Villa Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8965 Magnolia Avenue, Riverside, California 92503
- CMS Provider Number
- 555353
- Inspections on file
- 28
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Villa Health Care Center during CMS and state inspections, most recent first.
A resident with multiple healing fractures and a right arm splint and sling, who had difficulty performing daily tasks and required help with activities such as dating food, reported that call lights were answered between five and 30 minutes. During a surveyor observation, the resident activated the call light and waited about 15 minutes before a nurse responded, despite the care plan and facility policy requiring prompt response and staff interviews indicating expectations ranging from immediate to within 10 minutes.
A resident with multiple complex conditions was administered Eliquis 5 mg twice daily instead of the intended 2.5 mg twice daily after returning from a hospital stay. The medication reconciliation process failed to identify the discrepancy, resulting in four doses at double the prescribed strength before the error was recognized and clarified by the DON.
A resident with multiple fractures and non-weight bearing status was transferred using a Hoyer lift by a CNA without the required assistance of a second staff member. During the transfer, a lift strap slipped, causing the resident to fall onto the bed and feel unsafe. Staff interviews and facility policy confirmed that at least two staff are required for Hoyer lift use, but this protocol was not followed.
Several residents with various medical conditions were not provided with documented follow-up information or education regarding their right to formulate an advance directive, despite expressing uncertainty or requesting more information. The facility did not ensure that quarterly care conferences included this follow-up, as required by policy, and the Social Services Director confirmed the lack of documentation for these actions.
Surveyors found that five large plastic basins used for ice and food items were stacked and stored while still wet in the kitchen. Both the Dietary Services Supervisor and the Registered Dietitian confirmed that all kitchenware should be air-dried before storage to prevent bacteria or mold growth. This practice did not meet FDA food code standards and had the potential to impact 52 medically vulnerable residents.
A nurse left potassium chloride at the bedside of a resident without observing its administration, contrary to facility policy requiring staff to remain with residents until all medications are taken. The DON confirmed that medications should not be left at the bedside and that staff are expected to observe residents taking their medications.
A nurse did not follow the manufacturer's required two-minute contact time when disinfecting a shared blood pressure cuff and stethoscope with germicidal wipes after use with a resident. The nurse believed the required time was one minute, but both the product instructions and facility policy specified two minutes. Interviews with the IP and DON confirmed that staff are expected to follow these instructions to ensure proper disinfection.
The facility did not provide the required minimum of 80 sq ft per resident in 16 multi-resident rooms, as confirmed by facility records and staff interviews. Despite this, no negative impacts on care, comfort, or privacy were observed, and residents reported no concerns regarding room size.
A facility failed to report an alleged abuse incident involving a resident with Huntington's Disease to the CDPH within the required timeframe. The incident, where a CNA reportedly slapped a resident, was internally investigated and deemed a misunderstanding of a calming technique. Despite this, the facility's policy required immediate reporting of all allegations, which was not followed.
A resident with Huntington's Disease experienced involuntary movements, but the facility failed to update the care plan to reflect effective interventions. Staff interviews revealed a lack of awareness and documentation of a method used by a CNA to calm the resident's movements, which was not included in the care plan. The DON acknowledged the importance of including such interventions for person-centered care.
A resident with a multidrug-resistant organism (MDRO) was not placed in a single room or cohorted with others with the same infection, contrary to the facility's policy. The resident, who tested positive for ESBL, remained in a shared room with two other residents. Staff were unclear about the necessary precautions, and the facility's policy, which follows CDC guidelines, was not followed, potentially exposing roommates to the infection.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS was incorrectly coded to show antipsychotic medication use, omitting antianxiety and hypnotic medications. Another resident's MDS did not capture a documented fall. The MDS Coordinator and DON confirmed these inaccuracies.
The facility failed to ensure that pressure injury interventions ordered by the physician were implemented for a resident at risk for pressure injuries. Despite an order to float the resident's heels off the bed with pillows every shift, observations revealed that the resident's heels were lying against the mattress without the required support. Staff interviews confirmed the inconsistency in following the physician's order.
The facility had a medication error rate of 5.56%, with errors involving the administration of amlodipine and MiraLAX powder to a resident. The resident's heart rate was below the threshold for administering amlodipine, and the MiraLAX powder was not fully dissolved, resulting in incomplete dosing.
A facility failed to prevent significant medication errors when an LVN administered amlodipine to a resident with a heart rate below the physician-specified threshold. The LVN repeatedly gave the medication despite documented low heart rates, contrary to the facility's policy and physician's orders.
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident for 16 out of 22 rooms observed. Despite having a room size waiver, the facility did not meet the regulatory requirements for resident living space, although no adverse effects on care provision or resident comfort were observed.
The facility failed to provide a written Notice of Discharge to two residents and their representatives prior to the date of discharge. Both residents signed the discharge instructions and Notice of Discharge on the day of discharge, and the Ombudsman was notified only on the day of discharge, not prior as required.
Delayed Call Light Response for Resident Requiring Assistance With Daily Tasks
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure timely response to a resident’s call light. During an unannounced complaint investigation for quality-of-care issues, a resident with decision-making capacity and recent fractures of the right ulna, right radius, and multiple right-sided ribs was observed and interviewed. The resident, who was right-handed and wearing a long arm splint and sling on the right arm, reported difficulty performing normal daily tasks and stated that call lights were typically answered between five and 30 minutes. The resident also stated she required assistance with dating her food and was waiting for staff to come and help. During the interview, the resident activated her call light at 12:17 p.m., and the Treatment Nurse did not respond until approximately 15 minutes later, at 12:32 p.m. Staff interviews revealed inconsistent expectations for call light response times: the Treatment Nurse stated all staff are responsible for answering call lights and that residents should not wait 15 minutes; the CNA stated call lights should be answered within five to 10 minutes; and the LVN stated call lights should be answered immediately and that delays of up to 15 minutes could result in the resident’s needs not being met and increase the risk of falls. The resident’s care plan indicated the resident was at low risk for falls and required that the call light be within reach, with encouragement to use it for assistance, and that the resident needed a prompt response to all requests for assistance. The facility’s policy on answering call lights directed staff to respond timely and, when possible, complete the resident’s request within five minutes.
Failure to Reconcile and Administer Correct Eliquis Dosage
Penalty
Summary
The facility failed to ensure proper medication reconciliation for a resident who was admitted with multiple complex medical conditions, including infected amputated stump, renal dialysis, diabetes mellitus type 2, peripheral vascular disease, and bilateral below-knee amputations. Upon return from a general acute care hospital, the resident's discharge medication list specified Eliquis 2.5 mg to be taken orally twice daily. However, the facility's order summary and medication administration record indicated that Eliquis 5 mg was administered twice daily for four doses, which was double the intended strength. Interviews and record reviews revealed that the medication list from the hospital was reviewed and sent to the physician for reconciliation, but the discrepancy in Eliquis dosage was not identified before administration. The DON confirmed that the resident received the higher dose before a telephone order was obtained to confirm the medication. The facility's policy required careful comparison of pre- and post-discharge medications, including dose, route, and frequency, to prevent unintended changes, but this process was not effectively followed, resulting in the administration of an incorrect medication dose.
Failure to Follow Safe Hoyer Lift Procedures During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and procedure for the safe use of a Hoyer lift during a resident transfer. The resident involved had multiple significant injuries, including fractures to the ankle, fibula, breastbone, cervical and thoracic vertebrae, ribs, and a bed sore, and was non-weight bearing at the time. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to use the Hoyer lift to transfer the resident without the required assistance of a second staff member. During the transfer, one of the lift straps slipped out of place, causing the resident to fall onto the bed. The resident was assessed for injuries and none were found, but the incident left the resident feeling unsafe. Interviews with staff confirmed that facility policy required at least two staff members to operate the Hoyer lift. The CNA involved acknowledged being aware of this requirement but proceeded to use the lift alone. Another CNA witnessed the incident and reported that the resident requested not to be lifted again, but observed the same CNA attempt another lift with the resident. The facility's policy, as well as staff interviews, confirmed that the use of the Hoyer lift by a single staff member was not permitted and constituted a failure to provide adequate supervision and accident prevention.
Failure to Provide and Document Follow-Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives (ADs) were fully honored and documented for five of seven residents reviewed. Multiple residents, including those with intact or moderate cognitive function, expressed uncertainty about whether they had an AD or requested more information about formulating one. Despite this, there was no documented evidence that these residents or their resident representatives (RPs) were provided with follow-up information or education about their right to formulate an AD after admission. Record reviews for each resident showed that, upon admission, residents were provided with an acknowledgment form regarding ADs, and if they did not have an AD, they were to be given a handout and education on how to create one. The facility's policy also required quarterly follow-up during care conferences for residents without an AD. However, for all five residents cited, there was no documentation that such follow-up or education occurred during the relevant care conferences, even when residents indicated a desire for more information or were unsure about their AD status. Interviews with the Social Services Director (SSD) confirmed that the expected process was not consistently documented or followed. The SSD acknowledged that if there was no AD on file, there was a potential for the facility to be unable to honor residents' wishes for care. The lack of documentation and follow-up regarding ADs was observed across multiple residents with varying medical conditions, including stroke, chronic obstructive pulmonary disease, diabetes, hypertensive heart disease, major depressive disorder, chronic kidney disease, and malnutrition.
Wet-Stored Food Basins Violate Food Safety Standards
Penalty
Summary
Surveyors observed five large plastic basins used for ice and food items that were stacked while still wet and stored on a metal storage shelf in the facility's kitchen. During interviews, both the Dietary Services Supervisor and the Registered Dietitian confirmed that all dishes, pots, pans, and utensils should be air-dried and completely dried before being stored, as moisture can promote bacteria or mold growth. The facility's practice of stacking and storing wet basins did not comply with professional standards for food service safety, specifically the FDA Federal Food Code requirement that equipment and utensils be air-dried after cleaning and sanitizing before coming into contact with food. This deficiency had the potential to affect 52 medically vulnerable residents who consumed food prepared and served in the facility.
Medication Administration Not Observed by Nurse
Penalty
Summary
A licensed vocational nurse failed to follow proper medication administration practices by leaving a cup containing potassium chloride, an orange liquid medication, at the bedside of a resident instead of observing the resident take the medication as required. The nurse confirmed that the medication was scheduled for administration at 9 a.m. and acknowledged that it should not have been left unattended. The resident identified the liquid as her medication during the observation. The Director of Nursing confirmed that facility policy requires nursing staff to remain with residents until all medications have been taken and that medications should not be left at the bedside. A review of the facility's policy on administering oral medications reiterated this expectation.
Failure to Follow Manufacturer's Disinfection Instructions for Shared Equipment
Penalty
Summary
Nursing staff failed to implement proper infection control practices during medication administration for one of four residents reviewed. Specifically, a licensed vocational nurse (LVN) was observed cleaning a shared manual blood pressure cuff and stethoscope with a germicidal disposable wipe but did not allow the equipment to remain visibly wet for the required two minutes as specified by the manufacturer's instructions. The LVN incorrectly believed the required contact time was one minute, despite the instructions on the wipe container indicating a two-minute wet time was necessary to effectively disinfect the equipment. Interviews with the LVN, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that staff are expected to disinfect shared equipment according to the manufacturer's instructions, which include maintaining the specified contact time. The facility's policy also requires reusable resident care equipment to be decontaminated between residents per manufacturer guidelines. The failure to follow these procedures was observed during a medication pass and was corroborated by staff interviews and a review of the facility's policy and the manufacturer's instructions.
Failure to Meet Minimum Square Footage Requirements in Multi-Resident Rooms
Penalty
Summary
The facility failed to ensure that multi-resident bedrooms provided the required minimum of 80 square feet per resident in 16 out of 22 rooms, as identified through observation, interview, and record review. A facility document listing room measurements showed that several three-bed and two-bed rooms had less than the required square footage per resident, with some rooms offering as little as 71.7 to 73.7 square feet per resident. During the survey, care was observed in these rooms, and the room sizes did not appear to limit the provision of care. No negative impacts on residents' health, safety, or comfort were observed, and residents interviewed reported being comfortable and having no concerns about space or privacy. Interviews with the DON and Administrator confirmed awareness of the room size deficiency, with both stating there had been no complaints or concerns from staff or residents regarding space or privacy. The facility maintained a policy to ensure resident comfort with living space and to assess for any adverse effects on health and safety related to room size. The Administrator noted that the facility was requesting a continued room waiver for the affected rooms.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged physical abuse incident to the California Department of Public Health (CDPH) and other officials within the required two-hour timeframe. The incident involved a resident with Huntington's Disease, who was reportedly slapped on the leg by a Certified Nurse Assistant (CNA) during a transfer to a shower chair. The Director of Nursing (DON) was informed of the incident by student nurses and initiated an internal investigation, which included suspending the CNA involved and interviewing other staff members. However, the facility did not report the incident to the CDPH as it was deemed unsubstantiated after the internal investigation. The investigation revealed that the alleged abuse was a misunderstanding of a calming technique used by the CNA to manage the resident's involuntary movements. The resident, who was cognitively severely impaired, denied being hit, and other staff members, including the Social Services Director (SSD), confirmed that the CNA was using a rhythmic tapping method to calm the resident. Despite these findings, the facility's policy required that even unsubstantiated allegations of abuse be reported immediately to the appropriate authorities. The facility's failure to report the incident was acknowledged by the DON, who admitted that the incident should have been reported to the CDPH regardless of the investigation's outcome. The facility's policy on abuse reporting clearly states that all allegations must be reported within two hours, highlighting a lapse in adherence to regulatory requirements. This oversight had the potential to delay the investigation and expose residents to further risk.
Failure to Update Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to review and revise the care plan for a resident with Huntington's Disease, who exhibited involuntary twitching and jerking movements. The care plan, initially created in October 2022, was not updated to reflect the resident's changing needs or to assess the effectiveness of interventions aimed at controlling these movements. This oversight was identified during an unannounced visit to investigate an abuse allegation, where it was found that the care plan had not been periodically reviewed or updated. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care plan. A registered nurse was unaware of any recent revisions to the care plan, and the Social Services Director noted that a method used by a CNA to calm the resident's movements was not documented in the care plan. The Director of Nursing acknowledged that the effective intervention of rhythmic tapping, which helped reduce the resident's involuntary movements, was not included in the care plan, highlighting a gap in ensuring person-centered care through documented and shared interventions.
Failure to Isolate Resident with MDRO
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy by not placing a resident with a multidrug-resistant organism (MDRO) in a single room or cohorting them with other residents with the same infection. Resident A, who tested positive for extended spectrum beta-lactamase (ESBL) in her urine, was placed on contact isolation but remained in a shared room with two other residents. The Certified Nursing Assistants (CNAs) caring for the residents were observed wearing gloves, but there was confusion about the necessity of additional personal protective equipment (PPE) and the reason for the contact isolation sign. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both acknowledged that Resident A was not moved to a private room despite the positive ESBL test. The LVN was unaware of when Resident A tested positive and whether it was an active infection. The facility's policy, which follows CDC recommendations, states that residents with known or suspected MDRO colonization or infection should be prioritized for single-resident rooms or cohorted with others with the same MDRO. This oversight had the potential to expose Resident A's roommates to the infection.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #37's quarterly MDS was inaccurately coded to indicate the resident had taken an antipsychotic medication during the seven-day assessment period, while it did not include the resident's use of antianxiety or hypnotic medication. The resident's care plan and Medication Administration Record (MAR) confirmed the use of lorazepam and Ambien, but no antipsychotic medication was documented. The MDS Coordinator confirmed the incorrect coding during an interview, and the Director of Nursing (DON) stated that the antipsychotic medication had been discontinued upon admission. Resident #17's quarterly MDS inaccurately indicated that the resident had no falls since admission, despite an incident review documenting a fall in November 2023. The resident, who had severe cognitive impairment and other significant diagnoses, was found on the floor next to their bed, which was in the lowest position. The MDS Coordinator acknowledged that the fall should have been captured in the MDS assessment but was not. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments.
Failure to Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to ensure that pressure injury interventions ordered by the physician were implemented for a resident at risk for pressure injuries. The resident, who had severe cognitive impairment and was at risk for pressure ulcers due to decreased mobility, poor safety awareness, and incontinence, had an order to have their heels floated off the bed with pillows every shift. However, observations on multiple occasions revealed that the resident's heels were lying against the mattress without the required pillow support. Interviews with staff, including a Treatment Nurse, Licensed Vocational Nurse, and Certified Nurse Aide, confirmed that the pillow was not consistently in place as ordered. The Director of Nursing and the Administrator both acknowledged that the resident's heels should have been offloaded using a pillow and that staff should have ensured the pillow remained in place. Despite the facility's policy and the physician's order, the staff failed to implement the necessary intervention to prevent pressure injuries, as evidenced by the repeated observations and staff admissions. The deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a lapse in adherence to prescribed care protocols for pressure injury prevention.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 5.56%. This was based on observations, interviews, record reviews, and facility policy reviews. Specifically, there were 2 medication errors out of 36 opportunities, affecting one resident. The errors involved the administration of amlodipine and MiraLAX powder to Resident #19. The resident had a physician's order to hold amlodipine if their heart rate was less than 60 beats per minute, but the medication was administered despite the resident's heart rate being 57 beats per minute. Additionally, the MiraLAX powder was not fully dissolved in the liquid before administration, resulting in the resident not receiving the full dose of the medication. During interviews, LVN #3 acknowledged the errors, stating that she thought it would be okay to administer the amlodipine despite the low heart rate and admitted to not ensuring the MiraLAX powder was completely dissolved. The Director of Nursing confirmed that medications should be held if vital signs are outside the specified parameters, and the Administrator stated that medications are expected to be given according to physician's orders and professional standards.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure no significant medication errors occurred for one resident during the medication administration task. Specifically, a Licensed Vocational Nurse (LVN) administered amlodipine to a resident despite the resident's heart rate being below the parameters specified by the physician's order. The resident's heart rate was documented as 57 beats per minute, below the threshold of 60 beats per minute, at the time of administration. The LVN admitted to administering the medication despite the low heart rate, citing that the resident's heart rate was frequently in the 50s and she thought it would be okay. This action was contrary to the physician's order, which specified holding the medication if the heart rate was less than 60 beats per minute. Further review revealed that the same LVN had administered amlodipine to the resident on multiple occasions when the resident's heart rate was below 60 beats per minute, as documented in the Medication Administration Records (MAR) for February and April 2024. Interviews with the Physician Assistant and the Director of Nursing confirmed that administering amlodipine with a heart rate below 60 could be detrimental and that the medication should have been held according to the physician's order. The facility's policy on administering medications also required verification of vital signs prior to administration, which was not adhered to in this case.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident for 16 out of 22 resident rooms observed. The facility's policy, revised in July 2023, mandates that each resident in a multiple-resident bedroom should have at least 80 square feet of space. However, a review of the Client Accommodations Analysis form dated April 12, 2024, revealed that several rooms did not meet this requirement, with some rooms providing as little as 71.7 square feet per resident. Despite this, observations during the recertification survey indicated that the room sizes did not restrict the provision of care, and residents did not voice any concerns regarding their space or room size. Maintenance staff confirmed the measurements, and the Director of Nursing and the Administrator both stated that the facility had a room size waiver for these rooms. During interviews, the Director of Nursing and the Administrator emphasized that staff were expected to respect resident privacy and ensure comfort despite the smaller room sizes. The Administrator also mentioned that staff were mindful of equipment needs to ensure that the room sizes did not impact the residents' quality of life. However, the facility's failure to comply with the required room size standards constitutes a deficiency, as it did not meet the regulatory requirements for resident living space.
Failure to Provide Timely Notice of Discharge
Penalty
Summary
The facility failed to provide a written Notice of Discharge to two residents and their representatives prior to the date of discharge. Resident 1, admitted with a fracture of the right pubis, was given discharge instructions and signed the Notice of Transfer/Discharge on the same day of discharge. Similarly, Resident 2, admitted with a fracture of the left Ilium, signed the discharge instructions and Notice of Discharge on the day of discharge. Both residents were not informed of their discharge in advance, and the Ombudsman was notified only on the day of discharge, not prior as required. Interviews with the Social Services Discharge Planner, Nursing Supervisor, and Director of Nursing revealed that the facility's process involved notifying the Ombudsman on the day of discharge, contrary to the facility's policy which mandates that the Ombudsman be notified at the same time the resident is informed. The facility's policy requires a 30-day advance written notice of discharge, or as soon as practicable if the resident has not resided in the facility for 30 days. The failure to adhere to this policy resulted in the residents and the Ombudsman not being properly informed in a timely manner.
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.
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