Tracy Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tracy, California.
- Location
- 545 West Beverly Place, Tracy, California 95376
- CMS Provider Number
- 555080
- Inspections on file
- 30
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Tracy Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic kidney disease and type 2 DM repeatedly refused skilled services, morning medications, blood draws, and participation in a care conference, and experienced significant weight loss over several weeks. Although the admission record identified a family member as the responsible party and care conference contact, staff did not notify this representative of the refusals of care, the request not to be disturbed, the significant weight loss, or the scheduled care conference, and did not invite the representative to participate. The DON acknowledged that the responsible party had the right to be informed of such changes, and facility policies required notification of the representative and involvement of family in person-centered care planning, but these policies were not followed.
A resident with multiple chronic conditions, including CKD stage 3B, asthma, post-stroke hemiplegia, HTN, PTSD, and type 2 DM, repeatedly refused skilled services, morning medications, a blood draw, and participation in a care conference. Despite these ongoing refusals, staff confirmed that no comprehensive, person-centered care plan was developed to address the refusals or to guide interventions to encourage acceptance of care and involvement in care planning. This was inconsistent with facility policies requiring the IDT to assess residents who refuse care, offer alternative treatments when appropriate, and create measurable, time-bound care plan objectives to direct daily care and prevent decline.
Staff failed to follow hand hygiene requirements for a resident on Enhanced Barrier Precautions (EBP) who had multiple infections, including UTI, E. coli, cellulitis, a stage 4 pressure ulcer, and C. perfringens. An EBP sign was posted at the room door, yet the DSD entered and exited the room to respond to a call light without performing hand hygiene. In a separate instance, a CNA handled a meal tray from the hallway cart, entered the room, assisted with meal preparation, then exited and returned to the meal cart without performing hand hygiene. Both staff later acknowledged the lapse, while the IP and DON confirmed that facility policy and standard precautions require hand hygiene before entering and after exiting rooms and after contact with the resident’s environment.
A resident with multiple serious diagnoses and a documented Full Code status was found unresponsive and without vital signs. Despite clear documentation and the representative's wishes for full resuscitation, licensed staff did not initiate CPR or call a Code Blue, and no life-saving measures were attempted prior to hospice arrival. Staff interviews confirmed a lack of protocol adherence and understanding, and the facility's policy requiring basic life support in the absence of a DNR order was not followed.
The facility failed to honor the end-of-life preferences for three residents by not verifying or obtaining Advance Directives upon admission. For two residents, the facility did not determine if they had or wished to formulate an Advance Directive, and for another resident, the facility did not have a copy of the existing Advance Directive on file. Interviews with staff revealed a lack of adherence to policies and procedures regarding Advance Directives and POLST forms.
A resident was admitted with incorrect discharging documents from an acute hospital, leading to significant medication errors for three days. The facility staff failed to thoroughly check the interfacility transfer documents, resulting in the resident receiving medications not prescribed for them. The error was discovered during an unannounced survey after the acute hospital reported the mistake.
A resident with an amputation and Type 2 diabetes was not provided with a prosthetic leg despite being motivated and having an order for evaluation. The facility failed to document and follow up on the prosthetic evaluation, leaving the resident without the necessary adaptive device. The facility's policy on evaluating and accommodating residents' needs was not adhered to, as acknowledged by the DON and Administrator.
A resident was unable to store personal belongings due to inadequate space and previous resident's items left in drawers. Staff confirmed the issue, and the DON acknowledged it was against policy, impacting the homelike environment.
A resident with an indwelling catheter did not have a specific care plan developed upon admission, despite having diagnoses that required catheter care. The facility's procedures and policies were not followed, as confirmed by interviews with staff, including the DON, who acknowledged the oversight.
A resident did not receive scheduled showers over a nine-day period, as confirmed by the facility's Director of Staff Development and Director of Nursing. The resident, with a history of diabetes and heart disease, was supposed to receive showers twice a week, but documentation showed missed showers. This failure to provide basic hygiene care was against the facility's policy, which emphasizes the importance of bathing for cleanliness and skin assessment.
A resident was administered incorrect medications and care for three days due to an error in interfacility transfer documents, which had a different name despite correct stickers. The error was discovered when the acute hospital contacted the facility. Staff interviews revealed reliance on stickers without verifying document names, leading to the deficiency.
A resident with multiple diagnoses, including a history of falls and disorientation, was found outside the facility due to inadequate supervision and failure to implement care-planned interventions. The care plan required a wheelchair alarm and bed alarm checks, which were not fully executed. The facility's policy emphasized individualized safety measures, but these were not effectively applied, leading to the resident's unsupervised wandering.
A resident's IV saline lock was not managed according to professional standards, with the dressing undated, no care plan, and lack of documentation for site care and flushing. The IV was left in place for eight days, exceeding the recommended duration, despite the resident having a PICC line in place.
A facility failed to properly handle controlled medications for a deceased resident. After the resident's death, controlled medications were not removed from the medication cart or counted at shift change by the LNs. The facility's policies require that controlled medications be counted by two LNs at each shift change and stored securely until destruction. The DON confirmed that these procedures were not followed, which could have led to medication errors or diversion.
A resident experienced dental pain for two months without receiving recommended dental services, including a full mouth x-ray for a broken tooth. Despite reporting the issue to staff, no follow-up care was provided. The facility lacked a system to ensure follow-up on treatment recommendations, leading to a significant delay in addressing the resident's dental needs.
A resident with a left leg amputation and Type 2 diabetes was waiting for a prosthetic leg for a year due to missing evaluation notes in her medical record. Despite being highly motivated and having an order for a prosthetic evaluation, the facility failed to obtain and include the necessary documentation. Interviews with staff confirmed the absence of these notes, which were crucial for medical providers to review recommendations. The facility's policy on documentation was not followed, as acknowledged by the DON and Administrator.
The facility failed to maintain infection control measures when a CNA entered a Contact Isolation Precautions room without PPE and did not perform hand hygiene. Additionally, clean water pitchers were distributed from a cart with dirty items, risking cross-contamination. A resident's urinary catheter bag was found on the floor, contrary to policy, posing an infection risk. These actions did not adhere to the facility's infection control policies.
The facility did not meet the minimum space requirement of 80 square feet per resident in seven shared rooms, affecting rooms 1, 3, 5, 6, 8, 10, and 11. Despite this, staff and residents reported no complaints about room sizes, and the Department recommended continuing the room size waiver.
Failure to Notify Responsible Party of Significant Changes and Care Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of significant changes in the resident’s condition and refusals of care, despite the RP being identified in the admission record as the contact person for care conferences. The resident was admitted with chronic kidney disease stage 3B and type 2 diabetes mellitus, and the care plan indicated a preference for having family involved in discussions about care. The resident’s physical therapy evaluation documented refusal of any skilled services and identified a risk for falls. Progress notes showed that over a period of several weeks the resident repeatedly refused morning medications, requested not to be disturbed for care, refused a blood draw, and refused to attend a care conference. The interdisciplinary team also discussed the resident’s significant weight loss during this time. During interviews, a licensed nurse confirmed that the RP was not notified of the resident’s refusals of prescribed morning medications, refusal of a blood draw, request not to be disturbed, refusal to participate in a care conference, or the significant weight loss, and that the RP was not invited to the care conference. The DON stated that the RP had the right to be informed of changes in the resident’s condition, such as significant weight loss or refusal of care or treatment, and acknowledged that the RP was not given the opportunity to participate in care planning and decision-making. Review of facility policies showed requirements to inform the resident/representative regarding refusal or discontinuation of treatment, to notify the physician and RP of significant weight changes, and to develop a comprehensive person-centered care plan in conjunction with the resident and family or legal representative. These documented policies were not followed in this case.
Failure to Care Plan for Ongoing Refusals of Care and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address one resident's repeated refusals of care, treatment, and participation in a care conference. The resident was admitted with multiple significant diagnoses, including chronic kidney disease stage 3B, asthma, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, essential hypertension, PTSD, and type 2 diabetes mellitus. A PT evaluation dated 11/25/25 documented that the patient was refusing any skilled services and identified a risk for falls due to physical impairments and functional deficits. Progress notes from 11/25/25 through 12/20/25 showed ongoing refusals of morning medications, a request not to be disturbed, refusal of a blood draw, and refusal to participate in a care conference. During interviews and concurrent record reviews, an LN confirmed that these refusals required a care plan with effective interventions to encourage acceptance of care, treatment, and participation in care planning, but acknowledged that no such care plan existed for this resident. The DON stated that nursing staff were expected to assess residents who refused care and treatment and initiate a care plan to address refusals and implement appropriate interventions to prevent potential health decline. Facility policies on refusing care and on comprehensive, person-centered care plans required the interdisciplinary team to assess needs, offer alternative treatments when appropriate, and develop measurable objectives and timetables to meet residents' physical, psychosocial, and functional needs, with care plans used to guide daily care routines. Despite these policies, the resident's refusals were not incorporated into a written care plan, which, according to staff, placed the resident at risk for worsening underlying conditions, overall health decline, and preventable complications.
Failure to Perform Hand Hygiene for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently performed hand hygiene as part of its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident had multiple serious infections and conditions, including a urinary tract infection, unspecified Escherichia coli as the cause of disease, cellulitis of the buttock, local skin and subcutaneous tissue infection, resistance to multiple antimicrobial drugs, a stage 4 pressure ulcer of the right buttock, and Clostridium perfringens as the cause of disease. An EBP sign was posted outside the resident’s room. During observation, the Director of Staff Development (DSD) entered the resident’s room in response to a call light without performing hand hygiene, turned off the call light, and exited the room without performing hand hygiene. The DSD acknowledged not performing hand hygiene upon exiting the EBP room and stated that hand hygiene was supposed to be performed to prevent the spread of infections in the facility. In a separate observation, a Certified Nurse Assistant (CNA) picked up a meal tray from the meal cart in the hallway, entered the same resident’s room, delivered the tray, placed it on the over-bed table, and assisted with meal preparation, then exited the room and approached the meal cart without performing hand hygiene. The CNA stated she forgot to perform hand hygiene after exiting the room and before handling another resident’s meal tray, and acknowledged that this failure placed other residents at risk for infection. The Infection Prevention Nurse stated that staff were required to perform hand hygiene before entering and after exiting a resident’s room and before and after performing any task for residents, and that failure to do so placed other residents at risk for infection. The DON stated that staff were required to perform hand hygiene as part of standard precautions to break the infection cycle and prevent the spread of infection. Facility policies on Enhanced Barrier Precautions and Infection Control Guidelines for All Nursing Procedures required visual alerts for high-contact care and hand hygiene after contact with objects in the immediate vicinity of the resident.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented code status of Full Code, as indicated in the medical record, hospice documentation, and a POLST form signed by the resident's representative. Despite this, when the resident was discovered unresponsive, nursing staff did not initiate CPR or call a Code Blue, and no resuscitation efforts were made prior to the arrival of hospice personnel, who subsequently pronounced the resident deceased. The resident had multiple significant diagnoses, including chronic obstructive pulmonary disease, dementia, hypertensive heart disease with heart failure, and was under hospice care. The code status was discussed and confirmed with the resident's representative, who wished for all life-saving interventions to be performed. The facility's own policy required staff to provide basic life support in the absence of a valid DNR order, and the staff were aware of the resident's Full Code status. Interviews with the Director of Staff Development, a licensed nurse, and certified nursing assistants confirmed that no CPR was attempted, and the facility's emergency response protocol was not followed. Staff interviews revealed a lack of clarity and adherence to protocol, with the nurse on duty stating she did not know the facility's procedures and had concerns about reviving the resident. The Director of Nursing confirmed that the facility's policy was not followed and that the decision to perform CPR was not up to the nursing staff, as the representative's wishes were clearly documented. The failure to initiate CPR resulted in the resident's representative's wishes not being honored and potentially contributed to the resident's death.
Failure to Honor Residents' End-of-Life Preferences
Penalty
Summary
The facility failed to ensure that the preferences for end-of-life or emergency care were honored for three residents. For Resident 43, the facility did not determine upon admission whether the resident had an Advance Directive or wished to formulate one. The clinical records, including the Physician Orders for Life-Sustaining Treatment (POLST), did not indicate if an Advance Directive was discussed or if the resident had the capacity to make decisions. Interviews with the Director of Nursing (DON) and Medical Records staff revealed that the facility did not verify or obtain a copy of an Advance Directive for Resident 43. Similarly, for Resident 49, the facility did not ascertain if the resident had an Advance Directive or wished to create one during the admission process. The POLST form did not reflect any discussion about an Advance Directive. Interviews with the Social Services Director and the DON confirmed that the facility did not explain or assist the resident in formulating an Advance Directive. The Medical Records staff acknowledged the absence of an Advance Directive on file for Resident 49. For Resident 12, although the clinical record indicated the presence of an Advance Directive, the facility failed to have a copy available. The Preferred Intensity of Care form noted that a copy should be attached, but it was not. Interviews with the Licensed Nurse, Social Services Director, and Medical Records staff confirmed that the facility did not follow up to obtain a copy of the Advance Directive, despite being informed by the resident's responsible party that it had been provided. The facility's policies and procedures were not adhered to, as acknowledged by the DON and the Administrator.
Medication Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they were admitted with incorrect discharging documents from an acute hospital. This error was not identified for three days, resulting in the resident receiving medications that were not prescribed for them. The error was discovered during an unannounced annual recertification survey after the acute hospital contacted the facility to report the mistake. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications intended for another patient. These medications included antibiotics, anticoagulants, blood pressure medications, and others not prescribed for the resident. The facility's staff, including the Admissions Coordinator and the Director of Nursing, confirmed that the interfacility transfer documents had the correct sticker with the resident's name but contained a different name in smaller print on each page. Interviews with facility staff revealed that the nursing staff did not thoroughly check the interfacility transfer documents, relying instead on the stickers attached to the documents. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the medication errors.
Failure to Follow Up on Prosthetic Leg Request
Penalty
Summary
The facility failed to meet the needs of a resident, identified as Resident 12, by not adequately following up on her request for a prosthetic leg. Resident 12, who has Type 2 diabetes and an amputation above the knee, expressed her desire to regain independence and mobility through the use of a prosthetic leg. Despite having an order for a prosthetic evaluation from her physician, the facility did not ensure the completion and documentation of this evaluation. Interviews with the Medical Director and Director of Rehab revealed that although referrals for a prosthetic evaluation were made, the evaluation notes were missing from Resident 12's clinical record, leaving the physician unaware of the recommendations. The Prosthetic Representative confirmed that Resident 12 was assessed for a prosthetic leg and was highly motivated to receive one, but the evaluation notes were not provided to the facility. The facility's policy on Quality of Life, which mandates the evaluation of residents' needs for adaptive devices, was not followed. The Director of Nursing and the Administrator acknowledged this oversight, admitting that the facility did not adhere to its policy and procedure, resulting in Resident 12's needs not being met.
Inadequate Storage Space for Resident's Belongings
Penalty
Summary
The facility failed to provide a homelike environment for Resident 55, as evidenced by the lack of adequate space for storing personal belongings. Upon admission in July 2024, Resident 55 was assigned to bed A, but the space allocated for personal items was insufficient. During an observation and interview, a family member expressed frustration over the narrow closet space and the inability to use the drawers, which were labeled with a previous resident's name and contained their belongings. This situation prevented Resident 55 from utilizing the space for personal items, compromising the homelike environment. Further observations and interviews with facility staff, including a CNA and LN, confirmed the presence of a discharged resident's name and belongings in the drawers meant for Resident 55. The staff acknowledged that the drawers should have been cleared and relabeled for the new resident. The DON stated that the facility's policy does not include labeling drawers with resident names and emphasized that all belongings should be removed upon discharge. The failure to adhere to these policies resulted in Resident 55 being unable to use the designated space for personal belongings, thus not ensuring a homelike environment.
Failure to Develop Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan for Resident 317, who was admitted with diagnoses including a urinary tract infection and artificial openings of the urinary tract. The Minimum Data Set (MDS) assessment indicated that Resident 317 had an indwelling catheter, which required specific care. However, upon review, it was found that there was no care plan created for the use of the indwelling catheter, despite the Order Summary Report specifying catheter care every shift and monitoring for signs and symptoms of urinary tract infection. During interviews, both Licensed Nurse 8 and the Director of Nursing acknowledged the absence of a care plan for catheter care. The Director of Nursing stated that a care plan should have been created upon admission to ensure all necessary care was provided. The facility's procedures and policies emphasized the importance of a comprehensive, person-centered care plan to meet the resident's needs, which was not adhered to in this case.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living (ADLs) for one resident, identified as Resident 22, by not ensuring that the resident received scheduled showers. Resident 22, who was admitted to the facility with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, did not have documented evidence of receiving a shower from August 6 through August 15, 2024. This lapse was confirmed through interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of shower documentation and confirmed that the showers were missed. The facility's policy on ADLs, revised in March 2018, mandates appropriate support and assistance with hygiene, including bathing, for residents unable to perform these tasks independently. The DSD and DON both emphasized the importance of showers for maintaining hygiene, preventing infections, and conducting thorough skin assessments. The lack of showers not only compromised Resident 22's hygiene but also potentially affected their psychosocial well-being, as noted by the DSD. The facility's failure to adhere to its own procedures for bathing and showering, as outlined in their policy, resulted in this deficiency.
Medication and Care Plan Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that correct medications were administered and the correct plan of care was followed for a resident due to an error in the interfacility transfer (IFT) documents. Upon admission, the resident was given incorrect medications and care for three days because the IFT documents from the acute hospital contained a different name, although a sticker with the resident's name was attached to each page. This discrepancy was not identified until the acute hospital contacted the facility three days after the resident's admission. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications that were not prescribed for her. These included antibiotics, anticoagulants, and medications for conditions such as high blood pressure and Alzheimer's disease. The error was discovered when the acute hospital called to inform the facility that the IFT documents did not belong to the resident. Interviews with facility staff, including the Admissions Coordinator, Director of Nursing, and Licensed Nurses, revealed that the error occurred because the staff relied on the stickers attached to the IFT documents without verifying the names on the documents themselves. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the administration of incorrect medications and care for the resident.
Failure to Implement Care-Planned Interventions and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions for a resident, identified as Resident 62, which led to a deficiency. Resident 62, who was admitted in the spring of 2024, had multiple diagnoses including benign prostatic hyperplasia, a history of falling, anxiety disorder, major depressive disorder, and disorientation. The resident was found on his knees in the facility's front parking lot, indicating a lapse in supervision and monitoring. The care plan for Resident 62 included the use of a wheelchair alarm and a bed alarm to alert staff if the resident attempted to get up unassisted, but these interventions were not fully implemented. Interviews and record reviews revealed that the facility did not have a physician's order for a wheelchair alarm for Resident 62, despite the care plan indicating its necessity. Additionally, the bed alarm checks were not documented during the night shift on a specific date, which was a part of the facility's protocol. The Director of Nursing (DON) confirmed the absence of a wheelchair alarm order and expressed concern over the missing documentation of bed alarm checks. The DON also acknowledged that Resident 62 was at risk for falls due to psychiatric diagnoses and unsteady gait, and that closer supervision was warranted. The facility's policy on safety and supervision emphasized individualized, resident-centered approaches to address safety and accident hazards. However, the failure to implement the care-planned interventions and adequately supervise Resident 62 resulted in the resident being found outside the facility, which could have been prevented with proper monitoring. The DON and Administrator admitted that Resident 62's behaviors, such as wandering and removing the mattress from the bed, required more vigilant supervision and possibly the use of a Wander Guard, which was not in place at the time of the incident.
Failure to Adhere to IV Therapy Protocols
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident receiving parenteral medication. Specifically, the resident's peripheral IV saline lock dressing was not dated, and there was no care plan developed for the IV saline lock. Additionally, there was no documentation of IV site care and flushing in the resident's medical record, and the IV saline lock was left in place for eight days, exceeding the recommended duration of seven days. The resident, who was admitted in Spring 2024, had diagnoses including a wedge compression fracture, low back pain, and osteoarthritis. During an observation, it was noted that the IV saline lock in the resident's left hand was covered with a transparent dressing without a date or nurse's initials. The facility's policy required transparent dressings to be changed every seven days and labeled with the date and nurse's initials. The Director of Staff Development confirmed the lack of documentation and adherence to policy, and the Director of Nursing stated that the policy should have been followed.
Failure to Properly Handle Controlled Medications for Deceased Resident
Penalty
Summary
The facility failed to ensure the proper handling and accounting of controlled medications for a deceased resident, identified as Resident 58. After the resident's death, the controlled medications, which included hydrocodone and lorazepam, were not removed from the medication cart, nor were they counted at shift change by the licensed nurses, LN 1 and LN 6. During an observation and interview, both nurses acknowledged that they forgot to count the controlled medications, which is a critical step to prevent medication errors or drug diversion. The facility's policies and procedures require that controlled medications be counted by two licensed nurses at each shift change and stored securely until they are destroyed or picked up by a hospice nurse. The Director of Nursing (DON) confirmed that the facility's policies and procedures were not followed in this instance. The policies stipulate that discontinued medications should be marked and stored in a designated secure area until they are destroyed. The DON stated that the controlled medications should have been given to her for destruction with the pharmacist, and that the ongoing and off-going nurses were responsible for counting the medications until they were properly disposed of. This oversight in following established protocols could have led to medication being administered incorrectly or diverted for unauthorized use.
Failure to Provide Recommended Dental Services
Penalty
Summary
The facility failed to ensure that a resident received recommended dental services, specifically a full mouth x-ray for a broken tooth identified months earlier. The resident, who experienced dental pain for about two months, reported the issue to multiple staff members but did not receive the necessary follow-up care. During interviews, the resident expressed frustration over not being heard and feeling neglected. The Social Services Director (SSD) confirmed that there were no referrals or notices for service from the nurses regarding the resident's complaint of tooth pain. The SSD also noted that the facility lacked a follow-up process for treatment recommendations, which contributed to the oversight. The Director of Nursing (DON) reviewed the resident's dental notes and confirmed the absence of follow-up orders for the recommended treatment. The DON acknowledged that the facility should have a system in place to ensure follow-up with outside dental services and that the four-month delay was excessive. The lack of follow-up posed a risk to the resident, as untreated dental issues could lead to further complications. The facility's policy on dental services indicated that routine and emergency dental services should be available to meet residents' oral health needs, but this was not adhered to in this case.
Missing Prosthetic Evaluation Notes in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that copies of evaluations for a prosthetic leg were included in the medical records of a resident, identified as Resident 12. This deficiency was identified during a review of Resident 12's clinical records, which revealed that the resident had been waiting for a prosthetic leg for a year. Despite having an order for a prosthetic evaluation, the facility did not have access to the evaluation notes, which were crucial for medical providers to review recommendations regarding the prosthetic leg. Interviews with the Medical Director, Director of Rehab, and Licensed Nurse confirmed that the evaluation notes were missing from the clinical record, and attempts to obtain them from the prosthetic company were unsuccessful. Resident 12, who had a left leg amputation and a diagnosis of Type 2 diabetes, expressed a strong desire to receive a prosthetic leg to improve her mobility and independence. The Prosthetic Representative confirmed that Resident 12 was highly motivated to have a prosthetic leg and had been assessed multiple times the previous year. However, the representative did not provide the facility with copies of the evaluation notes, stating it was not her practice to do so. The facility's policy on documentation required such information to be included in the resident's medical record, but this policy was not followed, as acknowledged by the Director of Nursing and the Administrator.
Infection Control Deficiencies in PPE Use, Water Distribution, and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures in several instances. A Certified Nurse Assistant (CNA) entered a room designated for Contact Isolation Precautions without wearing the necessary personal protective equipment (PPE) and exited without performing hand hygiene. The CNA was unaware of the isolation status of the room, which was confirmed by a Licensed Nurse who informed the CNA of the requirement for PPE. The Director of Staff Development and the Director of Nursing confirmed that the facility's policy required PPE and hand hygiene for such rooms, but these protocols were not followed. Another deficiency was observed when a CNA distributed clean water pitchers from a cart that also contained dirty water pitchers, a dirty cup, and a partially eaten food tray. This practice posed a risk of cross-contamination, as acknowledged by the CNA and the Director of Staff Development. The Director of Nursing confirmed that the procedure for distributing clean water pitchers was not adhered to, which increased the risk of infection. Additionally, a resident's urinary catheter bag was found resting on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. Both a CNA and a Licensed Nurse confirmed the improper placement of the catheter bag, and the Infection Preventionist and Director of Nursing acknowledged the infection risk associated with the bag being on the floor. The facility's policy on urinary catheter care was not followed, leading to potential cross-contamination and infection risk.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms met the minimum space requirement of at least 80 square feet per resident in seven shared rooms. This deficiency was identified during a recertification survey, where it was observed that rooms 1, 3, 5, 6, 8, 10, and 11, each housing three residents, did not meet the required space per resident. The room sizes ranged from 229 to 238 square feet, which is below the required 240 square feet for three residents. Interviews with the Administrator and Maintenance Director confirmed the measurements of these rooms. Despite the deficiency, interviews with staff and residents revealed that there were no complaints regarding the room sizes. Licensed nurses and the Director of Nursing stated that they had not received any complaints from residents about the room sizes affecting their ability to perform their duties safely. Residents interviewed expressed that they had enough space for their personal belongings and were comfortable, although one resident mentioned a preference for sharing the room with only one other resident. The Department recommended the continuation of the room size waiver for the affected rooms.
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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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