Town & Country
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 555 East Memory Lane, Santa Ana, California 92706
- CMS Provider Number
- 555141
- Inspections on file
- 19
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Town & Country during CMS and state inspections, most recent first.
A resident with documented lack of decision-making capacity and unclear, slurred speech on the MDS had multiple skilled nursing evaluations recorded over several days indicating clear speech, contrary to staff observations. During interviews, an LVN, a treatment nurse, and a CNA all reported that the resident’s speech was not clear and was difficult to understand, and the DON verified that the medical record entries documenting clear speech were inaccurate and inconsistent with the resident’s actual condition.
A resident admitted with an ileostomy did not have a baseline care plan initiated within 48 hours, as required by facility policy. Despite clear hospital discharge instructions for ostomy care, hydration, and monitoring intake/output, staff did not document or implement these interventions, and the DON confirmed the omission.
A resident experienced nausea, vomiting, poor meal intake, and significant weight loss, but staff did not develop or update a care plan to address these changes in condition. Despite facility policy requiring care plan updates for such changes, interviews with the LVN, DON, and RD confirmed that no care plan was initiated for the resident's poor appetite and weight loss.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required.
The facility failed to ensure CNAs followed infection control practices by not wearing gowns during high-contact resident care activities, despite facility policies and signage indicating the requirement. This was observed when CNAs wore only masks and gloves while repositioning a resident, contrary to the guidelines for preventing MDRO transmission. Interviews confirmed the oversight, and the facility administrator acknowledged the findings.
The facility's kitchen failed to meet food safety and sanitation standards, with issues such as unclean ice machines, improperly stored ice scoopers, expired food items, and unsanitary utensils and equipment. Staff did not consistently wear hair and beard restraints, and hand hygiene practices were not followed, increasing the risk of foodborne illnesses among residents.
The facility failed to implement proper infection control measures for a resident with shingles, as a family member was not adequately informed about necessary precautions. Personal items were found in the laundry's clean folding area, violating infection control standards. Additionally, the facility lacked recent documentation for testing Legionella in water systems, with the last assessment completed in 2018.
The facility failed to properly clean two kitchen ice machines according to the manufacturer's instructions, potentially leading to unsanitary ice. The service provider used a sanitizing solution that did not contain the required active ingredient, resulting in residue and particles inside the machines. The DON acknowledged the need to follow the correct cleaning instructions.
The facility failed to conduct entrapment assessments and record measurements for residents using bed rails, affecting 16 out of 53 residents. Observations and interviews revealed that assessments were not performed, and necessary documentation was missing. The Director of Facilities admitted to not being familiar with entrapment zones, and inspections were only conducted upon discharge and quarterly, not upon admission or as needed.
A facility failed to obtain informed consent from a resident's responsible party for the use of side rails and alprazolam, a psychotropic medication. The resident, who lacked decision-making capacity, was observed using side rails without proper consent, and there was no documented consent for alprazolam in the medical records. Interviews with staff confirmed these deficiencies, highlighting a breach in the facility's policies and procedures.
The facility failed to obtain and maintain advance directives for six residents, despite acknowledgments in their records. Interviews and medical record reviews revealed that the facility did not follow up to secure these documents, and POLST forms were incomplete for two residents. This deficiency indicates a failure to adhere to the facility's policy on managing advance directives, potentially impacting residents' healthcare decisions.
A resident with severe cognitive impairment did not receive an individualized activity program to meet their interests, such as group activities and independent pursuits like watching TV and music-related activities. The facility documented the resident's participation in activities only three times, and observations showed the resident often remained in bed without sensory stimulation. The Director of Activities confirmed the lack of documented evidence for daily activities, despite the resident's care plan indicating a need for such engagement.
The facility failed to properly administer medications and monitor residents' conditions, leading to deficiencies in care. A resident received medications simultaneously against physician orders, another resident's significant weight changes were not reported to the physician, and a third resident's blood pressure was not documented when administering hypertension medication. These issues were confirmed by staff during interviews and record reviews.
The facility failed to ensure proper reconciliation and disposal of controlled medications for two residents. One resident's morphine and oxycodone/acetaminophen records did not match the actual count, and the LVN admitted to not signing the records immediately. Another resident's discontinued hydrocodone/acetaminophen was found in the medication cart. The DON confirmed that discontinued medications should be removed promptly, highlighting potential risks for drug diversion and medication errors.
The facility failed to adhere to physician-ordered parameters for medication administration for two residents. One resident received losartan potassium despite having a systolic blood pressure (SBP) below the prescribed threshold, while another received midodrine hydrochloride when their SBP was above the specified limit. These errors were confirmed by staff and acknowledged by the DON.
A facility failed to monitor side effects for a resident prescribed alprazolam for anxiety, as required by their policy. Despite a care plan intervention to monitor behaviors and side effects every shift, there was no documented evidence of such monitoring. This oversight was confirmed by an RN during an interview, highlighting a lapse in adherence to the facility's procedures for psychotropic drug use.
The facility failed to ensure proper storage and labeling of medications, leading to potential cross-contamination. Orally administered medications were stored with external use products, and disinfectant wipes were not separated from treatment supplies. Additionally, a medication bottle was found with sticky residue. These issues were confirmed by nursing staff and acknowledged by the DON.
The facility did not adhere to pureed diet recipes for three residents, potentially compromising their nutritional needs. During an observation, a staff member was seen preparing pureed biscuits and rice without following the specified recipes, using incorrect amounts of hot water. The RD, DSS, Executive Chef, and DON acknowledged the oversight.
The facility failed to provide palatable green beans to four residents, as observed during dining. The residents reported the green beans were tough and not easy to chew, which did not meet their dietary requirements. This issue was confirmed by staff, including an LVN and an RD, who acknowledged the problem with the texture of the green beans.
The facility failed to update its policy on the use and storage of foods brought by visitors and did not educate visitors on safe food handling. The facility lacked a designated refrigerator for resident use, and visitors were not informed about maintaining perishable foods at safe temperatures. This oversight could lead to foodborne illnesses among residents.
The facility failed to ensure resident privacy and confidentiality when the Director of Activities used her personal cell phone to take pictures of residents during activities, violating the facility's policy. The Director admitted to this action, and the Administrator confirmed that staff should use facility-provided devices for such purposes.
The facility failed to remove a CNA from resident care areas pending an alleged abuse violation. After a resident reported being hit by the CNA, the CNA was reassigned to care for another resident and remained at work until the end of her shift, contrary to the facility's policy. This was confirmed through interviews with the CNA, an LVN, and the Administrator.
Inaccurate Documentation of Resident Speech Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, relevant, and complete documentation in the medical record for one resident, as required by its policy on medical record documentation. The facility’s policy, revised on 8/23/23, states that licensed staff and interdisciplinary team members must document all assessments, observations, and services in accordance with state law and facility policy, and that documentation must be accurate and contain sufficient detail about residents’ care and responses to care. For Resident 1, who was admitted on an unspecified date, the history and physical dated 1/11/26 documented that the resident had no capacity to understand and make decisions. The Minimum Data Set (MDS) assessment for this resident documented unclear speech characterized as slurred or mumbled words. Despite the MDS assessment indicating unclear speech, multiple skilled nursing evaluations dated 2/16, 2/18, 2/20, 2/21, 2/22, 2/24, 2/25, 2/27, and 3/1/26 documented that the resident’s speech was clear. During interviews on 3/9/26, LVN 1 stated that the resident was able to answer yes or no when asked about pain, but confirmed that the resident’s speech was not clear as documented. LVN 2, a treatment nurse, reported that when she assessed the resident’s skin, the resident’s speech was not clear. CNA 1 stated that the resident talked a little but was very hard to understand. In a subsequent interview, the DON reviewed the record and verified these findings, confirming that the documentation indicating clear speech was inaccurate in relation to the resident’s actual speech status.
Failure to Initiate Baseline Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who had an ileostomy, as required by facility policy and procedure. Upon admission, the resident's medical records, including a hospital discharge summary, indicated specific instructions for ostomy care, hydration, and monitoring of intake and output to prevent dehydration. Despite this, the facility did not develop a baseline care plan addressing the resident's ileostomy care or the necessary nutritional interventions to maintain or prevent weight loss. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's intake and output were not monitored and that a baseline care plan for ileostomy care was not initiated. The lack of a baseline care plan meant that essential information for the resident's care was not documented or implemented, contrary to the facility's own admission policy and procedures.
Failure to Develop Care Plan for Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who experienced a significant change in condition, specifically nausea, vomiting, poor meal intake, and notable weight loss. The facility's policy required that all changes in a resident's condition be communicated to the physician, documented in the nursing progress notes and twenty-four hour report, and that the resident's care plan be updated as indicated. Despite these requirements, the medical record review showed that the resident lost 17 pounds over four days and had complaints of nausea, but no care plan was initiated to address these issues. Interviews with facility staff, including an LVN, the DON, and the RD, confirmed that the resident's care plan was not updated to reflect the new problems of poor appetite and weight loss. The RD acknowledged that the resident was at risk for weight loss and verified that no care plan had been initiated to address the resident's poor intake and weight loss. The RD also stated that she did not initiate a care plan problem until the MDS was completed.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in accordance with established directives, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse was observed during the survey process, but the report does not specify the number of residents affected, their medical histories, or their conditions at the time of the deficiency.
Inadequate PPE Use by CNAs During Resident Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) adhered to evidence-based practices (EBP) for infection prevention and control, specifically regarding the use of personal protective equipment (PPE). The deficiency was observed when CNAs 2 and 3 were seen wearing only surgical masks and gloves while repositioning a resident in bed, despite a sign outside the resident's room indicating that both gloves and gowns were required for high-contact activities. This oversight was confirmed during interviews with CNA 2, who admitted uncertainty about the necessity of wearing a gown for such activities, and the Infection Preventionist (IP), who stated that a yellow gown was required. The facility's policies and procedures (P&P) for Enhanced Barrier Precautions and Infection Control Prevention and Control of Multidrug-Resistant Organism (MDRO) Transmission were reviewed, indicating that gowns should be worn during high-contact activities that pose a risk for transmission of MDROs. Despite these guidelines, the CNAs did not comply with the requirement to wear gowns, as verified by the Minimum Data Set (MDS) Registered Nurse (RN) and Director of Staff Development (DSD). The facility administrator acknowledged these findings, highlighting a lapse in adherence to infection control protocols designed to prevent the spread of infections.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The ice machines were not properly cleaned, with white residue and hardened crusts noted on their surfaces. Ice scoopers were not stored in a manner that protected them from contamination, contrary to the facility's policy. Additionally, several food items, including boiled eggs, hoagie breads, fries, and milk, were found to be past their best-by dates, posing a risk of serving expired products to residents. The kitchen equipment and utensils were not maintained in a sanitary condition. Multiple cutting boards were heavily marred, and various utensils such as spatulas, frying pans, measuring cups, scoopers, and a peeler were observed with discoloration and residue. A hot tray transportation warmer also had brown streak residue inside. Furthermore, kitchen staff were not adhering to dress guidelines, as observed with staff not wearing hair and beard restraints, which could lead to contamination of food. Hand hygiene practices were not consistently followed by the kitchen staff. Instances were noted where staff entered the kitchen and handled food without washing their hands or changing gloves, increasing the risk of cross-contamination. Additionally, water liners were transported uncovered in the hallway, contrary to facility protocol. These deficiencies collectively had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Infection Control Deficiencies in Resident Care, Laundry, and Water Management
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with shingles, as evidenced by the lack of adherence to contact and droplet precautions. A family member visiting the resident was observed wearing inadequate personal protective equipment (PPE), including an untied gown and personal eyeglasses instead of goggles, and was not wearing gloves. The family member was not informed of the necessary precautions before entering the room, and the signage indicating the required precautions was not noticed by the visitor. The Licensed Vocational Nurse (LVN) on duty did not ensure the visitor was properly instructed on the precautions, which could have prevented the spread of infection. In the laundry room, the facility failed to maintain infection control standards by allowing personal items, such as a cellphone and body lotion, to be present in the clean folding area. This was confirmed by the Laundry Aide, who acknowledged that the items belonged to her. The Housekeeping Manager stated that the clean folding area should be free of personal belongings to prevent contamination of linens and the spread of infection. The facility also failed to maintain accurate documentation of its water management program, specifically regarding testing protocols for Legionella and other opportunistic pathogens. The last documented risk assessment was completed in 2018, and there was no recent documentation available. The Director of Facilities confirmed this oversight, acknowledging that testing was conducted by an outside company. The Administrator also acknowledged the findings, indicating a lapse in maintaining the required documentation for infection control in the water systems.
Improper Cleaning of Kitchen Ice Machines
Penalty
Summary
The facility failed to ensure that two ice machines in the kitchen were properly cleaned according to the manufacturer's instructions, which could lead to unsanitary ice being served. The Hoshizaki Instruction Manual, revised in November 2018, specifies the use of a sanitizing solution containing 5.25% sodium hypochlorite solution (chlorine bleach) for cleaning. However, the facility's service provider, Ram Air Engineering, used a different sanitizing concentrate that did not contain the specified active ingredient. During an observation, white and brown residue and gray particles were noted inside the ice machines, indicating improper cleaning. Interviews with the Maintenance Staff and the Registered Dietitian (RD) confirmed that the facility relied on an outside company to clean the ice machines every six months. The RD verified that the sanitizing solution used by the service provider did not comply with the Hoshizaki Instruction Manual's requirements. The Director of Nursing (DON) acknowledged these findings and confirmed that the current instructions from the manual should be followed to ensure the ice machines are properly sanitized.
Failure to Conduct Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using bed rails. This deficiency was identified for 16 out of 53 residents who had bed rails, posing a potential risk of entrapment, serious injury, or death. The facility's policy required assessments to be conducted prior to the installation of bed rails, and periodically thereafter, to ensure the safety of residents. However, observations and interviews revealed that these assessments were not performed, and the necessary measurements were not documented. Several residents, including those with cognitive impairments and those requiring assistance with mobility, were observed using bed rails without documented evidence of entrapment assessments. Interviews with CNAs and LVNs confirmed the use of bed rails for mobility and repositioning, but also highlighted that the entrapment assessments were not part of the bed rail assessment process. The Director of Facilities admitted to not being familiar with the entrapment zones and confirmed that bed inspections were only conducted upon resident discharge and quarterly, rather than upon admission or as needed. The facility's documentation, including Bed Maintenance and Inspection forms, lacked evidence of entrapment zone assessments. The Director of Facilities acknowledged the absence of such documentation and the lack of knowledge regarding the use of the Bionix safety measuring device. The DON and Administrator were informed of these findings, which underscored the facility's failure to adhere to its own policies and procedures regarding bed rail safety and entrapment prevention.
Failure to Obtain Informed Consent for Psychotropic Medication and Side Rail Use
Penalty
Summary
The facility failed to ensure that Resident 43, who was deemed incapable of making medical decisions, was provided the right to self-determination regarding the use of psychotropic medication and side rails. Specifically, the facility did not obtain informed consent from Resident 43's responsible party for the use of side rails and the administration of alprazolam, an antianxiety medication. The facility's policies and procedures require informed consent to be obtained from the resident or their representative before initiating treatment with psychotropic drugs or installing side rails, but these protocols were not followed. Observations and medical record reviews revealed that Resident 43 was using bilateral 1/4 side rails without documented consent from a responsible party. Additionally, there was no evidence of informed consent for the use of alprazolam in the resident's medical records. Interviews with RN 1 and the DON confirmed these findings, indicating that the consent for bed rail use was incorrectly obtained from Resident 43, who lacked decision-making capacity, and that the consent for alprazolam was only signed by the physician and uploaded to the electronic medical record after the medication had already been administered.
Failure to Obtain and Maintain Advance Directives
Penalty
Summary
The facility failed to obtain and maintain copies of advance directives for six residents, which are legal documents stating a person's wishes about receiving medical care if they are no longer able to make decisions. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. Specifically, the facility did not have copies of advance directives for Residents 8, 37, 43, 44, 320, and 669, despite acknowledgments in their records indicating that these documents existed and should have been provided to the facility. For Residents 8, 37, 43, and 669, the medical records showed that they had executed advance directives, but the facility failed to obtain or document attempts to obtain these directives. Interviews with the Social Services Designee confirmed that although these residents had advance directives, there was no follow-up to secure copies for the facility's records. Additionally, for Residents 44 and 320, the facility not only failed to obtain advance directives but also did not complete the POLST forms, which are crucial for documenting medical orders for life-sustaining treatment. The facility's policy on advance directives requires verification and modification of these documents upon admission, ensuring that residents' healthcare preferences are respected. However, the facility did not adhere to this policy, as evidenced by the incomplete documentation and lack of follow-up. Interviews with the Director of Nursing and other staff confirmed these findings, highlighting a systemic issue in managing advance directives and POLST forms, which could potentially lead to residents' healthcare decisions not being honored.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident with severe cognitive impairment. The resident, who was admitted for short-term therapy, expressed interest in group and independent activities such as watching TV, visitations, planting orchids, fishing, camping, and music-related activities. However, the facility only documented the resident's participation in activities on three occasions since admission, and there was no evidence of daily activities being provided to meet the resident's identified interests. Observations revealed the resident often remained in bed without sensory stimulation, and interviews with staff indicated a lack of consistent activity engagement. The Director of Activities acknowledged the resident's limited participation and the absence of documented evidence for daily activities, such as providing the Daily Chronicles or turning on the TV. The resident's care plan included encouraging independent activities, but the facility did not adequately document or implement these interventions, leading to potential social isolation and frustration for the resident.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to provide appropriate medication administration for Resident 621, as observed during a medication administration session. LVN 3 did not adhere to the physician's order to administer furosemide 30 minutes before spironolactone-hydrochlorothiazide, instead giving both medications simultaneously. This oversight was confirmed during an interview with LVN 3, who acknowledged the error in following the prescription instructions. For Resident 37, the facility did not comply with the physician's order to notify the physician of significant weight changes. The resident experienced weight fluctuations of three pounds on multiple occasions, which should have triggered a notification to the physician as per the order. However, the medical records showed no evidence that the physician was informed of these changes, as verified by the DON during a review of the resident's records. Resident 52's care was compromised when the licensed nurse failed to document blood pressure readings before and after administering clonidine hydrochloride, a medication prescribed for hypertension. The medication was given as needed for high systolic blood pressure, but the necessary documentation to justify its administration and assess its effectiveness was missing. This lapse was acknowledged by the IP and the DON during interviews and record reviews.
Failure in Controlled Medication Reconciliation and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the reconciliation and disposal of controlled medications for two residents. For one resident, a bubble pack of morphine was found with 10 tablets, but the controlled drug record indicated that 11 tablets should have been present after one was removed. Similarly, a bubble pack of oxycodone/acetaminophen was found with 103 tablets, while the record showed 104 tablets should have been present after one was removed. The Licensed Vocational Nurse (LVN) responsible admitted to not signing the controlled drug record or the Medication Administration Record (MAR) immediately after administering the medications, which is against the facility's policy. For another resident, a bubble pack of hydrocodone/acetaminophen was found in the medication cart despite the medication being discontinued. The LVN confirmed that the medication should not have been in the cart as it was discontinued. The Director of Nursing (DON) stated that nurses are required to remove discontinued medications at the end of their shift and bring them to the DON, or if discontinued on a weekend, remove them the following weekday. These lapses in procedure had the potential for drug diversion and medication errors.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the administration of medications outside of the physician's ordered parameters. Resident 2 was prescribed losartan potassium to manage hypertension, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 120 mmHg. However, the medication was administered on multiple occasions when Resident 2's SBP was below this threshold, with readings as low as 110/61 mmHg. This oversight was confirmed during an interview with the Infection Preventionist (IP) and acknowledged by the Director of Nursing (DON). Similarly, Resident 56 was prescribed midodrine hydrochloride for hypotension, with instructions to hold the medication if the SBP exceeded 110 mmHg. Despite this, the medication was administered on several occasions when the SBP was above the specified limit, with readings reaching as high as 132/79 mmHg. This error was verified by LVN 6 during a concurrent interview and medical record review, and the findings were also acknowledged by the DON. These failures indicate a lack of adherence to physician orders, potentially exposing the residents to unnecessary medications and associated side effects.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically alprazolam, an antianxiety medication. The facility's policy required documentation of the resident's response to the medication, including progress towards goals and the presence or absence of adverse consequences. However, the medical record for the resident did not show documented evidence of monitoring for side effects related to the use of alprazolam. This oversight was confirmed during an interview with RN 1, who acknowledged the lack of documentation for side effect monitoring. The resident in question was admitted to the facility with no capacity to understand and make decisions. A physician's order was in place for alprazolam to be administered as needed for anxiety, and the medication was given on a specific date. The resident's care plan included interventions to monitor behaviors and side effects every shift, but the facility did not adhere to this plan. The failure to monitor side effects posed a potential risk to the resident's well-being, as the facility did not follow its own policy and procedures regarding the use of psychotropic drugs.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, posing a risk for cross-contamination. During an inspection of Medication Room A, it was observed that orally administered medications were not stored separately from externally used medications. Specifically, Fever All suppositories were stored with oral loperamide tablets, DHEA mood and stress tablets were stored with eye drops, and nasal moisturizing spray was stored with earwax removal drops. These findings were verified by RN 1. Additionally, disinfectant wipes were not stored separately from medications and treatment supplies. In Medication Cart A, hand sanitizing wipes were stored with ammonia lactate lotion, Optifoam Gentle EX, and tubular elastic retainer net dressing. In Medication Cart B, germicidal disinfectant wipes were stored with NexTemp thermometer strips and a spill kit. Furthermore, a bottle of potassium chloride on Medication Cart C was found with sticky residue around its neck. These storage issues were confirmed by LVN 2 and LVN 3, respectively. The DON acknowledged the improper storage practices and emphasized the need for separate storage of orally administered and external medications.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that pureed recipes were followed for three residents who were on a pureed diet. Specifically, the pureed recipes for biscuits and rice were not adhered to, which could potentially result in not providing nutritional meals that meet the residents' needs. The facility's policy and procedure for meal/tray assembly, revised in January 2024, requires that meals are prepared accurately to preserve nutrient content and that the current diet spreadsheet is followed at each meal period. However, during an observation on September 11, 2024, it was noted that the staff member responsible for preparing the pureed meals did not follow the recipes as outlined. During the preparation of pureed biscuits, the staff member added 34 oz of hot water to the blended biscuits, and for the pureed rice, 8 oz of hot water was added, deviating from the specified recipes. The staff member confirmed that no recipe was followed during the preparation. Subsequent interviews with the Registered Dietitian (RD), Dietary Services Supervisor (DSS), Executive Chef, and Director of Nursing (DON) confirmed the findings and acknowledged that the recipes should have been followed as per the instructions.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to ensure that the food provided to four residents was palatable, specifically regarding the texture of green beans served during dining observations. Residents 17, 26, 39, and 65 all reported that the green beans were tough and not easy to chew, which did not meet the dietary requirements for their respective diets. These observations were confirmed by staff, including a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), who acknowledged the issue with the texture of the green beans. Resident 17, who had the capacity to understand and make decisions, was on a regular diet with an easy-to-chew texture requirement. Resident 26, who lacked decision-making capacity, was on a no-restriction diet with the same texture requirement. Resident 39, with fluctuating decision-making capacity, was on a no-added-salt diet with regular texture requirements. Resident 65, who was on a regular diet, also found the green beans tough and refused to eat them. The facility's policy on modified texture foods was not adhered to, as the green beans did not meet the required easy-to-chew texture, potentially affecting the residents' nutritional intake.
Deficiency in Food Safety Policy and Visitor Education
Penalty
Summary
The facility failed to update its policy and procedures (P&P) regarding the use and storage of foods brought to residents by family and visitors, as well as to educate visitors on safe food handling practices. The facility's P&P, revised in July 2023, acknowledged the right of residents to receive food from outside sources but required that such food be for immediate consumption. However, the facility did not have a designated refrigerator for resident use, as confirmed by the Registered Dietitian (RD) and the Director of Nursing (DON). This lack of proper storage facilities for perishable food items brought by visitors could potentially lead to foodborne illnesses among the medically vulnerable resident population. Additionally, the facility did not provide visitors with information on safe food handling practices, such as maintaining perishable foods at temperatures below 41 degrees Fahrenheit. The RD confirmed that visitors were informed that food should be for immediate consumption but were not educated on safe handling practices, including proper hand hygiene. The DON acknowledged these findings, indicating a gap in the facility's responsibility to ensure food safety for residents consuming food from outside sources.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by allowing the Director of Activities to use her personal cell phone to take pictures of residents during activities. This action was in direct violation of the facility's policy and procedure (P&P) titled 'Resident Photos,' which was revised on 4/19/24. The policy clearly states that residents have a right to privacy and confidentiality, including through photographs, videos, and digital recordings, and that permission must be obtained from the resident or their representative before taking photographs during facility events. During an observation and interview on 9/12/24, the Director of Activities admitted to using her personal cell phone to take pictures of residents and staff during a scheduled activity. She acknowledged that she was not supposed to have pictures of residents on her personal device. The facility's P&P, revised on 4/5/24, also prohibits employees from using personal cell phones while on the clock, except during meal or rest breaks. The Administrator confirmed that the facility provides devices such as Apple tablets and cell phones for staff use and that personal cell phones should not be used to take pictures of residents.
Failure to Remove CNA Pending Abuse Investigation
Penalty
Summary
The facility failed to remove a Certified Nursing Assistant (CNA 1) from resident care areas pending an alleged violation of abuse for a resident (Resident 1). According to the facility's policy and procedure (P&P) for reporting allegations of abuse, the accused employee should be removed from resident care areas and suspended pending the completion of the investigation. However, after Resident 1 reported that CNA 1 hit her left shoulder, CNA 1 was reassigned to care for another resident and remained at work until the completion of her shift. This was confirmed through interviews with CNA 1, LVN 3, and the Administrator, who acknowledged that CNA 1 was not sent home after the abuse allegation was reported. The incident was reported on a SOC 341 form, and the facility's Nursing Assignment Sheet showed that CNA 1 was assigned to different rooms, including Resident 1's room, on the day of the incident. The Administrator confirmed that the facility's protocol for abuse allegations involving staff members requires the alleged staff to be immediately excused from the facility and suspended pending the investigation. Despite this protocol, CNA 1 completed her shift and clocked out at 2251 hours on the day of the incident. The Administrator acknowledged the potential risk of having the alleged perpetrator remain in the facility, which could create an opportunity for retaliation against the victim.
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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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