Vineyard Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reedley, California.
- Location
- 1090 East Dinuba Avenue, Reedley, California 93654
- CMS Provider Number
- 055799
- Inspections on file
- 20
- Latest survey
- February 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vineyard Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe and sanitary environment in the housekeeping closet on Wing B, with observations of residue on the floor, missing baseboards, and rust-colored debris. Interviews revealed that the janitor was not on duty until the evening shift, and the Administrator acknowledged the need for cleaning and maintenance. The IP/MDSN expressed concerns about safety hazards and infection control issues due to the conditions observed.
The facility failed to properly store and label medications, with 15 blister packs missing expiration dates and an expired narcotic found in a cart for a hospice resident. Additionally, an unlocked cart with loose pills was discovered outside, posing safety risks. The DON and staff acknowledged these issues, emphasizing the importance of proper medication management.
The facility failed to ensure that the Maintenance Director and Dietary Cooks had the necessary competencies to safely carry out food and nutrition services. The Maintenance Director did not follow proper cleaning procedures for the ice machine, while Dietary Cook 1 misused test strips for sanitizing solutions, and Dietary Cook 2 improperly recalibrated thermometers. These deficiencies could lead to contamination and foodborne illness among residents.
A dietary staff member failed to weigh roast turkey before serving it to a resident, contrary to the dietary spreadsheet and meal card instructions. The resident, with a history of type 2 diabetes, atrial flutter, hypertension, and abnormal weight gain, was on a therapeutic diet requiring small portions. This oversight could have led to unplanned weight gain, as confirmed by the Director of Culinary Services and the Registered Dietitian.
The facility failed to maintain food safety and sanitation standards, affecting 50 of 51 residents. Issues included unlabeled and expired food items, contamination risks from black particles and cobwebs, and improper cleaning practices. The DCS, RD, and MAIND acknowledged these deficiencies, which violated the facility's policies on food storage, cleaning, and hair restraints.
A resident with a history of cerebral infarction, Alzheimer's, and other conditions fell from her wheelchair, hit her head, and was unconscious. The incident was not reported to the California Department of Public Health within the required time frame, delaying the investigation. The facility's policy required such incidents to be reported within 24 hours, but the report was submitted late.
A facility failed to implement a behavior monitoring care plan for a resident receiving anti-psychotic medication. The resident, with multiple diagnoses including schizoaffective disorder and dementia, was moderately cognitively impaired. Despite facility policies requiring behavior monitoring for such medications, the care plan lacked this component, as confirmed by staff interviews and policy reviews.
A resident with multiple health conditions was found to be receiving oxygen at 2.5 L/min instead of the prescribed 3 L/min, as observed by an LVN and confirmed by the DON. The facility's policy required adherence to physician orders for oxygen settings, which was not followed, placing the resident at risk of unmet respiratory needs.
A resident with severe cognitive impairment was discharged from a facility without the knowledge or consent of their designated representative. The discharge was signed by another family member, contrary to the facility's policy requiring notification and involvement of the designated representative. Interviews with facility staff confirmed the lack of proper documentation and communication with the representative.
A resident with a history of respiratory issues was receiving continuous oxygen despite having a prn order. The facility's Licensed Nurses did not notify the Attending Physician of this change in condition, which was necessary to update the care plan and physician orders. The resident was cognitively intact and had been using oxygen continuously for over a month without the required notification to the physician.
A resident experienced unrelieved knee pain that limited her participation in physical therapy due to the facility's failure to provide effective pain management. Despite the resident's complaints and a documented care plan, staff did not consistently communicate her therapy refusals due to pain to the appropriate personnel, nor was the physician notified or pre-medication administered. The facility's policies on pain management were not followed, resulting in a deficiency in individualized care.
A resident on a mechanical soft diet was served a regular diet meal, contrary to their prescribed dietary needs. The resident, who was severely cognitively impaired and admitted for hospice care, was at risk of choking due to this oversight. Facility staff confirmed the meal did not match the prescribed diet texture, and procedures to ensure diet orders were followed were not adhered to.
A facility failed to maintain effective infection control practices. An RN did not change gloves or perform hand hygiene during a dressing change for a resident on Enhanced Barrier Precautions, while an LVN did not perform hand hygiene between resident medication administrations. The DON confirmed these lapses, which contradicted the facility's infection control policies.
A facility failed to develop a comprehensive person-centered care plan for a bedbound resident, leading to the resident spending her waking hours picking on her skin, resulting in excoriations. The resident, with multiple diagnoses including Parkinson's disease and paraplegia, expressed boredom, and it was found that an activity care plan was not created at the time of admission. The lack of an activity care plan was acknowledged by the Activity Director, LVN, MDS Nurse, and DON.
The facility failed to maintain a functioning call light system, affecting seven residents who could not request assistance. A resident used a handbell due to a non-working call light, and the Director of Maintenance was unaware of the issue due to a lack of routine checks. The Administrator and Director of Staff Development were also unaware of the extent of the problem, despite the facility's policy requiring operable call lights and routine inspections.
Sanitation and Safety Deficiencies in Housekeeping Closet
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the housekeeping closet on Wing B. Observations revealed brown/gray and white residue on the floor, missing plastic baseboards exposing multiple layered holes near the base of the left wall, and a metal drain with rust-colored debris and an uneven untiled surface. The sink piping had peeling paint and brown-colored staining. These conditions were observed during a concurrent observation and interview with the housekeeper, who indicated that the janitor was responsible for cleaning the closet. Interviews with the Administrator and the Infection Preventionist/Minimum Data Set Nurse (IP/MDSN) revealed that there was no janitor on duty until the evening shift, and the janitor was scheduled for the evening shift. The Administrator acknowledged the need for the closet drywall to be swept, the floors stripped and waxed, and the area under the sink to be cleaned. The IP/MDSN expressed concerns about the rust on the pipes and the uneven surfaces, which could pose safety hazards and infection control issues. Further observations with the Maintenance Director and the IP/MDSN showed that the floor was in the process of being wax stripped, revealing brown liquid, debris, and missing tiles. The Maintenance Director explained that the wall damage was due to the vacuum hitting against the wall without the baseboard protector. The IP/MDSN reiterated concerns about the uneven drain surface and the potential for cross-contamination. The Administrator later stated that maintaining a safe, clean, and sanitary environment was part of her role, but the facility faced challenges such as budgeting, scheduling, and provider availability.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles. During observations, it was found that 15 out of 383 sampled medication blister packs lacked visible expiration dates. This issue was acknowledged by the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1, who both confirmed that medications should have expiration labels. The Pharmacy Consultant (PC) also emphasized the importance of visible expiration dates, noting that medications without them could be expired, potentially affecting their effectiveness. Additionally, an expired liquid narcotic medication was discovered in a medication cart for a resident on hospice care. The narcotic had an expiration date of 8/30/24, and the LVN responsible stated that expired medications should be logged and stored in a double-locked area until disposal by the pharmacy. The PC confirmed that expired medications could lose potency, posing a risk to residents if administered. Furthermore, an unlocked medication cart containing 10 unidentified loose pills was found on the back patio. The Maintenance Director and Director of Staff Development acknowledged that the cart should have been emptied and cleaned before being taken outside. The DON expressed concern about the potential for overdose or allergic reactions due to the unidentified pills. The PC reiterated that medications should not be loose and should be properly documented and stored to ensure resident safety.
Inadequate Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the Maintenance Director (MAIND) and Dietary Cooks (DC) 1 and 2 had the appropriate competencies to safely and effectively carry out the functions of the food and nutrition services for 50 of 51 residents. The MAIND did not demonstrate or verbalize the proper cleaning procedure for the ice machine according to the manufacturer's guidelines. This was observed during an interview where the MAIND used an incorrect solution mixture and cleaning method, admitting to using personal experience rather than formal training. The Director of Culinary Services (DCS) and Registered Dietitian (RD) confirmed that the MAIND lacked competency in cleaning the ice machine, which could lead to contamination and foodborne illness. DC 1 failed to demonstrate the proper use of a test strip for the sanitizing bucket, which is crucial for ensuring the correct concentration of quaternary ammonium compounds. During an observation, DC 1 incorrectly used the test strip and misinterpreted the acceptable concentration range. The DCS and RD confirmed that DC 1 did not follow the correct procedure, which could result in improper disinfection and increased risk of pathogen transmission. DC 2 did not demonstrate competency in recalibrating a thermometer according to the facility's policy. During an observation, DC 2 incorrectly placed the thermometer in a cup of ice water, allowing it to touch the bottom, which could lead to inaccurate temperature readings. The DCS and RD confirmed that DC 2 did not follow the correct recalibration procedure, which could result in food being prepared at unsafe temperatures, posing a risk of foodborne illness to residents.
Failure to Follow Portion Control for Resident's Meal
Penalty
Summary
The facility failed to ensure proper portion control for a resident's meal, specifically regarding the serving of roast turkey. During an observation, a dietary staff member did not weigh the roast turkey before cutting and serving it, contrary to the dietary spreadsheet and meal card instructions, which specified a 2 oz portion. The dietary staff member acknowledged the importance of weighing the meat to ensure the resident received the correct portion size, as per the dietary requirements. The resident involved had a medical history that included type 2 diabetes mellitus, atrial flutter, hypertension, and abnormal weight gain. The resident was on a therapeutic diet requiring small portions and chopped meat texture. The failure to weigh the roast turkey could have led to the resident consuming more than the prescribed amount, potentially affecting their health condition. Interviews with the Director of Culinary Services and the Registered Dietitian confirmed that the dietary staff did not follow the established procedures, which could have resulted in unplanned weight gain for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 50 of 51 residents. An open box of green tea was found without a label indicating the open and received date, which is crucial to prevent serving expired tea. The Director of Culinary Services (DCS) and the Registered Dietitian (RD) acknowledged the importance of labeling to avoid potential foodborne illness. Additionally, an expired bottle of ground rosemary seasoning was discovered on the kitchen shelf, which should have been discarded according to the facility's policy. Further observations revealed black particles on a red wine vinegar bottle, which the DCS attributed to dust and acknowledged as a contamination risk. Spider cobwebs and brown and black particles were found behind the ice machine, which the Dietary Aide (DA) and DCS recognized as a potential source of contamination. The Maintenance Director (MAIND) was observed cleaning the ice machine without a beard net, contrary to the facility's policy, posing a risk of cross-contamination. The ice machine itself had black substances inside, indicating a lack of proper cleaning and maintenance. The RD confirmed that the black substance could be from dust, bacteria, mold, or other pathogens, posing a risk of foodborne illness. The facility's policies on food storage, cleaning, and hair restraints were not followed, leading to these deficiencies in food safety and sanitation practices.
Failure to Timely Report Resident Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury to the California Department of Public Health within the required time frame for a resident who fell from her wheelchair, hit her head, and was unconscious. This incident occurred on January 8, 2025, and the resident was subsequently transferred to a General Acute Care Hospital for further evaluation. The failure to report the incident in a timely manner resulted in the fall not being investigated within the required time frame, potentially compromising the resident's safety needs. The resident involved in the incident had a history of cerebral infarction, Alzheimer's disease, schizophrenia, major depressive disorder, and a history of falling. At the time of the incident, the resident was unable to complete a cognitive assessment, as indicated by a Brief Interview for Mental Status score of 99. The fall was initially witnessed by a Licensed Nurse who observed the resident lean forward and fall out of her wheelchair, resulting in a head injury and loss of consciousness. Interviews with facility staff revealed that the necessary forms for notifying the state or authorities were not included in the investigation packet. The Director of Nursing acknowledged that the incident was reportable due to the resident's loss of consciousness. However, the report to the state office was submitted late, as confirmed by the Administrator. The facility's policy required unusual occurrences, such as falls with major injury, to be reported to appropriate agencies within 24 hours, which was not adhered to in this case.
Failure to Implement Behavior Monitoring for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 25, who was receiving anti-psychotic medication. The deficiency was identified when it was observed that Resident 25 did not have a care plan for behavior monitoring, which is essential for residents on such medication. This oversight was noted during a concurrent observation and interview with Resident 25, who was found in her room, unable to recall how long she had been at the facility and expressing a lack of desire to answer questions. Resident 25 was admitted to the facility with multiple diagnoses, including Parkinson's disease, respiratory failure, heart failure, schizoaffective disorder, dementia, and major depressive disorder. A review of her Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. Despite these conditions, the care plan lacked a behavior monitoring component, which was confirmed during an interview with a Licensed Vocational Nurse (LVN) who acknowledged the necessity of such a plan to ensure the medication's effectiveness and minimize side effects. Interviews with facility staff, including a Certified Nursing Assistant (CNA), a Pharmacy Consultant (PC), and the Administrator (ADM), revealed that behavior monitoring was expected for residents on anti-psychotic or psychotropic medications. The facility's policies and procedures also emphasized the importance of behavior monitoring and updating care plans accordingly. However, these protocols were not followed for Resident 25, leading to the deficiency noted in the report.
Failure to Adhere to Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who was receiving oxygen therapy. The resident, who had been at the facility for two to three years, was observed receiving oxygen at a flow rate of 2.5 L/min instead of the physician-prescribed 3 L/min. This discrepancy was noted during an observation and interview with the resident, who had a history of congestive heart failure, type 2 diabetes mellitus, morbid obesity, shortness of breath, end-stage renal disease, chronic gout, anxiety disorder, and depression. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged the incorrect oxygen setting and confirmed that the oxygen rate should have been set to 3 L/min as per the physician's order. The Director of Nursing (DON) also stated that licensed nurses should follow physician orders for oxygen settings to ensure residents receive the proper dose of oxygen. The facility's policy on oxygen administration emphasized the importance of verifying physician orders and adjusting the oxygen delivery device to administer the correct flow of oxygen. The failure to adhere to these standards placed the resident at risk of unmet respiratory needs.
Failure to Notify Designated Representative of Resident Discharge
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident, identified as Resident 60, who was discharged without the knowledge or consent of their designated representative, RP 2. The resident, who had a history of dementia and a BIMS score indicating severe cognitive impairment, was discharged against medical advice (AMA) with the paperwork signed by another family member, OF 1. The facility's records indicated that RP 2 was the designated representative, yet there was no documentation of communication with RP 2 regarding the discharge. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the facility did not follow proper procedures in notifying the designated representative. The SSD acknowledged the lack of documentation and the importance of contacting the representative, while the DON stated that the documentation was insufficient and emphasized the need to involve the representative in such decisions. The facility's policy required that the resident or their representative sign a release of responsibility form when discharged without a physician's approval, which was not properly adhered to in this case.
Failure to Notify Physician of Continuous Oxygen Use
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive person-centered care plan for a resident who had an order for prn oxygen but was receiving it continuously due to episodes of increasing shortness of breath. The Licensed Nurses did not notify the Attending Physician of this change in condition, which was necessary to update the care plan and physician orders to reflect the resident's continuous use of oxygen. The resident, who was cognitively intact with a BIMS score of 14, had a medical history of shortness of breath, acute respiratory failure with hypoxia, heart failure, hypertension, obstructive sleep apnea, and muscle weakness. Despite the resident's continuous use of oxygen for over a month, the Licensed Nurses failed to notify the Attending Physician, which was a requirement according to the facility's policy and procedure for changes in a resident's condition or status.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in frequent complaints of knee pain that went unrelieved. The resident, who had been at the facility for two to three years, was observed experiencing knee pain that limited her ability to participate in physical therapy sessions. Despite the resident's complaints and the presence of a surgical scar on her right knee, the facility did not adequately address her pain management needs, which were documented in her care plan. The resident's care plan indicated that she had pain in her right knee and required monitoring and reporting of changes to her physician. However, the facility's staff, including CNAs and LVNs, failed to consistently communicate the resident's refusal of therapy due to pain to the appropriate personnel. The RNA reported the resident's refusal of therapy to the licensed nurse, but there was no evidence that the physician was notified or that pre-medication was administered to manage the resident's pain before therapy sessions. Interviews with facility staff, including the DON and IP, revealed that the licensed nurse should have notified the physician immediately upon the resident's refusal of therapy due to pain. The facility's policy on pain assessment and management emphasized the importance of recognizing and addressing pain, but the staff did not adhere to these guidelines. The lack of communication and failure to update the resident's care plan contributed to the deficiency in providing individualized care for the resident.
Failure to Provide Appropriate Diet Texture for Resident
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for a resident on a mechanical soft diet. During an observation, the resident was served a regular diet meal, which included chunks of cooked meat, rice, a whole flour tortilla, and fresh tomato pieces, despite being prescribed a mechanical soft diet. This discrepancy was noted on the resident's meal ticket, which clearly indicated the need for a mechanical soft diet. The resident, who was admitted for hospice care with diagnoses including Alzheimer's disease, depression, anxiety, and Type 2 Diabetes Mellitus, was severely cognitively impaired with a BIMS score of 3. The dietary staff, including the Dietary Aide, Director of Culinary Services, and Registered Dietician, confirmed that the meal served did not match the prescribed diet texture. They acknowledged the increased risk of choking for residents on a mechanical soft diet who are served regular diet texture foods. Interviews with facility staff, including the Activities Assistant and Director of Nurses, revealed that there were procedures in place to ensure meal trays matched diet orders. However, these procedures were not followed, resulting in the resident receiving an inappropriate meal. The facility's policy and procedure on food preparation guidelines emphasized the importance of providing food in a form that meets each resident's individual needs, which was not adhered to in this instance.
Infection Control Lapses in Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN 1 and LVN 1. RN 1 did not change her gloves after cleansing a wound and before applying medication and a clean dressing to a resident who was on Enhanced Barrier Precautions (EBP). Additionally, RN 1 did not perform hand hygiene after removing her gown and exiting the resident's room. This resident had a history of hemiplegia, hemiparesis, dysphagia, Parkinson's disease, respiratory failure, and dementia, making them particularly vulnerable to infections. During the dressing change, RN 1 wore gloves to handle supplies but did not sanitize the bedside table before placing the supplies. After assisting with the resident's wound dressing change, RN 1 applied a new dressing without changing gloves, discarded her supplies and gloves, and performed hand washing. However, she failed to perform hand hygiene after removing her gown and before exiting the room. The Director of Nursing (DON) confirmed that RN 1 should have performed hand hygiene before starting the dressing change, after removing soiled gloves, and after leaving the resident's room. Similarly, LVN 1 did not perform hand hygiene before entering and exiting resident rooms and between residents during medication administration. LVN 1 acknowledged the importance of hand hygiene to prevent contamination and transfer of germs. The DON stated that the licensed nurse should have performed hand hygiene before entering and after exiting resident rooms and between each resident's medication pass. The facility's policy emphasized hand hygiene as the primary means to prevent the spread of infections, which was not adhered to by the staff involved.
Failure to Implement Activity Care Plan for Bedbound Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was bedbound for eight months and did not have an activity care plan. This oversight led to the resident spending her waking hours picking on her skin, resulting in excoriations on various body parts, including the abdomen, left hip, and right hip. The resident was readmitted to the facility with multiple diagnoses, including Parkinson's disease, congestive heart failure, major depressive disorder, contracture of muscles in the lower legs, and paraplegia. Her Minimum Data Set indicated moderate cognitive impairment. Observations and interviews revealed that the resident was often bored, as evidenced by her staring at the ceiling and expressing boredom. The Activity Director admitted that an activity care plan should have been created at the time of admission but was not. The lack of an activity care plan was acknowledged by the Licensed Vocational Nurse, Minimum Data Set Nurse, and Director of Nursing, who all noted that the resident's behavior of picking on her skin could have been avoided with appropriate activities. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not done in this case.
Non-Functioning Call Light System in Facility
Penalty
Summary
The facility failed to maintain a functioning call light system, which is essential for residents to request assistance. During observations and interviews, it was found that seven out of 56 resident call lights were not functioning properly. Residents in rooms 14 A, 14 B, 14 C, 13 A, 18 B, 19 B, and 20 A were affected. For instance, a resident in room 14 A had been using a handbell for several weeks because the call light was not working. The Certified Nursing Assistant (CNA) confirmed that the call lights in rooms 14 B and 14 C were also non-functional, which was previously unknown to her. The Director of Maintenance (DOM) admitted that routine checks of the call lights were not conducted, and he relied on staff to report any issues. The DOM was unaware of the non-functioning call lights until the survey, and he acknowledged that the call buttons were faulty and needed replacement. The Administrator (ADM) and the Director of Staff Development (DSD) were also interviewed. The ADM was unaware of the multiple call light failures, although she acknowledged the importance of a functioning call system. The DSD, who conducted daily rounds, was aware of the malfunctioning call light in room 14 A and noted that the resident used a handbell as an alternative. The facility's policy and procedure documents indicated that the call light system should be operable and routinely inspected by maintenance staff, and any non-operable call lights should be reported. However, these procedures were not followed, leading to the deficiency.
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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