Village Square Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Marcos, California.
- Location
- 1586 W. San Marcos Blvd, San Marcos, California 92078
- CMS Provider Number
- 555754
- Inspections on file
- 46
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Village Square Healthcare Center during CMS and state inspections, most recent first.
A resident admitted with psychoactive substance abuse and post-surgical aftercare needs had physician orders and a care plan for daily methadone to treat opioid dependence, along with hydromorphone and oxycodone for pain. For three consecutive days, the methadone was not administered and was documented as not available on the MAR. An LN reported that the facility had not ensured methadone availability at admission, that attempts to obtain it from the methadone clinic were unsuccessful due to lack of transportation, and that the resident became upset, agitated, threw water at staff, called 911, and left AMA. The DON acknowledged that by accepting the admission, the facility had agreed to meet the resident’s needs, but the ordered methadone was not provided.
Controlled medications and narcotic records for multiple residents were removed from medication carts without nurses’ knowledge and later found at another facility during a drug diversion investigation involving an agency nurse. Record review showed numerous discrepancies, including undated or missing pharmacy packing slips, lack of RN/LPN signatures acknowledging receipt of controlled drugs, incomplete documentation of pill quantities, and missed signatures on narcotic records. Although staff described a process for shift-to-shift narcotic counts and use of a narcotic binder, these procedures did not detect that controlled substances and Individual Patient’s Narcotic Records had been taken and left unaccounted for, even as residents with significant pain-related diagnoses were prescribed various oxycodone and tramadol regimens.
A resident with an unstageable sacral pressure ulcer and functional quadriplegia did not have the physician-ordered low air-loss mattress in place for an extended period. Staff, including the TXN and LN, were unaware of the missing mattress and continued to sign off on required checks without verifying its presence, despite care plan and policy requirements for monitoring and use of the mattress for skin management.
Dietary staff did not consistently cover facial hair during food preparation and service, failed to maintain cold food items at or below 41°F on the tray line, and did not remove expired food or properly store items in the freezer to prevent freezer burn. Facility leadership and staff interviews confirmed knowledge of these requirements, but observations showed repeated noncompliance.
Two residents were not provided care in a dignified manner: one was left exposed during incontinence care with the room door open and privacy curtain not drawn, while another was fed by a CNA who stood at the bedside instead of sitting at eye level, contrary to facility policy. Staff interviews confirmed awareness of proper procedures, but these were not followed, resulting in a lack of dignity for the residents.
A resident with COPD and pneumonia, who was cognitively intact, was found to be self-administering an inhaler without the required assessment or physician order. Staff confirmed the resident kept the inhaler at bedside and used it as needed, contrary to facility policy that mandates an interdisciplinary assessment and physician approval before self-administration of medications.
A resident with metastatic prostate cancer and deep vein thrombosis became unresponsive and was transferred to a hospital without notifying the family, despite facility policy requiring such communication. Staff interviews confirmed the oversight, affecting the family's involvement in care planning.
A CNA was observed standing over a resident with schizoaffective disorder while assisting them to eat, contrary to facility policy which requires staff to sit at eye level. The resident, who had no cognitive deficits, threw a pitcher across the room, potentially indicating distress. Interviews with staff confirmed that standing over residents can be intimidating and does not promote dignity.
A resident with a history of heart failure received intravenous fluids over 26 hours instead of the prescribed 20 hours, and the IV tubing was not labeled with the date and time of use. The licensed nurse and DON acknowledged the oversight, which could lead to complications such as inadequate fluid delivery and infection. The facility's policy on IV therapy was not followed.
A resident with a history of heart failure received intravenous fluid (IVF) over 26 hours instead of the prescribed 20 hours, and the IV tubing was not labeled with the date and time of use. The responsible nurse acknowledged the oversight, and the Director of Nursing confirmed the deviation from infection control protocols, as the facility's policy required all parenteral fluids to be used or discarded within 24 hours.
A facility failed to provide a written notice to a resident regarding a room change when another resident was moved for dialysis convenience. The Social Services Director did not inform the affected resident, citing a lack of awareness of the requirement. The facility's policy mandates that roommates be informed of transfers, including reasons, to respect their rights.
The facility failed to provide a comfortable and home-like environment for residents due to malfunctioning televisions and elevated room temperatures. Residents expressed frustration with non-working TVs, which had been an issue for weeks. Additionally, room temperatures often exceeded the facility's policy range, causing discomfort and potential health complications. The facility's Administrator acknowledged issues with the air conditioning system and outdated TV cable boxes, but the problems persisted, affecting residents' comfort.
Failure to Provide Ordered Methadone for Three Consecutive Days
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered methadone for a resident for three consecutive days, despite having accepted the resident for admission with a care plan and physician orders that included daily methadone for opioid dependence and pain management. The resident was admitted with diagnoses including other psychoactive substance abuse and surgical aftercare needs, and was documented as alert and oriented x4 on admission. Physician orders and the care plan specified methadone concentrate 135 mg orally once daily, along with hydromorphone and oxycodone for breakthrough and PRN pain. The medication administration record showed that methadone was not administered on three consecutive days and was marked as not available on each of those days. The facility’s policy stated that it would admit only residents whose needs could be met and that if a non‑contract pharmacy could not provide ordered medications, the provider pharmacy could be contacted to supply them. During interviews, an LN reported that the facility did not administer the resident’s methadone because it was not available for three days and acknowledged that, on admission, the facility should have ensured it could meet the resident’s need for methadone. The LN stated the resident became upset and agitated due to not receiving the medication, threw water at a staff member, called 911, and left the facility against medical advice. Progress notes indicated the LN attempted to contact the methadone clinic and arrange for transport to obtain the medication, but the facility did not have transportation available for the resident to pick up the methadone. The DON confirmed that when the facility accepts a resident, it agrees to meet and provide the resident’s needs. The facility’s failure to secure and administer the ordered methadone as required resulted in the resident not receiving the medication for three consecutive days and experiencing distress.
Unsecured and Unaccounted Controlled Medications and Narcotic Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled medications and associated Individual Patient’s Narcotic Records (IPNRs) were properly secured and accounted for in the medication carts. Controlled substances and original narcotic sheets were removed from the carts without the knowledge of licensed nurses and were later discovered at another skilled nursing facility during a drug diversion investigation involving an agency nurse. The facility’s Administrator stated that original narcotic sheets and medication bubble packets traced back to this facility were found elsewhere, indicating that controlled medications and records had been taken from the facility without staff awareness. Record review for ten residents showed multiple discrepancies and documentation gaps related to controlled medications. For one resident with liver cancer and a PRN order for Tramadol, the pharmacy packing slip showed 30 tablets received, while the IPNR indicated 26 tablets remaining in the bubble pack. Another resident with chronic back pain and orders for Hydrocodone-Acetaminophen and Oxycontin had multiple controlled prescriptions where the number of tablets dispensed per pharmacy packing slips did not clearly reconcile with the remaining counts documented on the IPNRs. Additional residents with chronic pain, venous ulcers, ischemic colitis, chronic pain syndrome, end-stage renal disease, cervical disc disorder, bilateral knee osteoarthritis, and a leg fracture had controlled medications such as Oxycodone and Oxycodone-Acetaminophen dispensed, but several pharmacy packing slips were undated, lacked licensed nurse signatures acknowledging receipt, or were missing altogether. In some cases, IPNRs showed remaining tablets, in others they showed zero tablets left, and there were missed nurse signatures on the narcotic records. Interviews with the Director of Staff Development and licensed nurses described the facility’s intended process for receiving and counting controlled medications, including signing pharmacy packing lists, maintaining a narcotic binder, and performing shift-to-shift counts where incoming and outgoing nurses verified bubble pack quantities against the narcotic count sheets. However, one nurse stated that when new refills were received, the receiving nurse documented only the number of cards received, not the quantity of pills, and several packing slips in the records lacked any nurse signature to confirm receipt of the medications. Despite these described procedures, the Administrator and DON reported they were unaware of any discrepancies in controlled drug counts until notified of the external drug diversion investigation, indicating that controlled medications and narcotic records had been removed from the carts and left unaccounted for without detection by the facility’s counting and reconciliation processes. The report notes that there were no missed doses for the affected residents, but controlled substances and IPNRs for all ten residents were removed from the medication carts without the knowledge of the licensed nurses and were not accounted for within the facility’s own systems. The combination of missing or unsigned packing slips, incomplete documentation of quantities received, missed signatures on narcotic records, and the discovery of original narcotic sheets and bubble packs at another facility demonstrate that the facility did not maintain secure control and accurate accountability of controlled medications as required.
Failure to Provide Ordered Low Air-Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air-loss mattress, as ordered by the physician and documented in the care plan, was in place for a resident with an unstageable sacral pressure ulcer and functional quadriplegia. Despite orders and care plan directives for the use of a low air-loss mattress to aid in skin management and wound healing, the resident was found to have a regular mattress on her bed. The resident reported concerns about the mattress settings to a CNA, who confirmed the absence of the air-loss mattress. Interviews with the treatment nurse and a licensed nurse revealed that both were unaware the mattress had been missing for weeks, and that nurses had been signing off on the Treatment Administration Record (TAR) for the mattress placement and settings without verifying its presence or function. Record reviews showed that the care plan and physician's orders required monitoring of the low air-loss mattress every shift, but this was not done. The DON acknowledged that the mattress may have been switched to another bed and confirmed the importance of the air-loss mattress for the resident's multiple skin issues. The facility's policy required the implementation of interventions for pressure ulcer prevention and treatment, but these procedures were not followed, resulting in the resident not receiving the prescribed pressure ulcer care.
Dietary Staff Noncompliance with Food Safety and Hygiene Standards
Penalty
Summary
Dietary staff failed to adhere to facility policy and professional standards regarding personal hygiene and food safety. Multiple staff members with facial hair were observed preparing and serving food without appropriate facial hair coverings, despite facility policy requiring beard or mustache covers during meal preparation and service. Interviews revealed inconsistent staff training and enforcement of this policy, with some staff stating they were not told to wear facial hair covers, while others admitted to forgetting. Facility leadership, including the Dietary Director, Registered Dietitian, DON, and Administrator, all stated their expectation that facial hair be covered or staff be clean shaven. Cold food items on the tray line were not maintained at the required temperature of 41°F or below. Observations showed tossed salad and peach yogurt being served at temperatures significantly above this standard, with staff and the Dietary Director failing to intervene or replace the food items. Staff interviews confirmed knowledge of the temperature requirements, but no corrective action was taken at the time of the deficiency. The Dietary Director and other leadership confirmed their expectation that cold foods be held and served at or below 41°F. Additional deficiencies included the storage of expired food items and improper storage of food in the walk-in freezer. Pre-boiled eggs with a use-by date that had passed were found in the refrigerator, and large quantities of corn kernels and chicken breasts were stored in open bags, exposing them to air and potential freezer burn. The Dietary Director acknowledged that food should be stored in airtight, moisture-resistant wrappers, and leadership confirmed the expectation that expired and improperly stored food be removed from storage.
Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents during routine care activities. In the first instance, a resident with end stage renal disease and intact cognition, who was dependent on staff for toileting hygiene, was left exposed during incontinence care. The CNA responsible for the resident left the room with the door open and the privacy curtain not drawn, leaving the resident with their pants and incontinence brief down and their buttocks exposed to the hallway. The CNA acknowledged being aware of the need to provide privacy but admitted to rushing and not following proper procedures. The resident reported being left in this state for more than five minutes and expressed discomfort and dissatisfaction with the lack of privacy. In the second instance, another resident with severe cognitive impairment, hemiplegia, and hemiparesis, who was dependent on staff for eating, was fed by a CNA who stood at the bedside rather than sitting at eye level as required by facility policy. The CNA stated she did not sit because there was no chair available in the room. The resident had to turn their head to receive food and drink, and the staff did not position themselves as directed in the care plan. Other staff members, including an LVN and the DON, confirmed that feeding should be done while seated at eye level to maintain dignity, and that a chair should have been obtained if one was not present. Both incidents were observed and confirmed through interviews with staff, residents, and facility leadership. Facility policies reviewed indicated clear expectations for maintaining resident privacy during personal care and for staff to be seated at eye level when assisting residents with eating. The actions and inactions of the staff in these cases did not align with these policies, resulting in a failure to honor the residents' rights to dignity and proper care.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for their ability to self-administer medication, as required by facility policy. The policy stated that if a resident wished to self-administer medication, the interdisciplinary team must complete a specific assessment to determine the resident's capability. In this case, a resident with a history of COPD and pneumonia, who had intact cognition as evidenced by a BIMS score of 15, was observed with an inhaler at their bedside. The resident reported using the inhaler as needed and confirmed that staff were aware of this practice. Record review showed there was no physician order permitting the resident to self-administer the inhaler, nor was there documentation of an assessment for self-administration. Interviews with staff, including a CNA, LVN, and RN, confirmed that the resident kept the inhaler at their bedside and self-administered it without the required assessment or physician order. The facility's DON also confirmed that the necessary procedures for self-administration had not been followed in this case.
Failure to Notify Family of Resident's Health Status Change
Penalty
Summary
The facility failed to notify the family of a resident's change in health status, which was a deficiency identified during a survey. The resident, who had metastatic prostate cancer and deep vein thrombosis, became unresponsive and was transferred to an acute hospital. Despite the facility's policy requiring notification of the resident's representative in such events, the resident's brother, who was the emergency contact and responsible party, was not informed of the transfer. Interviews with the Administrator, Director of Nursing, Licensed Nurses, and the Social Service Director confirmed the oversight in communication. The deficiency was highlighted during an unannounced visit following a complaint about the lack of family notification. Staff members, including a CNA who witnessed the resident's condition change, acknowledged that the family should have been contacted. The facility's policy on notifying the resident's representative during changes in condition was not followed, as confirmed by multiple staff interviews. This failure to communicate affected the family's ability to be involved in care planning and decision-making for the resident.
Failure to Promote Resident Dignity During Feeding
Penalty
Summary
The facility failed to promote dignity for a resident when a CNA was observed standing over the resident while assisting them to eat in bed. The resident, who was admitted with a history of schizoaffective disorder, had a BIMS score indicating no cognitive deficits. During the observation, the resident threw a pitcher across the room, which could suggest emotional distress. The CNA admitted to standing over the resident and acknowledged that she should have been seated at eye level to promote dignity and better communication. Interviews with the nursing staff, including a Licensed Nurse and the Director of Nursing, confirmed that standing over a resident while feeding them can be intimidating and does not promote dignity. The facility's policy on assisting residents to eat specifies that staff should sit at eye level in front of the resident. The CNA involved also noted that the resident sometimes made non-sensical statements and could become physical with staff, which may have contributed to the situation.
Failure to Administer IV Fluids as Prescribed
Penalty
Summary
The facility failed to adhere to a physician's order for the administration of intravenous fluids (IVF) for a resident, resulting in the IVF being infused over 26 hours instead of the prescribed 20 hours. The resident, who was admitted with a history of heart failure, was receiving sodium chloride 0.9% at a rate of 50 ml per hour to address hyperkalemia. Observations revealed that the IV tubing was not labeled with the date and time of use, which is a critical step for infection control. The resident's IVF was started in the morning, and by the following day, a significant amount of fluid remained in the bag, indicating the infusion was not completed within the prescribed timeframe. Interviews with the licensed nurse responsible for the resident's IV care and the Director of Nursing (DON) highlighted the oversight in monitoring the IVF flow rate and the failure to label the IV tubing. The licensed nurse acknowledged that the IVF should have been completed by the early morning of the next day but continued to run beyond the prescribed period. The DON confirmed that the lack of proper labeling and timely completion of the IVF could lead to complications such as inadequate fluid delivery, phlebitis, infiltration, and infection. The facility's policy on IV therapy, which mandates the use or disposal of parenteral fluids within 24 hours, was not followed in this instance.
Failure to Follow Physician's Order for IVF Administration
Penalty
Summary
The facility failed to adhere to a physician's order regarding the infusion of intravenous fluid (IVF) for a resident, resulting in the fluid being administered over 26 hours instead of the prescribed 20 hours. The resident, who had a history of heart failure and no cognitive deficits, was receiving sodium chloride 0.9% at a rate of 50 ml per hour for hyperkalemia. Observations revealed that the IV tubing was not labeled with the date and time of use, which is a critical step for infection control. Licensed Nurse 1, responsible for the resident's IV care, acknowledged that the IVF should have been completed within the specified time frame and that the lack of proper monitoring could lead to complications such as irritation, infection, and inadequate fluid administration. The Director of Nursing confirmed that the IV tubing should have been labeled to prevent infection control issues and that the fluid should have been discarded appropriately. The facility's policy indicated that all parenteral fluids should be used or discarded within 24 hours, highlighting a deviation from established protocols.
Failure to Provide Written Notification of Room Change
Penalty
Summary
The facility failed to provide a written notice and reason for a bed change to a resident, identified as Resident 6, when another resident, Resident 3, required a bed change. Resident 3 was moved from the third floor to the second floor due to the convenience of accessing transportation services for dialysis appointments, as the elevators were not working. This move resulted in Resident 3 sharing a room with Resident 6 for five days until Resident 6 was discharged. However, there was no written notification provided to Resident 6 regarding this room change, which is a violation of the resident's rights. The Social Services Director (SSD) admitted to not providing a written room change notification to Resident 6, stating a lack of awareness of the requirement to notify roommates of bed changes. The facility's policy on room and roommate assignments clearly indicates that roommates should be informed of any new transfers into or out of their room, including the reasons for such transfers. The Administrator confirmed that the expectation was for room change notifications to be given both verbally and in writing to all affected residents and their responsible parties, to ensure awareness and respect for their rights and preferences.
Facility Fails to Maintain Comfortable Environment Due to Malfunctioning TVs and High Temperatures
Penalty
Summary
The facility failed to ensure a comfortable and home-like environment for four residents due to malfunctioning televisions and elevated room temperatures. During an unannounced visit, it was observed that televisions in several residents' rooms were not functioning properly, with issues such as incorrect remotes and poor WiFi signals preventing residents from watching their preferred programs. Residents expressed frustration and dissatisfaction with the non-working TVs, which had been an ongoing issue for at least three weeks. The Director of Maintenance had resigned earlier in the month, which may have contributed to the delay in addressing these issues. Additionally, the facility struggled to maintain appropriate room temperatures, with several areas recording temperatures above the facility's policy range of 71-81 degrees Fahrenheit. Observations and interviews revealed that temperatures in resident rooms and common areas were often in the 80s, with some areas reaching as high as 92.3 degrees Fahrenheit. Residents and staff reported discomfort and potential health complications due to the excessive heat, such as difficulty breathing and irritability. The facility had placed fans in hallways to help circulate air, but this measure was insufficient to maintain a comfortable environment. The facility's Administrator acknowledged the issues with the air conditioning system and the televisions, citing problems with the AC control box and outdated TV cable boxes. Despite attempts to address these issues, the problems persisted, affecting the residents' physical and psychosocial comfort. The facility's policy on maintaining a home-like environment was not adhered to, as evidenced by the malfunctioning equipment and failure to maintain appropriate room temperatures.
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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