions prior to administration of medication initiated on 6/23/25 by DON/Designee and will be completed by 7/10/25. • 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. An audit of all residents with tramadol was done by the DON/designee on 7/3/25. We found 2 other residents on tramadol, no errors were found with the pain assessment and non-pharmacological interventions were attempted prior to administration of medication. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Medical records director/designee will conduct an audit of residents on tramadol to check if non-pharmacological interventions were provided prior to administration of medications. Medical records director/designee will also validate if the initial pain level is being documented. These audits will be done 3x/week x 3 months. Any significant findings will be reported to DON/designee for follow-up. • How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The IP/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25 F 697
Failure to Rotate Insulin Injection Sites and Timely Replace Emergency Medication Kits
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of its residents by not ensuring consistent rotation of injection sites for subcutaneous insulin administration for five residents. Medical record reviews for these residents showed repeated administration of insulin injections at the same anatomical sites over consecutive days. For example, one resident received Lantus insulin in the same arm for multiple days, while others received insulin injections repeatedly in the same quadrant of the abdomen. Interviews with nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged that sites should have been rotated to prevent complications such as lipohypertrophy and non-absorption of insulin. Additionally, the facility did not adhere to its policy and procedure regarding the timely replacement of emergency medication kits. The policy required that emergency kits for intravenous and oral medications be replaced within 72 hours of being opened. However, documentation showed that items were removed from the emergency kits, and the kits were not replaced within the specified timeframe. Nursing staff verified that the replacement did not occur as required by facility policy. The residents involved in these deficiencies had significant medical needs, including diabetes mellitus requiring regular insulin administration. Several residents lacked the capacity to make medical decisions, as documented in their histories and physicals. The failure to rotate injection sites and to timely replace emergency medication kits was confirmed through interviews with nursing staff and review of facility records and policies.
Plan Of Correction
F 755 Pharmacy services - Insulin injection sites not rotated. 5 residents affected. IV and oral e-kit were not replaced within 72 hours. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The five identified residents were checked by DSD and ADON. Skin assessments done on 6/20/25. No lipodystrophy (lypohypertrophy) noted on all 5 sample residents. Skilled nursing pharmacy was called and asked to replace the IV and oral emergency kits on 6/16/25. IV e-kit and oral e-kit were delivered on 6/16/26. 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. An audit of residents with insulin injections was done by DSD on 7/3/25. Identified 4 residents with insulin injection sites not rotated. 1:1 training with the nurses who made the errors will be completed by 7/4/25 by DON/designee on proper administration of insulin. All new e-kits were delivered by Skilled Nursing Pharmacy on 6/16/25 and replaced by the ADON. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Med records will check documentation of insulin injection sites during weekdays x 3 months. Findings will be reported to DON for follow up. Inservice for replacement of e-kit in for all licensed nurses on 7/2/25. Inservice for rotating insulin injection sites initiated on 6/20/25 by DON/designee and will be completed by 7/11/25. ADON/designee will check IV and oral e-kits daily Monday to Friday weekly x 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The IP/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/11/25
Deficiencies in Medication Storage, Labeling, and Sanitation
Penalty
Summary
Surveyors identified several deficiencies related to the storage, labeling, and disposal of medications and biologicals. During inspections of medication storage areas, it was observed that medication cabinets were dusty and not maintained in a clean and sanitary condition, as acknowledged by a registered nurse. Additionally, a bottle of geri-tussin was found with an illegible expiration date, and the nurse confirmed that expiration dates should be legible for resident safety. The facility's policy requires that medications be stored safely, securely, and properly, and that storage areas are kept clean and free of clutter. Further inspection of a treatment cart revealed multiple packets of Dermaseptin ointment and Dermarite Boarder Gauzes without expiration dates after being removed from their original packaging. A licensed vocational nurse confirmed that these items should have been labeled with expiration dates when removed from the original box. The facility's policy also states that outdated, contaminated, or deteriorated medications, or those in compromised containers, should be immediately removed and disposed of according to procedure. The Director of Nursing was informed and acknowledged these findings.
Plan Of Correction
F 761 F761 Label/Store Drugs and Biologicals Corrective Action Initiated For Resident/s On 6/16/25, medication room A cabinets were immediately cleaned, disinfected, and the hanger was removed by ADON. On 6/16/25, the bottle of Geri-Tussin with an illegible expiration date was removed and discarded from Medication Room B by ADON. On 6/16/25, all Dermaseptin ointment packets and Dermarite bordered gauze without visible expiration dates were removed. New supplies with expiration dates verified from the original box were placed in a clear container with clear expiration dates labeled by the treatment nurse on 6/16/25. How Potential Other Residents Were Identified and Corrective Action Taken Other residents are at risk for this noted practice. On 6/17/25, a spot check of medication and treatment rooms, carts, and storage areas was initiated. No additional issues were found during this audit. Measures to Prevent Recurrence Systemic The DON/designee conducted an in-service training on 7/3/25 to all licensed nursing staff on P&P on Medication Storage, labeling, and emphasizing proper labeling and visibility of expiration dates for all medications and supplies, as well as the importance of a cleaned and sanitary medication area. The ADON/designee will conduct weekly audits for four weeks, then monthly for three months to validate that medication storage areas remain clean and free of unnecessary items, and to ensure that all medications and treatment supplies are clearly labeled with expiration dates. Any findings will be reported to DON for follow-up. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for three months or until such time that consistent substantial compliance has been achieved, as determined by the committee. Date of compliance: 7/3/25
Failure to Honor Resident Food Preferences and Dislikes
Penalty
Summary
The facility failed to honor the documented food preferences of several residents, specifically those who preferred Korean cuisine and one resident who disliked carrots. Observations during meal service revealed that residents who had a preference for Korean pureed meals were instead served items from the American pureed menu, with only pureed kimchi from the Korean menu being provided. The Lead Cook confirmed that the American menu was used for all pureed meals and that the Korean menu pureed items, aside from kimchi, were not prepared. The Dietary Services Supervisor (DSS) acknowledged that the kitchen staff were informed of residents' preferences via meal tickets but was unaware that the full Korean pureed menu was not being prepared as required. Medical record reviews for two residents confirmed their documented preference for Korean food at lunch and dinner, yet both received American pureed meals during the observed lunch service. Meal tickets for these residents also indicated their preference for Korean food, which was not honored. Additionally, another resident who had a documented dislike for carrots was served a meal containing carrots, which she did not eat. This was verified by both the attending LVN and the DSS, who confirmed the resident's preference was clearly indicated on the meal ticket but not followed. These failures were identified through direct observation, interviews with staff, and review of medical records and meal tickets. The deficiencies were acknowledged by the DSS and DON during interviews, with the DSS attributing the failure to a mistake made by the cook. The report documents that these actions and inactions resulted in residents not receiving meals in accordance with their documented preferences and dislikes.
Plan Of Correction
F806 Resident Allergies, Preferences, Substitutes Corrective action for residents found to have been affected by this deficiency: - DS visited Residents 7, 16, 27, 35, 96, and 40 on 7/7/25, ensuring meal satisfaction, updating all food preferences per resident or resident representative. - DS in-serviced all dietary staff initiated on 6/17/25 and completed for all dietary staff on 7/7/25, utilizing P&P "Menus and Adequate Nutrition," emphasizing the importance of honoring all food preferences, including cultural foods, ensuring residents' nutritional adequacy and satisfaction. Measures that will be put into place to ensure that this deficiency does not recur: - DS, RD, or trained designee will conduct test tray and tray line audits, 3 times per week X 3 months, ensuring all food preferences are honored, including all Korean cultural food preferences, and that no foods residents dislike are on the meal trays. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - DS, or RD will report their findings regarding honoring food preferences and cultural food requests to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved.
Resident Served Incorrect Diet Texture Despite Physician Order
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered carbohydrate controlled, soft and bite-sized (SB6) diet was served a regular texture slice of bread during a lunch meal. The resident's meal ticket indicated the correct diet order, and both the Assistant Director of Nursing (ADON) and Dietary Services Director (DSD) were observed checking the meal and diet orders prior to service. Despite these checks, the resident received food inconsistent with the prescribed diet. The facility's policy requires that therapeutic diets, including mechanically altered diets, be provided as ordered by the physician or a delegated registered or licensed dietitian, and that dietary and nursing staff ensure the correct form and content of meals. The resident in question had a history of severe cognitive impairment and had been recommended a soft and bite-sized diet by the Speech Language Pathologist (SLP). The SLP confirmed that any changes to a resident's diet are not active until a physician's order is written and entered into the electronic health record (EHR). At the time of the incident, the order had not been updated to allow regular bread, and the SLP verified that the resident should not have received it. The failure to provide the correct diet as ordered posed a risk of aspiration and unmet nutritional needs for the resident.
Plan Of Correction
F808 Therapeutic Diet Prescribed by Physician Corrective action for residents found to have been affected by this deficiency: - DS and RD in-serviced dietary staff immediately on 6/16/25 and completed for all dietary staff on 6/17/25, utilizing P&P "Therapeutic Diet Orders" ensuring that all diet textures are followed according to the physician's orders. - DS audited dinner for Resident 61 on 6/16/25, ensuring the resident's diet order was followed and the correct food items were served. Corrective action for residents that may be affected by this deficiency: - DS, RD, or trained designee will conduct tray line audits at various mealtimes, comparing resident meals with the PCC Diet Type Report, ensuring meal tray accuracy. Measures that will be put into place to ensure that this deficiency does not recur: - Licensed nurses will continue to audit meal trays with the PCC Diet Type Report at all mealtimes before meal trays are provided to the residents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - DS, RD, or licensed nurse will report their findings regarding diet order monitoring to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 6/17/25
Deficient Facility Assessment Lacks Required Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed in accordance with federal requirements. Specifically, the assessment did not demonstrate the active involvement of required individuals, including direct care staff, direct care representatives, residents, resident representatives, and family members. This omission was confirmed during an interview with the Administrator, who acknowledged that these groups were not actively involved in the development of the Facility Assessment. Additionally, the Facility Assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff. The assessment also lacked a contingency plan for staffing needs in situations that do not require activation of the facility's emergency plan. These deficiencies were identified through a review of the facility's documentation and were verified by the Administrator. The Administrator further confirmed that the Facility Assessment had not been updated to reflect the latest CMS guidance, which requires these elements to be included. The lack of comprehensive identification and addressing of the resident population's needs and available resources had the potential to result in unmet care needs for residents.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 6/24/25, administrator completed the most current version of the Facility Assessment. The assessment was brought to the QA committee for discussion and approval on 6/25/25. 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 the deficient practice. The administrator will continue to gather feedback from emergency drills, monthly safety meetings, monthly all-staff meetings, and monthly QA for feedback on communication protocol and any necessary changes to Facility assessment and Emergency Operations Plan in the event of an emergency. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Administrator will verify the most recent version of the facility assessment prior to creating the Facility Assessment for 2026 and upcoming years. How the facility plans to monitor its performance to make sure that solutions are sustained. Facility Assessment will be discussed at the monthly QA meeting for feedback from floor staff and department heads to review findings from monthly safety committee/all-staff meetings and learnings from disaster/fire/emergency drills. Date of compliance: 6/25/25
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Linen Handling
Penalty
Summary
Facility staff failed to implement infection control practices as required by federal regulations. During a medication pass for a resident with a G-tube feeding, an LVN did not perform hand hygiene between glove changes. Specifically, after removing gloves, the LVN touched the bed and other surfaces, then donned new gloves without hand hygiene before continuing with tasks such as turning off the G-tube machine and checking tube placement. The LVN also failed to perform hand hygiene after removing gloves to retrieve spoons from the medication cart, instead immediately donning new gloves. The resident involved had no capacity to make decisions and was on enhanced barrier precautions due to the G-tube. In another instance, a CNA did not follow enhanced barrier precautions when assisting a resident with a urostomy back to bed. Although the resident's doorway had signage indicating enhanced barrier precautions and the CNA performed hand hygiene and donned gloves, the CNA did not wear a gown as required for high-contact care activities such as transferring the resident. Both the CNA and the infection preventionist confirmed that a gown should have been worn during this type of care, as outlined in the resident's care plan and physician's orders. Additionally, the facility failed to maintain proper infection control in the laundry area. The laundry aide stored personal items, including a cell phone charger, water bottle, and flask, on the counter designated for clean laundry sorting, adjacent to clean resident linens. The laundry aide and infection preventionist both acknowledged that personal items should not be stored near clean linens to prevent contamination. These observed failures in hand hygiene, use of personal protective equipment, and linen handling posed a risk for the transmission of infectious agents within the facility.
Plan Of Correction
F880 Infection Prevention and Control • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. 1:1 training was done by the IP nurse with the charge nurse who failed to ensure hand hygiene was performed in between changing of gloves during med pass observation with a resident who had enteral feeding. The 1:1 training included hand hygiene and universal precautions. CN A did not follow EBP precaution when assisting the resident back to bed. CNA 4 was given a 1:1 training by the DSD on 6/16/25 on policy and procedure for Enhanced Barrier Precautions. Laundry personnel failed to ensure the laundry aide did not store personal items adjacent to the resident clean linens in the laundry sorting area. 1:1 training with the laundry aide provided by IP nurse on 7/3/25 on storage of personal items in clean working stations. The personal item was discarded and the area was sanitized per facility protocol. Maintenance director verified that the water bottle did not touch or contaminate any clothing items and that no re-washing was necessary. In-services will be provided by the IP nurse on hand hygiene, EBP practice, personal items in clean working stations by 7/10/25. • 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 6/18/25, the DSD did a spot check on the CNAs observing EBP practices and no other issue was noted. On 6/18, IP performed a hand hygiene audit with the nursing staff and no other issue was identified. On 6/20/25, a spot check of the laundry room was done by the IP to check for personal items near the sorting area and no other issue was found. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. I.P. will do random checks on hand hygiene, EBP practices, and storing/using personal items in clean working areas 3x/week x 3 months. Report any findings to the DON. • How the facility plans to monitor its performance to make sure that solutions are sustained. IP nurse will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved as determined by the committee. • Include dates when corrective action will be completed. Date of compliance: 7/10/25
Failure to Offer Required Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer the PCV15 or PCV20 pneumococcal vaccination to a resident who had previously received the PPSV23 vaccine, as required by both the facility's policies and CDC guidelines. The resident, aged 93, was admitted to the facility and had documentation showing receipt of the PPSV23 vaccine in 2013. Upon admission, the responsible party declined consent for further pneumococcal vaccination, citing the previous PPSV23 dose as the reason. However, the facility's policy and CDC recommendations specify that adults aged 65 and older who have only received PPSV23 should be offered a dose of PCV15 or PCV20 at least one year after the last PPSV23 vaccination. Medical record review and the California Immunization Registry confirmed that the resident had not received PCV15 or PCV20, and there was no documentation that the vaccine was offered in accordance with current guidelines. The facility's immunization report also did not show administration of PCV15 or PCV20. During an interview, the Infection Preventionist verified that the resident's records did not reflect the required offer or administration of the additional pneumococcal vaccine, as outlined in the facility's policy and CDC recommendations.
Plan Of Correction
F883 Influenza and Pneumococcal Immunizations. Failed to follow up subsequent vaccine. • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Offered pneumococcal vaccine to resident/responsible party on 6/19/25. The responsible party declined the vaccine on 6/19/25. • 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. An audit of the pneumococcal vaccinations for all residents was done on 6/24/25 by the IP nurse. No other residents were found. IP was inserviced 6/24/25 by DON about resident pneumonia vaccinations being offered annually. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. DSD will audit the pneumococcal vaccine log once a week x 3 months. Significant findings will be reported to the DON. • How the facility plans to monitor its performance to make sure that solutions are sustained. IP nurse provide a summary of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 6/24/25
Failure to Ensure Bed Remote Controls Were Accessible to Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents by not ensuring that their bed remote controls were within reach. During an initial tour, one resident's bed remote control was observed at the foot of the bed, out of the resident's reach, while the resident was sleeping. Medical record review indicated that this resident lacked the capacity to understand and make decisions. A certified nursing assistant (CNA) confirmed that the bed remote control should be placed within the resident's reach, as the resident was able to use it to adjust their position for comfort. A licensed vocational nurse (LVN) also acknowledged that the bed remote control should be accessible to the resident. In a separate observation, another resident's bed remote control was found hanging by the left side of the bed, not within reach. When asked, the resident expressed a preference for having the bed remote control within reach. The infection preventionist (IP) verified that the remote should have been placed within the resident's reach. Medical records showed that this resident had intact cognition and the capacity to make decisions. These observations and interviews demonstrated that the facility did not consistently ensure that bed remote controls were accessible to residents, as required.
Plan Of Correction
F 558 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The bed remotes for residents 1 and 28 were placed within reach of each resident. • 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 6/24/25, the Director of Staff Development (DSD) conducted an audit of residents to ensure that bed remotes were accessible to all residents, unless contraindicated for safety. No additional residents were observed with bed remotes out of reach. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. An in-service for facility staff was initiated on 6/23/25 by the Director of Staff Development (DSD) regarding ensuring bed remotes are kept within reach of residents, unless contraindicated for safety. Inservices completed by 7/10/25. On 7/7/25, the maintenance department started installing clips on the bed remotes to ensure they are within reach of residents, unless contraindicated for safety reasons. Completion date: 7/10/25. The assistant director of nursing or designee will monitor 10 random residents (alert) from each station 3 times/week for 3 months to ensure their bed remotes are within reach. • How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25
Inaccurate MDS Coding for Hemodialysis Treatment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for one resident. Specifically, a review of the resident's Admission MDS assessment showed that the section for Special Treatments, Procedures, and Programs did not indicate that the resident was receiving hemodialysis. However, a physician's order dated prior to the assessment confirmed that the resident was scheduled for hemodialysis three times a week at a contracted dialysis facility. During interviews, the MDS Coordinator acknowledged that the MDS assessment was coded incorrectly and verified the omission. The Director of Nursing (DON) was also informed and acknowledged the findings. The facility's policy required that all assessments accurately reflect the resident's status at the time of assessment, but this was not followed in this instance, potentially impacting the development of individualized care plans for the resident.
Plan Of Correction
F641 - Accuracy of Assessments How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On 6/18/2025, The MDS Coordinator modified the Admission/5-day MDS assessment with ARD of 6/6/2025 to reflect the dialysis status for Resident 399. 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 that are on Dialysis could be affected by the deficient practice. On 6/18/2025, the MDS Coordinator conducted an audit of the MDS assessments of all residents that have dialysis to ensure that the MDS assessments are coded accurately to reflect resident's dialysis status. Out of 2 residents, 1 was modified and transmitted to reflect accurate coding in resident's dialysis status and the other 1 MDS assessment was coded accurately. What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur: On 6/18/2025, the MDS Consultant provided an In-service to the MDS Coordinator and MDS staff regarding dialysis and MDS coding per RAI Manual. MDS coding accuracy per RAI Manual was emphasized during the In-service. How the Facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficient practice will not recur: The MDS Coordinator will conduct quarterly and annual audits of residents who have dialysis to ensure that MDS assessments accurately reflect the resident's dialysis status. Any findings will be corrected and reported to the Director of Nursing (DON) and will be presented at the Monthly facility Quality Assurance meeting for further discussion and action plans as appropriate.
Inaccurate Documentation of Vital Signs for Absent Resident
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record by documenting vital signs for a date when the resident was not present in the facility. Specifically, the medical record for one resident showed that vital signs were obtained on 6/12/25, despite the resident having been transferred to an acute care hospital on 6/10/25 and remaining there thereafter. This discrepancy was confirmed during a review of the closed medical record and an interview with the Director of Nursing (DON), who verified that the resident was not in the facility on the date the vital signs were recorded. The inaccurate documentation included specific vital sign measurements such as blood pressure, respirations, pulse, and oxygen saturation, all recorded as if obtained in the facility after the resident's transfer. The error was identified during a closed record review initiated several days after the resident's transfer, and the DON acknowledged the inaccuracy in the resident's medical record. No information was provided regarding the resident's medical history or condition at the time of the deficiency beyond the fact that the transfer to the hospital was due to lethargy.
Plan Of Correction
F-842 Resident Records - identifiable information Corrective Action Initiated for Resident/ On 7/3/25, the inaccurate entry for Resident 94's vital signs dated 6/12/25 was identified and corrected by marking the documentation as an error in the electronic medical record (EMR) with appropriate notation by DON. CNA who made the error in documentation was given 1:1 training by the DSD on 6/18/25. A late entry progress note was added by DON on 7/3/25 clarifying that Resident 94 was hospitalized during that period and that the vital signs were entered in error RT #94 was discharged on 6/17/25. How Potential Other Residents Were Identified and Corrective Action Taken An audit was conducted by medical records/designee on 7/3/25 of residents who were transferred to acute care hospitals between 6/3/25 to 7/3/25 to ensure no other inaccurate entries were made post-discharge. 17 residents were checked with 1 resident noted with blood pressure taken after he was transferred to the hospital. Vital sign was struck out and progress note done on 7/3/25. 1:1 training with the charge nurse who made the error was done on 7/3/25. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 6/20/25, nursing staff received re-education by the DSD on proper documentation protocols, including: verifying resident presence before documentation, correct use of EMR templates, and discontinuing charting once a resident is discharged or transferred. Medical Records will audit each discharge record to ensure documentation entries are accurate -- findings will be submitted to DON for follow-up and resolution. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The MRD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/3/25
Deficiency in Denture Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the activities of daily living (ADL) capabilities for two residents, specifically in the area of denture care. Resident 1, who had severe cognitive impairment and required substantial assistance with oral hygiene, was observed with dentures improperly stored in a cup with a small amount of clear liquid. The resident's dentures were not cleaned as per the facility's policy, and there was no care plan addressing the resident's refusal to wear dentures. Similarly, Resident 2, who required partial to moderate assistance for oral hygiene, was found with dentures stored in a similar manner, and the dentures had not been cleaned as required. Interviews with facility staff, including CNAs, LVN, DSD, and DON, revealed a lack of adherence to the facility's policy on denture care. The CNAs were expected to clean and store dentures properly, but this was not done for the residents in question. The facility's policy required dentures to be cleaned and stored in water with a denture cleanser tablet, which was not followed. Additionally, there was no care plan in place for Resident 1's refusal to wear dentures, indicating a failure to accommodate the resident's needs and preferences as outlined in the facility's policies.
Failure to Continue Prescribed Medication for Resident
Penalty
Summary
The facility failed to ensure that necessary care and services were provided to meet the needs of a resident who was admitted from an acute care hospital. Specifically, the facility did not continue the resident's prescribed levothyroxine medication upon admission, despite it being listed in the hospital's discharge medication list. This oversight occurred because the admitting nurse did not thoroughly reconcile the discharge medications. The resident, who had a history of hypothyroidism, was admitted to the facility without the continuation of their levothyroxine medication, which was crucial for their condition. The medication was not ordered until six days after admission, resulting in a gap in treatment. The Assistant Director of Nursing (ADON) acknowledged the failure to reconcile the medications properly, which led to the resident not receiving the necessary medication for their hypothyroidism until several days later.
Failure to Conduct Initial Fall Risk Assessment
Penalty
Summary
The facility failed to conduct an initial fall risk assessment for Resident 1, which was necessary to prevent accidents and ensure adequate supervision. Resident 1 was admitted to the facility after being brought in by ambulance from home due to a mechanical trip and fall, resulting in a left hip intertrochanteric fracture. Despite the facility's policy requiring a fall risk assessment upon admission, the assessment form for Resident 1, dated 10/25/24, was signed by an LVN but left entirely blank. This oversight was confirmed during an interview and medical record review with the ADON, who acknowledged that the assessment should have been completed to identify risks and implement appropriate interventions to prevent falls.
Failure to Assess Bolster Mattress as Potential Restraint
Penalty
Summary
The facility failed to ensure an assessment was completed before applying a bolster mattress to a resident to determine whether it was a physical restraint. The facility's policy mandates that each resident should attain and maintain their highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience. However, the facility did not follow this policy for Resident #292, who was admitted with multiple diagnoses, including reduced mobility and a history of falls. The resident's care plan did not include an intervention for the use of a bolster mattress, and no assessment was conducted to determine if the bolster mattress was a restraint. Observations revealed that Resident #292 was lying in bed with high bolsters on each side, fitting tightly between them, which restricted the resident's movement. Interviews with staff, including the MDS Coordinator, CNA, LVN, and the Director of Nursing, confirmed that the bolster mattress was used to prevent the resident from falling out of bed. However, none of the staff could confirm if an assessment had been completed to determine if the resident could remove the bolsters independently. The Director of Nursing acknowledged that an assessment should have been completed during an interdisciplinary team meeting. The Administrator and the Director of Rehabilitation also confirmed that an assessment should have been conducted before applying the bolster mattress. The Administrator was unaware that the resident had a bolster mattress and expected an assessment to be completed to ensure it was not a restraint. The Director of Rehabilitation noted that physical therapy had been working with the resident but lacked documentation of the treatment plan. The failure to assess the bolster mattress as a potential restraint led to the deficiency identified in the report.
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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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