The Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunland, California.
- Location
- 10158 Sunland Blvd, Sunland, California 91040
- CMS Provider Number
- 555045
- Inspections on file
- 36
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at The Hills Healthcare Center during CMS and state inspections, most recent first.
Two residents were not treated with dignity during mealtime assistance as staff members stood over them while feeding. One resident, with severe cognitive impairment, was fed by an RNA standing due to space constraints, while another resident, with moderate cognitive impairment, was fed by a CNA standing to expedite the process. This was against the facility's policy, which requires staff to be seated to ensure residents' safety, comfort, and dignity.
The facility failed to ensure that call lights were within reach for two residents, both with severe cognitive impairments and requiring assistance with daily activities. Observations revealed that the call lights were improperly placed, making them inaccessible. The DON confirmed that call lights should be within reach to allow residents to summon help, as per facility policy.
The facility failed to provide non-pharmacological interventions before administering opioid medications to two residents. One resident with a pelvic fracture and severe cognitive impairment, and another with a history of falls and dementia, were both prescribed tramadol without attempts at non-pharmacological interventions, contrary to the facility's policy. The DON confirmed the oversight, highlighting the importance of such interventions to prevent unnecessary medication.
Two residents experienced medication administration discrepancies when Tramadol was removed from the CDR without corresponding entries in the MAR. One resident had a pelvic fracture and severe cognitive impairment, while the other had a history of falls and dementia. Interviews with an LVN and the DON confirmed the failure to follow facility procedures, posing a risk of medication errors and drug diversion.
The facility failed to implement the Medication Regimen Review (MRR) for two residents, resulting in missed communication of critical medication monitoring recommendations to physicians. A resident with multiple diagnoses, including hydrocephalus and dementia, did not have recommended blood tests for valproic acid and heparin levels conducted. Another resident with a subdural hematoma and dementia also missed a recommended PTT blood draw for heparin monitoring. The Director of Nursing did not follow the facility's policy to ensure MRR recommendations were communicated to physicians.
The facility failed to monitor medication levels for two residents, leading to a deficiency. One resident was prescribed valproic acid and heparin, while another was prescribed heparin. The Medication Regimen Review recommended monitoring levels, but these were not communicated to the physician, and necessary tests were not conducted. The Director of Nursing acknowledged the oversight, which put the residents at risk of adverse effects.
The facility failed to ensure residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. A resident with multiple diagnoses was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and PTT. Similarly, another resident was prescribed heparin, but the facility failed to follow up on the recommendation for a PTT blood draw. The DON acknowledged the oversight, which was considered a medication error.
The facility failed to label stored food with use-by dates, as observed during a survey. Items in the refrigerator and dry storage, including garlic, ham, apple sauce, puddings, gelatine desserts, and potatoes, lacked proper labeling. The Dietary Supervisor and DON acknowledged the oversight, which violated the facility's policy and posed a risk to residents.
The facility failed to maintain sanitary trash storage as two dumpsters were observed with open lids, positioned too close to the wall to be closed. The Dietary and Maintenance Supervisors confirmed that the dumpsters should have been closed to prevent attracting pests and potential infection control issues. The facility's policy requires dumpsters to be kept closed to prevent pest access.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by policy. Staff did not wear gowns during high-contact care activities, and EBP signs and PPE were not provided outside residents' rooms. The Infection Preventionist and Director of Nursing acknowledged the lack of implementation, despite CMS guidelines mandating EBP for such residents.
A facility failed to maintain a resident's advance directive in their active clinical record, despite the resident's severe cognitive impairment and need for assistance. The document was found in an overflow section, contrary to facility policy requiring it to be readily accessible to guide staff in honoring the resident's healthcare preferences.
A resident with severe cognitive impairment and mobility issues was found to have their Low Air Loss Mattress (LALM) incorrectly set at a higher weight than their actual weight, potentially compromising pressure injury care. The facility's failure to adhere to the physician's order for the correct LALM setting was confirmed by the Director of Nursing, who acknowledged the risk of further skin injuries.
The facility failed to store medications in a locked compartment, as observed at Nursing Station Two where the medication cabinet lacked a lock. This cabinet contained various medications, including iron supplements and acetaminophen. The Director of Staff Development confirmed the need for locked storage to prevent resident access, while the DON was unaware of the issue. Facility policy mandates locked storage for medications.
The facility did not meet the required 80 square feet per resident in multiple resident rooms, affecting 15 rooms. Despite this, observations showed adequate space for movement and care. The facility requested a waiver, claiming no adverse effects on residents.
The facility failed to schedule necessary follow-up appointments with cardiology and pulmonology for a resident as per discharge instructions and did not monitor the resident after a noted change in condition, leading to a significant lapse in care.
A facility failed to develop a comprehensive care plan for a resident with heart failure, despite multiple admissions and severe cognitive impairment. The absence of this care plan, which should have been created within 14 days, could negatively impact the resident's care.
The facility failed to ensure a resident's history and physical (H&P) was completed by the attending physician upon admission. The resident, with serious medical conditions and severely impaired cognition, had an undated and incomplete H&P, signed without a date. This could lead to inconsistent care coordination.
A facility failed to ensure an LVN documented the administration of Plavix for a resident with severe cognitive impairment and heart conditions. The RN confirmed the absence of documentation on the MAR, violating the facility's medication administration policy.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during mealtime assistance. Restorative Nursing Assistant 1 (RNA 1) was observed standing over Resident 49 while assisting with eating. Resident 49, who has severe cognitive impairment and requires supervision for daily activities, was seated in a wheelchair in the hallway. RNA 1 admitted to standing due to the lack of space for a chair in the hallway and the need to monitor other residents. This action was contrary to the facility's policy, which mandates that staff should be seated while assisting residents with meals to ensure safety, comfort, and dignity. Similarly, Certified Nursing Assistant 3 (CNA 3) was observed standing over Resident 18 while feeding them lunch. Resident 18, who has moderately impaired cognition and requires assistance with eating, was in a High Fowler's position in bed. CNA 3 acknowledged the need to be seated during feeding but chose to stand to expedite the process. This was also against the facility's policy, which emphasizes the importance of staff being seated at eye level with residents during meals to prevent aspiration and ensure residents do not feel rushed. Interviews with various staff members, including Treatment Nurse 1, Licensed Vocational Nurse 2, and the Director of Nurses, confirmed that the facility's policy requires staff to be seated while assisting residents with meals. The policy aims to maintain residents' dignity and ensure their safety and comfort during mealtimes. The failure to adhere to this policy potentially impacted the self-esteem and self-worth of the residents involved.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the resident call light was within accessible reach for two residents, Resident 23 and Resident 59. Resident 23, who was admitted with conditions such as spinal stenosis, a displaced fracture of the left femur, and aphasia, was observed to have a call light looped over the upper side of the wall light, making it inaccessible. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for moderate assistance with daily activities. During an observation, a Restorative Nursing Assistant (RNA) noted that the call light should have been clipped to the pillow to facilitate ease of use, acknowledging that its inaccessibility could prevent the resident from asking for help and potentially lead to a fall. Similarly, Resident 59, who had diagnoses including senile degeneration of the brain and aphasia, was found to have an adaptive call light located behind the head of the bed, out of reach. The MDS for Resident 59 also indicated severe cognitive impairment and dependency on assistance for daily activities. The RNA confirmed that the call light should have been clipped to the pillow for accessibility. The Director of Nursing (DON) stated that the call light should always be within reach to ensure residents can summon help when needed, as outlined in the facility's policy and procedure on the call system.
Failure to Implement Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid medications to two residents. Resident 36, who was admitted with a pelvic fracture and had severe cognitive impairment, was prescribed tramadol for moderate pain. The resident's care plan, however, did not include any non-pharmacological interventions, and the facility's policy required such interventions to be attempted before administering pain medication. Similarly, Resident 61, who had a history of falls and dementia, was prescribed tramadol for moderate to severe pain. Like Resident 36, the care plan for Resident 61 also lacked non-pharmacological interventions, despite the facility's policy. During a review of the residents' records and interviews with the Director of Nurses (DON), it was confirmed that non-pharmacological interventions were not attempted prior to administering pain medication. The DON acknowledged the oversight and emphasized the importance of attempting non-pharmacological interventions to reduce the risk of unnecessary medication administration. The facility's policy on pain management, which was last reviewed shortly before the survey, clearly stated the requirement for assessing pain and attempting non-pharmacological interventions before administering pain medications.
Medication Administration Discrepancies
Penalty
Summary
The facility failed to ensure that two residents were free from medication errors by not reconciling the Controlled Drug Record (CDR) with the Medication Administration Records (MAR). For Resident 36, the CDR indicated that Tramadol was removed on three occasions, but there were no corresponding entries in the MAR for those dates. Resident 36 was admitted with a pelvic fracture and was severely impaired in cognition, requiring moderate assistance with daily activities. The facility's policy required that controlled substances be reconciled upon administration, but this was not followed. Similarly, for Resident 61, the CDR showed that Tramadol was removed on two occasions without corresponding entries in the MAR. Resident 61 was admitted with a history of falls and dementia, and was moderately impaired in cognition, requiring supervision for personal hygiene and dressing. The facility's policy mandated that the administration of medications be recorded in the resident's medical record, but this was not adhered to, leading to discrepancies between the CDR and MAR. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the discrepancies and the failure to follow the facility's procedures. The LVN and DON both acknowledged the importance of signing both the CDR and MAR to ensure accurate accounting of controlled medications and to prevent potential medication errors. The failure to document the administration of controlled substances as per the facility's policy posed a risk of medication errors and drug diversion.
Failure to Implement Medication Regimen Review
Penalty
Summary
The facility failed to implement the Medication Regimen Review (MRR) for two residents, Resident 49 and Resident 63, as required by their policies and procedures. The MRR is a pharmacist's thorough evaluation of a resident's medication routine and recommendations, which should be communicated to the resident's physician for review and potential action. In both cases, the Director of Nursing (DON) did not notify the physicians of the MRR recommendations, which included necessary blood tests to monitor medication levels and prevent potential adverse effects. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis (DVT). The MRR recommended checking valproic acid levels and partial thromboplastin time (PTT) to ensure safety from bleeding, blood clots, and seizures. However, these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood test was not performed. The facility's policies clearly state that it is the responsibility of the DON to ensure that MRR recommendations are followed up with the physician, which did not occur in these instances.
Failure to Monitor Medication Levels for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs by not adequately monitoring valproic acid and heparin levels. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid to prevent seizures and heparin to prevent deep vein thrombosis. However, the Medication Regimen Review (MRR) recommended monitoring valproic acid levels and partial thromboplastin time (PTT), but these recommendations were not communicated to the physician, and the necessary blood tests were not conducted. Similarly, Resident 63, who was admitted with a nontraumatic subdural hematoma and unspecified dementia, was prescribed heparin to prevent DVT. The MRR recommended a PTT blood draw to monitor heparin levels, but this recommendation was also not communicated to the physician, and the blood tests were not performed. The Director of Nursing (DON) acknowledged the oversight and stated that it was her responsibility to notify the physician of the MRR recommendations. The failure to monitor these medication levels put the residents at risk of bleeding, blood clots, and seizures. The facility's policies and procedures required the consultant pharmacist to review each resident's drug regimen monthly and for the facility to follow up on the pharmacist's recommendations by providing them to the primary physician. The DON was responsible for ensuring proper follow-through. The policies also required the physician to assess the effects of medications through lab work and collaborate with the pharmacist and nursing staff. However, these procedures were not followed, leading to the deficiency.
Failure to Monitor Therapeutic Levels Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not checking therapeutic levels for two residents, leading to potential health risks. Resident 49 was admitted with multiple diagnoses, including hydrocephalus, a cerebrospinal drainage device, dysphagia, a history of falling, and dementia. The resident was prescribed valproic acid and heparin, but the facility did not follow up on the pharmacist's recommendation to check the valproic acid level and partial thromboplastin time (PTT). The Director of Nursing (DON) acknowledged that it was her responsibility to notify the physician of these recommendations, which were missed, putting the resident at risk for bleeding, blood clotting, and seizures. Similarly, Resident 63 was admitted with a nontraumatic subdural hematoma, a history of falling, and unspecified dementia. The resident was prescribed heparin, but the facility failed to follow up on the pharmacist's recommendation for a PTT blood draw. The DON admitted that the order to check the heparin level was missed, which was necessary to ensure the resident's safety from bleeding and blood clots. This oversight was considered a medication error, as the facility did not verify the appropriate medication dosage based on lab work. The facility's policies and procedures required monthly drug regimen reviews by a consultant pharmacist, with the responsibility to follow up on recommendations resting with the facility. The policies also indicated that the attending physician should assess the relevance of recommended interventions and collaborate with the pharmacist and nursing staff. However, these procedures were not adequately followed, leading to the deficiencies identified in the report.
Failure to Label Food with Use-By Dates
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling stored food items with a use-by date. During an observation and interview with the Dietary Supervisor, it was noted that several food items in the refrigerator, including a zip-lock bag of garlic, a plastic container of ham, and a plastic container of apple sauce, were not labeled with a use-by date. Additionally, in the dry storage room, various pudding and pie fillings, gelatine desserts, scalloped potatoes, instant mashed potatoes, and seasoned applesauce were also found without use-by date labels. The Dietary Supervisor acknowledged that the absence of these labels could potentially affect the residents' health. The Director of Nursing confirmed that all food should be labeled with a use-by date, as per the facility's policy and procedure on Food Receiving and Storage. This policy, reviewed shortly before the survey, mandates that dry food stored in bins should be removed from original packaging, labeled, and dated, and all food stored in the refrigerator should be covered, labeled, and dated. The failure to comply with these standards posed a risk of foodborne illness to 66 of the 67 residents who receive food from the facility kitchen.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain their trash storage in a sanitary manner, as observed during a survey. Two dumpsters located outside the facility were found with their lids open and positioned too close to the wall, preventing them from being closed. This was confirmed during an interview with the Dietary Supervisor, who acknowledged that the dumpsters should have been closed to prevent attracting flies and potential infection control issues. The Maintenance Supervisor also confirmed that the open dumpster lids could attract insects or rodents, posing an infection control risk if these pests entered the facility. The facility's policy on garbage and refuse disposal, dated January 2024, requires that garbage containing food waste be stored in a manner inaccessible to pests, with outside dumpsters kept closed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to prevent the spread of multidrug-resistant organisms (MDROs) by using gowns and gloves during high-contact resident care activities. This deficiency was observed in several instances involving residents with indwelling medical devices or wounds. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medication via a gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses, including Huntington's disease and hypertension. The facility's Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that the EBP policy was not implemented, despite being mandatory for residents with indwelling devices. Another instance involved a resident with multiple sclerosis, quadriplegia, and a methicillin-resistant Staphylococcus aureus (MRSA) infection. An LVN and a Certified Nursing Assistant (CNA) failed to don gowns while administering medication via the rectum, even though the resident had an indwelling catheter. The IP admitted to being unaware of the mandatory nature of the EBP policy and confirmed that it was not implemented for this resident. The facility's policy and procedure documents clearly indicated the need for gowns and gloves during high-contact care activities, yet these were not followed. Additionally, the facility did not post EBP signs or provide personal protective equipment (PPE) outside the rooms of residents with wounds or indwelling medical devices, such as gastrostomy tubes and nephrostomy tubes. This oversight was confirmed during observations and interviews with the IP, who stated that the facility was waiting for trash bins to be delivered before posting signs. The Centers for Medicare and Medicaid Services (CMS) guidelines, which the facility claimed to follow, require EBP for residents with wounds or indwelling devices, even if they are not known to be infected with MDROs.
Failure to Maintain Resident's Advance Directive in Active Record
Penalty
Summary
The facility failed to ensure that a resident's clinical records were updated with their advance directives, which are crucial documents outlining a person's medical treatment preferences in situations where they cannot communicate their wishes. This deficiency was identified for one resident, who had been admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack. The resident's Minimum Data Set indicated severe cognitive impairment, necessitating assistance for basic activities. Despite the resident having an advance directive, it was not maintained in their active clinical record, which could lead to conflicts with their healthcare wishes. During the investigation, the Director of Social Services acknowledged that the advance directive was missing from the active chart and was instead found in an overflow section of the medical record. Both the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been readily accessible in the active chart to guide staff in honoring the resident's healthcare preferences. The facility's policy on advance directives, reviewed shortly before the survey, stipulated that such documents should be kept in the resident's medical record and be easily retrievable by staff, highlighting a clear deviation from established procedures.
Incorrect LALM Setting for Resident with Pressure Injury Risk
Penalty
Summary
The facility failed to ensure the correct setting of a Low Air Loss Mattress (LALM) for a resident who required it for pressure injury care. The resident, who was admitted with conditions including senile degeneration of the brain, aphasia, and a history of transient ischemic attack, was found to have the LALM set between 150 to 180 pounds, while the resident's weight was approximately 106 pounds. This discrepancy was observed during an inspection by Treatment Nurse 1, who acknowledged that the incorrect setting could render the mattress ineffective in promoting wound healing and preventing further pressure injuries. The resident's care plan, dated several months prior, indicated the use of a LALM as a pressure-relieving device due to the resident's impaired mobility and risk for pressure injuries. The physician's order also specified the need for the Charge Nurse to check the proper placement and function of the LALM. However, during an interview, the Director of Nursing confirmed the importance of following the physician's order for the correct setting, emphasizing that failure to do so could lead to further skin injuries. The manual for the air mattress also highlighted the necessity of adjusting the pressure based on the resident's weight to ensure effective wound care therapy.
Medication Storage Deficiency Due to Unlocked Cabinet
Penalty
Summary
The facility failed to ensure that medications were stored in a locked compartment, as required by professional principles. During an observation and interview with the Director of Staff Development, it was noted that the medication cabinet at Nursing Station Two did not have a lock, unlike the left-side cabinet. This unlocked cabinet contained various medications, including iron supplements, bismuth subsalicylate, liquid multi-vitamins, acetaminophen, vitamin C supplements, constulose, and milk of magnesia. The Director of Staff Development acknowledged that the medication storage should not be left unlocked to prevent residents from accessing the medications. The Director of Nurses was interviewed and stated that she was unaware of the broken lock on the Station Two medication cabinet. She emphasized the importance of keeping medications in a locked cabinet to prevent resident access. A review of the facility's policy and procedure on medication storage, last reviewed on 10/16/2024, indicated that drugs and biologicals should be stored in locked compartments with proper controls for temperature, light, and humidity, and that only authorized personnel should have access to these medications.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified in 15 out of 28 resident rooms, where the space per resident was below the required standard. Specifically, rooms designed to accommodate two residents were only 156 square feet, providing 78 square feet per resident, and rooms designed for three residents were 228 square feet, providing only 76 square feet per resident. This shortfall in space allocation had the potential to result in inadequate space for safe nursing care and privacy for the residents. Despite the deficiency, observations during the survey indicated that both residents and staff had enough space to move about freely inside the rooms. The nursing staff was able to safely provide care, and there was sufficient space for beds, side tables, dressers, and resident care equipment. The facility had submitted a request for a continuation of its room size waiver, asserting that the current room sizes did not adversely affect the residents' health and safety or impede their ability to attain their highest practicable well-being.
Failure to Schedule Follow-Up Appointments and Monitor Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident as per the discharge instructions from the General Acute Care Hospital (GACH). The resident, who had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, was readmitted to the facility on multiple occasions. Despite clear instructions from the GACH to schedule follow-up appointments with cardiology and pulmonology within specified timeframes, the facility did not arrange these appointments. Interviews with the MDS Nurse and Registered Nurse 2 revealed that there was no documented evidence of these appointments being made, and there was confusion about who was responsible for scheduling them. The Social Services Director and nursing department both indicated that the other was responsible for making the appointments, leading to a lapse in care coordination. Additionally, the facility failed to monitor the resident after a noted change in condition on 10/30/2023. The resident exhibited delusional beliefs and refused medication, which should have triggered close monitoring every shift for 72 hours according to the facility's policy. However, there was no documented evidence that such monitoring occurred. This lack of monitoring was confirmed during an interview with Registered Nurse 2, who acknowledged the importance of close monitoring to detect any worsening of symptoms and to ensure timely intervention. The facility's policies and procedures, including those for admission assessment and follow-up care, as well as for changes in a resident's condition, were not adhered to. The failure to schedule necessary follow-up appointments and to monitor the resident after a change in condition represents a significant lapse in the standard of care, potentially jeopardizing the resident's health and well-being.
Failure to Develop Comprehensive Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address a diagnosis of heart failure for one of the sampled residents. The resident, who had been admitted and readmitted multiple times, had diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for various daily activities. Despite these needs, there was no documented evidence of a care plan specific to heart failure being developed within the required timeframe. During an interview and record review, the MDS Nurse confirmed that a comprehensive care plan for heart failure was not created for the resident. The facility's policy required such a care plan to be developed within 14 days of admission, but this was not done. The absence of this care plan had the potential to negatively affect the delivery of care and services to the resident, as it would guide staff on specific interventions needed for managing heart failure.
Incomplete History and Physical Documentation
Penalty
Summary
The facility failed to ensure the history and physical (H&P) for a resident was completed by the attending physician upon the resident's first admission. The resident was admitted with serious medical conditions including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximum assistance from staff for daily activities. However, the H&P document was undated and incomplete, lacking pertinent medical information, and was signed by the attending physician without a date. This incomplete documentation could lead to inconsistent care coordination for the resident. During an interview and record review, a registered nurse confirmed that the H&P was undated and incomplete, and emphasized the importance of having a completed and dated H&P to ensure proper assessment of the resident's condition upon admission or readmission. The facility's policy and procedure require that the medical care of each resident be supervised by a licensed physician, including participating in the resident's assessment and care planning. The failure to complete and date the H&P document is a violation of this policy and could result in inadequate care for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to implement its medication administration policy by not ensuring that a Licensed Vocational Nurse (LVN) documented the administration of Plavix for a resident. The resident, who had been readmitted to the facility with diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI), heart failure, and unstable angina, did not have documented evidence of receiving Plavix on a specified date. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for maximum assistance with daily activities, highlighting the importance of accurate medication administration and documentation. During an interview and record review, a Registered Nurse (RN) confirmed that there was no documentation on the Medication Administration Record (MAR) indicating that Plavix was administered or refused by the resident. The facility's policy required that medications be administered safely and timely, with the individual administering the medication initialing the MAR after each administration. The lack of documentation by the LVN on the specified date was identified as a failure to adhere to this policy, potentially leading to medication errors and confusion in care delivery.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
