Victoria Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ventura, California.
- Location
- 5445 Everglades Street, Ventura, California 93003
- CMS Provider Number
- 555478
- Inspections on file
- 48
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Victoria Care Center during CMS and state inspections, most recent first.
A resident with symptoms of a UTI did not receive the first dose of a newly ordered antibiotic, Cipro, in a timely manner. The nurse waited for pharmacy delivery instead of using the Emergency Medication Kit, and did not adjust the administration time, resulting in a delay of treatment.
A resident with a history of DVT and PE missed six doses of Lovenox due to unavailability, and staff did not notify the physician as required by facility policy. Interviews confirmed that both pharmacy and physician notification were expected but not completed.
The facility failed to implement care plan interventions for several residents, including not providing necessary equipment for skin maintenance, not completing medication administration, and not documenting IV hydration. Residents were not repositioned regularly, and one resident did not receive a snack during dialysis. These deficiencies were confirmed by staff and led to unmet resident needs.
The facility failed to maintain resident dignity and timely response to call lights, affecting three residents. A resident's confidential medical information was publicly displayed, violating their privacy. Two residents experienced significant delays in call light responses, leading to feelings of embarrassment and frustration. The facility's policy on call light response times was not adhered to, with observed delays far exceeding the expected 10-minute response time.
A facility failed to ensure consistent documentation of a resident's POLST across paper and electronic records. The paper POLST indicated selective treatment preferences, while the electronic version suggested full treatment, including intubation. Licensed nurses confirmed the discrepancies, which could lead to the resident's end-of-life wishes not being honored.
A resident was not involved in the review and revision of their care plan during an IDT meeting, contrary to facility policy. Staff interviews revealed that the resident was not invited to the meeting, and changes to the care plan were not reviewed with them afterward. This resulted in the resident not participating in deciding their treatment options.
A facility failed to maintain accurate medical records for two residents. One resident was relocated without proper notification or consent, violating facility policy. Another resident's depression and mood were not monitored as ordered, with missing documentation on specific shifts. The DON acknowledged these deficiencies, which could impact care planning and resident rights.
The facility failed to adhere to its Infection Prevention and Control Program, with staff not following Enhanced Barrier Precautions for a resident, improper hand hygiene during feeding, and inadequate labeling and storage of medical equipment. Additionally, a nurse did not change gloves after picking up a dropped item, and another did not perform hand hygiene during wound care, all contrary to facility policies.
The facility failed to ensure a functional environment by not providing pull cords for night lights in several resident rooms, as confirmed by maintenance staff. This deficiency denied residents the use of night lights, potentially increasing fall risk.
A resident experienced an unwitnessed fall and was found confused and forgetful. The facility failed to promptly notify the resident's representative, delaying their involvement in care decisions. The representative was informed hours later, after the physician ordered the resident to be sent to the ER due to anticoagulant therapy, which was deemed a life-threatening situation.
A resident experienced an unwitnessed fall, and the facility failed to ensure a prompt physician response, resulting in a delayed transfer to the ER. The facility's policy requires timely physician advice and treatment, but the physician took three hours to respond to the nursing staff's call. The Director of Nursing confirmed that this delay did not meet the facility's expectations for prompt communication.
A resident transferred to a skilled nursing facility for post-knee replacement care did not receive a scheduled dose of the prescribed antibiotic, sulfamethoxazole-trimethoprim (Bactrim DS), on the day of admission. The Director of Nursing confirmed the oversight, which could have impacted the effectiveness of the treatment.
A resident was discharged without receiving the necessary antibiotic medication for a knee surgical incision infection. The facility's policy required contacting the prescriber if medication delivery was delayed, but the pharmacy did not deliver the medication in time. The Director of Nursing confirmed the medication was unavailable at discharge, acknowledging the pharmacy's failure to meet the resident's needs.
The facility failed to include necessary interventions in the care plans of two residents with pressure ulcers. The care plans lacked measures for offloading heels and did not specify a frequency for turning and repositioning. Additionally, one resident's care plan did not include a specific fluid intake amount despite a physician's order for fluid restriction. These deficiencies were confirmed by the ADON during a review.
A facility failed to accurately document a resident's skin assessment, resulting in an inaccurate care history. The resident, admitted with congestive heart failure, had conflicting records regarding a coccyx pressure ulcer. The Initial Admission Record did not note the ulcer, while subsequent evaluations provided inconsistent onset dates. The Assistant Director of Nursing confirmed an error in the documentation, violating the facility's policy for accurate and chronological record-keeping.
A resident reported being physically abused by a CNA, but the facility delayed reporting the allegation to CDPH beyond the required 24-hour timeframe. The incident was initially reported internally to the Charge Nurse, Nurse Practitioner, DON, and Administrator, but external reporting was not timely, contrary to the facility's policy.
A resident requiring a Kosher diet was not provided with appropriate meals, as the facility failed to include this dietary need in the care plan. Despite informing the RD and DS of his dietary preferences, the resident was served non-Kosher foods. The care plan was only revised to include a Kosher diet after the resident's discharge, contrary to the facility's policy for comprehensive care planning.
A resident with a history of bipolar and anxiety disorders became agitated and wanted to leave the facility after a CNA was rude and used foul language. The incident was confirmed by the DON and documented in the resident's progress notes, highlighting a failure to uphold the facility's policy on Residents' Rights.
Delay in Administration of Antibiotic for UTI
Penalty
Summary
A deficiency occurred when a resident exhibiting signs of a urinary tract infection (foul smelling urine) did not receive the first dose of a newly ordered antibiotic, Cipro, within a reasonable timeframe. The physician's order for Cipro was placed in the late afternoon, with instructions for same-day delivery from the pharmacy. However, the medication was not administered as scheduled, and the nurse did not adjust the administration time for the first dose. The Medication Administration Record showed that the initial dose was not given at the intended time, and there was no documentation of an adjusted administration time. The Assistant Director of Nursing confirmed that the nurse did not utilize the Emergency Medication Kit to obtain the Cipro, instead waiting for the pharmacy delivery. Facility policy states that if a medication is not immediately available and is needed urgently, it should be obtained from the Emergency Medication Supply. The failure to follow this policy resulted in a delay in administering the antibiotic to the resident.
Failure to Administer Anticoagulant as Ordered and Notify Physician
Penalty
Summary
The facility failed to follow physician's orders for the administration of Lovenox (Enoxaparin Sodium Injection) for a resident who was admitted with a post-operative diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). The hospital discharge summary included orders for Lovenox 100 mg to be administered subcutaneously every 12 hours. Review of the electronic medication administration record and physician orders revealed that the resident missed six doses of Lovenox over a four-day period, and there was no documentation that the physician was notified about the unavailability or delay of the medication. Interviews with the nurse supervisor and the director of nursing confirmed that nursing staff are expected to notify the pharmacy and the physician if a medication is unavailable, and acknowledged that the physician should have been contacted. Facility policy also requires the prescriber to be contacted when medication delivery is delayed or unavailable.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to unmet needs and potential harm. Resident 61 did not receive a foot cradle and alternate pressure mattress as ordered for skin maintenance. Resident 123's care plan interventions, including oxygen therapy and monitoring for insomnia and pain, were not completed on multiple occasions. Similarly, Resident 138's interventions, such as being up to a chair for meals and monitoring for signs of bleeding, were not implemented as required. Resident 682, who was transferred to the facility after a hip fracture repair, did not have proper documentation for IV hydration, which was crucial for managing elevated BUN levels. The lack of documentation and administration of IV fluids as per the care plan was confirmed by the nursing staff. Additionally, Resident 5, who has multiple sclerosis, reported not being regularly turned and repositioned, which was a necessary intervention to prevent further decline in physical mobility and skin breakdown. Furthermore, Resident 36, who requires dialysis, was not provided with a snack during treatment as ordered, leading to potential nutritional deficiencies. Resident 121, who needed pillows to offload pressure from heels, did not have this intervention documented or implemented, despite a physician's order. The facility's failure to adhere to care plans and document interventions as required was acknowledged by the Director of Nursing and other staff members during interviews.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. Resident 110's confidential medical information was publicly displayed in their room, violating their right to privacy and dignity. An orange Swallow Guide containing specific treatment details was posted at the head of their bed, which should have been covered to protect their confidentiality. Two residents, Resident 240 and Resident 66, experienced significant delays in call light responses, leading to feelings of embarrassment, frustration, and anger. Resident 240 reported waiting up to an hour for staff to respond, resulting in instances where they had to void in their bed. The Nurse Call Activity Report (NCAR) for Resident 240 showed multiple instances of prolonged call durations, some exceeding 30 minutes. Similarly, Resident 66 expressed dissatisfaction with the night shift's response times, stating they often waited an hour or more for assistance. This delay caused Resident 66 to feel angry, frustrated, and embarrassed, as they were left in pain, hungry, and thirsty. The NCAR for Resident 66 also indicated numerous instances of extended call durations, with some exceeding 40 minutes. The facility's policy on call light response times was not adhered to, as the Director of Nursing acknowledged that a reasonable expectation for response time was 10 minutes, and the observed delays were unacceptable.
Inconsistent POLST Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident had the most current Physician Orders for Life-Sustaining Treatment (POLST) documented consistently across both paper and electronic records. The POLST is a critical document that outlines a resident's treatment preferences in the event of a medical emergency. In this case, discrepancies were found between the paper POLST and the electronic health record (eHR) for the resident. The paper POLST indicated a preference for selective treatment, avoiding burdensome measures, and not intubating, while the electronic POLST indicated a trial period of full treatment, including intubation and mechanical ventilation. During interviews and record reviews, it was confirmed by licensed nurses that the paper and electronic POLST documents did not match, which they acknowledged should not be the case. This inconsistency in documentation had the potential to result in the resident's end-of-life wishes not being honored, as emergency personnel might follow incorrect or outdated instructions during a medical emergency.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to ensure that Resident 106 was involved in the review and revision of their care plan during the interdisciplinary team (IDT) meeting. The facility's policy and procedure indicated that residents, along with their families or responsible parties, should participate in the development of the care plan. However, Resident 106 was not invited to the IDT meeting, and the changes made to the care plan were not reviewed with them afterward. This lack of involvement resulted in Resident 106 not being given the opportunity to participate in deciding their treatment options. Interviews with facility staff, including a social services designee (SSD), a minimum data set nurse assessment coordinator (MDS2), and the Director of Nursing (DON), confirmed that Resident 106 was not present at the care plan meeting. The SSD acknowledged speaking with Resident 106 before the meeting but did not review the care plan changes with them afterward. MDS2 admitted that residents are never present at these meetings and that the revisions are not reviewed with them, which was acknowledged as a deviation from the expected practice. The DON confirmed that all residents should be present at care plan meetings if they are able to attend, highlighting a systemic issue in the facility's process.
Deficiencies in Documentation and Resident Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care and resident rights. For one resident, the facility did not maintain a complete, accurately documented, and systematically organized room transfer form during their relocation. The resident was moved without prior notification or consent, as required by the facility's policy. The Director of Nursing (DON) confirmed that the resident was verbally informed, but no written notification or consent was obtained, and the form used was incorrectly titled 'STATUS CHANGE' instead of 'Notification of Room or Roommate Change.' This discrepancy in documentation and lack of proper notification violated the facility's policy and the resident's rights. For another resident, the facility failed to monitor the resident's depression and mood as ordered by the physician. The resident was on medication for mood disorders and depression, with specific orders to monitor episodes of depression and mood disorder using hashmarks every shift. However, there was no documentation of monitoring on two specific PM shifts. The DON acknowledged the lack of documentation, which was contrary to the facility's policy requiring a complete account of the resident's care and treatment in an accurate and chronological order. This failure to document monitoring could impact the resident's care planning and the provision of appropriate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program (IPCP) in several instances. Staff did not follow Enhanced Barrier Precautions (EBP) for a resident who required such measures. During an observation, an occupational therapist and a physical therapist provided direct care to the resident without wearing gowns, despite signage indicating the need for EBP. The facility's policy required the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. In another instance, a certified nurse assistant (CNA) was observed feeding two residents simultaneously, using the same hand and utensil without proper hand hygiene between feedings. The facility's policy allowed one staff member to feed two residents but required adherence to infection control guidelines to prevent cross-contamination. The CNA did not follow the hand hygiene policy, which mandates handwashing before and after direct contact with residents and before and after assisting with meals. Additionally, the facility failed to label and properly store oxygen and nebulizer equipment for two residents, and a medication nurse did not change gloves after picking up a dropped item before administering a patch to a resident. Furthermore, a treatment nurse did not perform hand hygiene between glove changes during wound care for another resident. These actions were contrary to the facility's policies, which required weekly changes and labeling of equipment and emphasized the importance of handwashing in infection control.
Missing Night Light Pull Cords in Resident Rooms
Penalty
Summary
The facility failed to provide a functional and comfortable environment for residents by not ensuring the availability of pull cords for overhead night lights in several resident rooms. During an initial tour observation, it was noted that rooms 109A, 110A, 113A, 113B, 114A, 114B, 115A, 116A, 116B, 118A, 118B, 119B, 120A, 121A, 124A, and 125A were missing night light pull cords. This deficiency was confirmed during an interview with the Director of Maintenance and the Assistant Maintenance, who acknowledged the absence of pull cords in the identified rooms. The lack of pull cords denied residents the use of night lights, potentially increasing the risk of falls during nighttime hours.
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to promptly notify the resident representative of a fall experienced by a resident, which was a deviation from the facility's policy and procedure on Fall Management System. The policy, dated January 2022, required that the resident representative be informed of any fall and the resident's status. On January 23, 2025, at 3:18 a.m., a progress note documented that the resident had an unwitnessed fall, was confused, and forgetful. However, the resident's representative was not informed of the incident until 6:08 a.m., resulting in a delay in their involvement in decision-making regarding the resident's care. The facility's policy on Change of Condition Reporting/Documentation, dated 2023, also required that the responsible party be notified of any change in the resident's condition. During an interview and record review, the Director of Nursing acknowledged that the resident's representative should have been notified at the time of the fall. The delay in notification meant that the resident's representative was not immediately involved in critical decisions, such as the physician's order to send the resident to the emergency room due to anticoagulant therapy, which was considered a life-threatening situation by the representative.
Delayed Physician Response After Resident Fall
Penalty
Summary
The facility failed to ensure prompt physician response following a resident's fall, leading to a delayed transfer to the emergency room. According to the facility's policy and procedure on physician services, physicians are expected to provide advice, treatment, and determine the appropriate level of care needed for each resident. On January 23, 2025, at 3:18 a.m., a progress note indicated that a resident had an unwitnessed fall, and the nursing staff communicated with the physician, awaiting a response. However, the physician did not respond until 6:08 a.m., approximately three hours later, at which point the order was given to send the resident to the hospital for further evaluation and treatment. During an interview and record review with the Director of Nursing, it was confirmed that the physician's delayed response did not meet the facility's expectations for prompt communication.
Antibiotic Administration Failure Post-Transfer
Penalty
Summary
The facility failed to ensure that a resident received their prescribed antibiotic treatment without interruption following a transfer from an acute care facility to the skilled nursing facility. The resident, a female admitted for aftercare following knee replacement surgery, was prescribed sulfamethoxazole-trimethoprim (Bactrim DS) to be taken twice daily for five days. The discharge instructions from the hospital indicated that the last dose was administered at 10 AM on the day of transfer. Upon review of the resident's records, it was found that the second dose of the antibiotic was not administered as scheduled at 5 PM on the day of admission to the nursing facility. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the dose should have been given. The failure to administer the antibiotic as prescribed had the potential to reduce the effectiveness of the treatment and/or prolong the resident's recovery process.
Failure to Provide Antibiotic Medication on Discharge
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary antibiotic medication upon discharge. The facility's policy and procedure required contacting the prescriber if there was a delay in medication delivery. The resident had an order for Bactrim DS to treat a right knee surgical incision infection. On the day of discharge, the facility sent a fax to the pharmacy requesting the medication, but it was not delivered in time. The Medication Administration Record indicated that the resident was discharged to home without the medication. A progress note documented concerns about how the resident would obtain the medication since it had not been delivered. The Director of Nursing confirmed that the medication was not available to send home with the resident, acknowledging that the pharmacy did not meet the resident's medication needs.
Deficiencies in Care Plans for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plans for two residents with pressure ulcers included necessary interventions. For both residents, the care plans did not specify the offloading of heels from pressure surfaces, which is a critical measure to prevent the worsening of pressure ulcers. Additionally, the care plans lacked a defined frequency for turning and repositioning the residents, which is essential for pressure ulcer prevention. These omissions were identified during a review of the care plans and confirmed by the Assistant Director of Nursing, who acknowledged that the interventions should have been included. Furthermore, the care plan for one of the residents did not specify the amount of fluid intake, despite a physician's order for a fluid restriction. The care plan merely encouraged fluid intake without detailing the specific amount, which could lead to fluid overload. This oversight was also confirmed during the review with the Assistant Director of Nursing, who noted that the intervention was not resident-specific as it lacked the necessary details regarding fluid intake.
Inaccurate Documentation of Resident's Skin Assessment
Penalty
Summary
The facility failed to ensure accurate documentation of a skin assessment for a resident, leading to an inaccurate resident care history. The resident, who was admitted with a primary diagnosis of congestive heart failure, had discrepancies in the documentation of a pressure ulcer on the coccyx. The Initial Admission Record (IAR) did not indicate the presence of a coccyx pressure ulcer upon admission, while the Change in Condition Evaluation (CiCE) noted the ulcer started on a later date. However, the Skin Pressure Ulcer Weekly (SPUW) report inaccurately documented the ulcer as present on admission with an onset date prior to the CiCE's noted start date. During a review with the Assistant Director of Nursing (ADON), it was confirmed that the SPUW contained an error regarding the onset date of the pressure ulcer. The facility's policy on documentation and charting requires a complete and accurate account of the resident's care in a chronological manner, which was not adhered to in this instance. This discrepancy in documentation highlights a failure in maintaining accurate medical records for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in a timely manner for one of the sampled residents. On July 17, 2024, at 6:35 p.m., a resident reported to the Charge Nurse that her assigned Certified Nursing Assistant (CNA) had physically abused her by pinching and pulling her hair. The Charge Nurse immediately informed the Nurse Practitioner, Director of Nursing (DON), and Administrator about the allegation. However, the facility did not report the incident to CDPH until July 19, 2024, at 3:30 p.m., which was beyond the required 24-hour reporting timeframe. The facility's policy and procedure on abuse prevention and prohibition mandates that such allegations be reported to the appropriate state or federal agencies within the applicable timeframes. The DON acknowledged the delay in reporting during an interview, admitting that the report should have been made within 24 hours.
Failure to Implement Kosher Diet in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required a Kosher diet, resulting in the resident receiving non-Kosher foods. The resident, who was discharged from the facility, reported that despite informing the Registered Dietician and Dietary Supervisor of his dietary needs upon admission, he was served ham and cheese sandwiches, which are not Kosher. The resident's dietary assessment, completed by the RD, indicated a preference for a Kosher diet and listed specific food dislikes, including ham and pork. The Nutritional Care Plan for the resident, initiated on the same date as the dietary assessment, identified an increased risk for malnutrition but did not include specific interventions for a Kosher diet until after the resident's discharge. The Director of Nursing acknowledged that the care plan was revised to include the Kosher diet only after the resident had left the facility. The facility's policy requires the interdisciplinary team, including the Dietary Supervisor/Dietician, to develop a comprehensive, person-centered care plan based on the resident's needs, which was not adhered to in this case.
Resident Rights Violation Due to CNA's Rude Behavior
Penalty
Summary
The facility failed to protect the rights of a resident when a Certified Nursing Assistant (CNA) was rude to them, resulting in the resident becoming agitated and wanting to leave the facility. The resident, who was admitted for rehabilitation therapy after gallbladder surgery and has a history of bipolar disorder and anxiety disorder, experienced emotional distress due to an argument with the CNA. During an interview, the Director of Nursing (DON) confirmed that the CNA used foul language and made inappropriate comments to the resident. The Nursing Progress Note indicated the resident was restless and emotionally distressed following the incident, and the Psychiatric Progress Note confirmed the resident's account of the CNA's rude behavior. The facility's policy on Residents' Rights emphasizes the right to be treated with respect and dignity, which was not upheld in this instance.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
