West Haven Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in West Covina, California.
- Location
- 1495 West Cameron Ave., West Covina, California 91790
- CMS Provider Number
- 056228
- Inspections on file
- 31
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at West Haven Healthcare during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of records showed incomplete documentation and planning, with missing interventions and unclear goals for the resident's care.
A resident did not receive IV fluids in a safe and appropriate manner when needed, as the facility failed to follow proper protocols for IV fluid administration.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to accepted professional standards, as observed by surveyors during their review of documentation and information handling practices.
During an active Group A Streptococcus (GAS) outbreak, several LVNs, CNAs, and other staff members lacked accurate knowledge about the nature and transmission of GAS, with some believing it was a virus or fungal infection and others unaware of the outbreak status. Despite in-services being conducted, interviews revealed significant gaps in staff competency regarding infection control, contrary to facility policy requiring such competencies.
Surveyors found that the facility did not post required outbreak notifications, failed to ensure staff performed hand hygiene and wore PPE as required, and did not educate or enforce contact precautions for visitors. These lapses were observed among residents with serious medical conditions, and staff acknowledged the importance of these protocols but did not consistently follow them.
The facility failed to maintain a clean and safe environment in two resident shower rooms, exposing residents to potential mold and injury risks due to broken tiles and cracked grout. Housekeeping staff reported the issues to maintenance, but repairs were not documented or completed. The facility's policies emphasize maintaining a safe environment, but communication and documentation failures led to the observed deficiencies.
The facility failed to transmit the MDS assessments for three residents within the required 14-day period, potentially affecting quality monitoring data. The residents had various medical conditions, including cerebral palsy, rheumatoid arthritis, chronic obstructive pulmonary disease, hypertensive heart disease, heart failure, and acute respiratory issues. The MDS Coordinator confirmed the delay in transmission.
A facility failed to monitor a resident's orthostatic hypotension as per physician's orders while administering antipsychotic medications. The resident, with a history of bipolar disorder and epilepsy, was at high risk for falls. Blood pressure readings were not taken 5 to 10 minutes apart as required, potentially leading to hypotension and increased fall risk. This deficiency was acknowledged by an LVN during a review of the resident's records.
The facility failed to store two boxes of dehydrated and seasoned potato (hash browns) in accordance with its P&P. The boxes were observed to be past their used by date, which was confirmed by the DS and DON. The facility's P&P required that food products be used before the specified date to ensure safety and quality.
The facility failed to provide updated arbitration agreements that included the selection of a neutral arbitrator and a convenient venue for two residents with severely impaired cognition. The outdated agreements were signed by the residents' responsible parties without the necessary information, contrary to the facility's policy requiring the use of the latest compliant version.
A resident with Alzheimer's and bipolar disorder was not assisted at eye level during meal times, compromising their dignity. Staff confirmed that feeding should occur at eye level for dignity and safety, but the practice observed did not align with the facility's policy on promoting dignity.
The facility failed to complete Advance Directive Acknowledgment Forms for two residents, leading to a lack of documentation regarding their treatment preferences. One resident, admitted with hypertension and diabetes, and another readmitted with hemiplegia and dementia, both lacked ADA forms in their records. This oversight was confirmed by the Social Service Director and nursing staff, highlighting a failure to adhere to the facility's policy on advance directives.
A resident with epilepsy and diabetes mellitus was at risk of injury due to torn foam pads on bed grab bars, exposing metal parts. The facility's policy to maintain a hazard-free environment was not upheld, as confirmed by an LVN who acknowledged the safety risk. The resident required partial assistance and was on seizure medication.
A facility failed to provide necessary set-up assistance during lunchtime for a resident with severely impaired cognition, leading to the resident's inability to reach and consume her meal. The resident was observed lying in bed with the food tray placed out of reach, contrary to the facility's policy requiring proper positioning and tray setup.
A resident with a gastrostomy tube was not provided with the necessary care as ordered by the physician. The resident was found with a GT site that had no dressing and bloody drainage, contrary to the prescribed daily treatment. Interviews with staff confirmed the importance of daily dressing changes to prevent infection, which was not followed, leading to a deficiency in care.
A facility failed to follow its policy on the use of grab bars for a resident with congestive heart failure and muscle weakness. The facility did not attempt alternative interventions, obtain informed consent, or develop a care plan before installing grab bars, placing the resident at risk for entrapment and injury. Observations and interviews confirmed these deficiencies, despite the resident having intact cognition and using grab bars for bed mobility.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on Lexapro, despite recommendations in the monthly Medication Regimen Review. The resident, who had no documented depressive behavior and was assessed as low risk, did not receive a GDR from February 2024 to January 2025. The Director of Nursing acknowledged the oversight due to hospital transfers, contrary to the facility's policy requiring monthly drug regimen reviews and GDR attempts.
A facility failed to follow infection prevention guidelines for an Enhanced Barrier Precaution (EBP) room when a private caregiver assisted with a bed bath for a resident with a stage 3 pressure ulcer without wearing a gown. The Infection Preventionist Nurse confirmed the requirement for gown use during close contact care, as outlined in the facility's policy. This oversight risked spreading infections within the facility.
A resident with COPD and a history of myocardial infarction was found to have a dirty and dusty electric fan in their room, which was not maintained in a sanitary condition. The facility's staff acknowledged that the fan's condition could cause allergies and respiratory illnesses, contrary to the facility's housekeeping policy requiring daily cleaning of equipment.
A resident at high risk for pressure ulcers was found on a low air loss mattress with improper layering, contrary to facility guidelines. The resident had multiple pressure ulcers and was dependent on staff for repositioning. Interviews with staff confirmed that the additional layers could interfere with the mattress's effectiveness, potentially worsening the resident's condition.
The facility failed to follow its policy on controlled medication storage, leading to missing Percocet tablets from the CS II E-kit. Only one nurse checked the E-kit instead of the required two, and discrepancies were not reported to the DON. This increased the risk of drug diversion.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
Failure to Safely Administer IV Fluids
Penalty
Summary
A deficiency was identified regarding the administration of IV fluids to a resident. The facility failed to ensure that IV fluids were provided in a safe and appropriate manner when needed for a resident. This indicates that the necessary protocols or procedures for IV fluid administration were not followed at the time care was required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Staff Lacked Competency in Infection Control During GAS Outbreak
Penalty
Summary
The facility failed to ensure that licensed vocational nurses (LVNs) and certified nurse assistants (CNAs) possessed the necessary competency to understand and manage different infection types, specifically Group A Streptococcus (GAS), during an active outbreak. Multiple staff members, including the Infection Prevention Nurse (IPN), Director of Staffing Development (DSD), LVNs, CNAs, and a Restorative Nurse Assistant, demonstrated a lack of knowledge regarding the nature of GAS, its mode of transmission, and the current outbreak status within the facility. Interviews revealed that some staff believed GAS was a virus or a fungal infection, while others were unaware of the ongoing outbreak or the type of infection GAS represented, despite in-services reportedly being conducted. Record review showed that the facility had an active GAS outbreak, and both the IPN and DSD stated that in-services had been provided to staff. However, staff interviews indicated significant gaps in understanding, with some staff not knowing that GAS is a bacterial infection spread through respiratory droplets or direct contact. The facility's own policy required competency evaluations, including infection control knowledge, but the observed deficiencies in staff awareness and understanding of GAS indicated that these competencies were not effectively ensured or maintained.
Failure to Implement and Enforce Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain standard infection prevention and control practices as outlined in its own policies and procedures. Surveyors observed that the facility did not post the required Group A Strep (GAS) Outbreak Notification Letter at the entrance, nor was the GAS FAQ/fact sheet made visible to all residents, visitors, and staff as recommended by the Public Health Nurse. The Infection Prevention Nurse confirmed that the notification letter was not posted at the entrance and that the FAQ/fact sheet was only available in the staff breakroom, limiting access for residents and visitors. Multiple instances of staff failing to follow proper infection control protocols were documented. One Certified Nurse Assistant (CNA) was observed not wearing a mask properly and not performing hand hygiene before or after assisting a resident in the lobby. Another CNA entered and exited a resident's room, which was under Enhanced Barrier Precautions (EBP), without performing hand hygiene, despite signage indicating this requirement. Additionally, a Licensed Vocational Nurse (LVN) was seen at the nurses' station with a mask pulled down below the nose and mouth, and another CNA entered a resident's room on EBP without donning the required gown, gloves, or properly wearing a mask. The facility also failed to ensure that visitors were educated and compliant with contact precautions. Family members visiting a resident on contact isolation for methicillin-sensitive Staphylococcus aureus (MSSA) were not informed by staff to wear masks, gowns, or gloves, despite signage and policy requirements. Staff interviews confirmed that it was the responsibility of all staff to remind and educate visitors about appropriate precautions, but this was not done. These failures were observed in residents with significant medical conditions, including end stage renal disease, sepsis, chronic kidney disease, and pressure ulcers, all of whom were at increased risk for infection.
Failure to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment in two resident shower rooms, which had the potential to expose residents to mold and injury from broken tile and cracked grout. During observations, a black substance was found on grout lines, and there were cracked, missing, and unsealed grout lines, as well as cracked, broken, and missing tiles. Housekeeping staff acknowledged the unclean condition of the showers and stated that they report repair needs to the Maintenance Department, although the exact date of reporting was not remembered. Housekeeping Staff 1 indicated that there is a maintenance logbook at Nursing Station 1 for reporting repair needs, and she verbally informs the Maintenance Department about issues. However, the Maintenance Supervisor stated that the necessary repairs were not reported to the Maintenance Department. The Maintenance Supervisor also confirmed that the condition of the shower rooms was dirty and posed a health risk to residents. A review of the Maintenance Department's QAPI Report and logbooks showed no entries for repair requests for the shower rooms in question. The facility's policies and procedures emphasize maintaining a safe, clean, and comfortable environment for residents, with specific guidelines for bathroom fixtures and surfaces, painting, and general housekeeping duties. Despite these policies, the facility did not document or address the repair needs in the shower rooms, leading to the observed deficiencies. The lack of communication and documentation between housekeeping and maintenance staff contributed to the failure to address the issues in a timely manner.
Delayed MDS Transmission for Three Residents
Penalty
Summary
The facility failed to complete and transmit the quarterly Minimum Data Set (MDS) assessments in a timely manner for three residents, as required by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual. Specifically, the MDS assessments for Residents 13, 44, and 50 were not transmitted within the mandated 14 days after their respective assessment dates. This delay in transmission had the potential to affect the facility's quality monitoring data. Resident 13 was admitted with cerebral palsy and rheumatoid arthritis, and their MDS indicated intact cognition but dependency on staff for certain activities. Resident 44, readmitted with chronic obstructive pulmonary disease and hypertensive heart disease, was severely cognitively impaired and required assistance with daily activities. Resident 50, admitted with heart failure and acute respiratory issues, was also severely cognitively impaired and needed substantial assistance. The Minimum Data Set Coordinator acknowledged the delay, stating that the assessments were completed but not transmitted to CMS on time.
Failure to Monitor Orthostatic Hypotension in Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order for the administration of antipsychotic medications, specifically Chlorpromazine and Risperidone. The physician's order required monitoring for orthostatic hypotension with two blood pressure readings taken 5 to 10 minutes apart, and observation for adverse side effects. However, the facility did not adhere to these orders, as blood pressure readings were only taken once at 9 a.m. and 5 p.m., without the required second reading in a sitting position. The resident involved, who was admitted with diagnoses including bipolar disorder, epilepsy, muscle weakness, and gait abnormalities, was identified as having intact cognition for daily decision-making. The resident required varying levels of assistance with daily activities and was assessed as high risk for falls due to a history of falls, secondary diagnoses, and mental status. Despite these risks, the facility's failure to follow the physician's orders for monitoring blood pressure could have led to a decrease in blood pressure, causing dizziness and fainting, which could result in falls and injuries. The facility's policy and procedure documents, including the Medication Administration-General Guidelines and the Fall Management Program, emphasize the importance of administering medications as prescribed and preventing falls through meaningful assessments and interventions. However, the facility did not comply with these guidelines, as evidenced by the lack of adherence to the physician's orders for monitoring orthostatic hypotension. This oversight was acknowledged by a Licensed Vocational Nurse during an interview, who confirmed that the required blood pressure readings were not conducted as per the physician's order.
Improper Food Storage of Hash Browns
Penalty
Summary
The facility failed to store food in accordance with its Policy and Procedure (P&P) for two boxes of dehydrated and seasoned potato (hash browns). During an observation and interview with the Dietary Supervisor (DS) in the dry food storage area, it was noted that the boxes had a received date of 11/19/2024 and a used by date of 1/19/2025, indicating they were past the specified use date. The DS confirmed that food products needed to be used before the used by date to ensure safety and quality. The Director of Nursing (DON) also stated that food items should be used within the specified date to prevent food-borne illnesses. A review of the facility's undated P&P titled 'Storage of Food and Supplies' indicated that labels should be visible, and supplies should be rotated to use the oldest items first, with all food products used per the times specified in the Dry Food Storage Guidelines.
Failure to Provide Updated Arbitration Agreements
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included the selection of a neutral arbitrator and a venue convenient to both the facility and the resident or the resident's responsible party. This deficiency was identified for two residents, both of whom had severely impaired cognition and required significant assistance with daily activities. For Resident 15, the arbitration agreement was signed by the responsible party but did not include the necessary information about a neutral arbitrator and a convenient venue. The Admission Coordinator acknowledged that Resident 15 had the old version of the arbitration agreement form and should have been provided with the updated version. Similarly, for Resident 65, the arbitration agreement was also signed by the responsible party without the inclusion of details regarding a neutral arbitrator and a convenient venue. The Admission Coordinator confirmed that Resident 65 had the outdated form and should have received the revised version. The facility's policy and procedure on arbitration agreements, dated February 2024, indicated that the administrator or designee is responsible for ensuring the use of the latest revision of the arbitration agreement that complies with applicable laws. However, this policy was not followed, leading to the deficiency.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 38, during meal assistance. Resident 38, who was admitted with Alzheimer's disease and bipolar disorder, required partial assistance for upper body dressing and transfers. During an observation, a Certified Nursing Assistant (CNA) was seen feeding Resident 38 ice cream while the resident was sitting up in bed, which was positioned at its lowest level due to fall risk. The CNA was bending over to feed the resident, rather than assisting at eye level, which is necessary for maintaining the resident's dignity. Interviews with staff, including a Licensed Vocational Nurse (LVN), confirmed that feeding should be conducted at eye level to respect the resident's dignity and ensure safety, as it allows staff to better observe for potential choking. The facility's policy on Privacy and Dignity emphasizes promoting resident care in a manner that maintains or enhances dignity and respect. However, the observed practice did not align with this policy, leading to a deficiency in maintaining the resident's dignity during meal assistance.
Failure to Complete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for two residents, resulting in the absence of Advance Directive Acknowledgment (ADA) Forms in their medical records. Resident 185, admitted with conditions including hypertension and diabetes, had no ADA form completed upon admission, as confirmed by the Social Service Director (SSD) and a Licensed Vocational Nurse (LVN). This omission meant that staff were unaware of Resident 185's treatment preferences, potentially leading to medical interventions against the resident's wishes during emergencies. Similarly, Resident 19, who was readmitted with diagnoses such as hemiplegia, sepsis, and dementia, also lacked an ADA form in their clinical record. Despite being cognitively intact and capable of making decisions, there was no documentation of Resident 19's treatment preferences. The Registered Nurse (RN) and SSD confirmed the absence of the ADA form, which should have been completed upon admission or readmission to ensure the resident's rights to accept or refuse treatment were respected.
Deficient Bed Safety Precautions for Resident with Seizures
Penalty
Summary
The facility failed to ensure that the bed grab bar foam pads for seizure precautions were in good condition for a resident diagnosed with epilepsy and diabetes mellitus. The resident, who was admitted in 2020, required partial assistance for daily activities and was on medication for seizure control. During an observation, it was noted that the foam pads on the grab bars of the resident's bed were ripped and torn, exposing the metal bars underneath. This condition posed a risk of injury to the resident, especially during seizure episodes. The facility's policy emphasized maintaining an environment free from accident hazards, yet the grab bars' condition contradicted this policy. A Licensed Vocational Nurse confirmed the poor state of the foam pads and acknowledged the safety risk they posed to the resident. The nurse highlighted that the foam pads were intended to prevent injuries during seizures by cushioning the resident from the metal bars. The facility's failure to maintain these safety precautions was a significant oversight in ensuring the resident's safety.
Failure to Provide Meal Set-Up Assistance
Penalty
Summary
The facility failed to provide necessary set-up assistance during lunchtime for Resident 15, who was at risk for dehydration, malnutrition, and weight loss. Resident 15, who had severely impaired cognition and required set-up assistance with eating, was observed lying in bed with the food tray placed on an overbed table that was too high and out of reach. Despite the resident's inability to reach the tray or stand up, the food was not set up in front of her, preventing her from eating while the food was warm. Licensed Vocational Nurse 1 confirmed that Resident 15 needed the food tray to be set up in front of her to eat independently. The Director of Nursing also stated that the resident should be positioned upright with the food tray set up and opened in front of her to ensure the food remains warm and palatable. The facility's policy on assisting residents with in-room meals was not followed, as it required the resident to be positioned upright and the tray to be adjusted to a comfortable position and height for easy access.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a gastrostomy tube (GT) as ordered by the physician and indicated in the care plan. Resident 234, who was admitted with diagnoses including dysphagia and gastrostomy, had an order for daily GT site treatment involving cleansing with normal saline, applying calcium alginate, and securing with a split gauze dressing. However, during an observation, the resident was found with a GT site that had no dressing and bloody drainage, indicating that the prescribed care was not being followed. Interviews with the Registered Nurse Supervisor and the Treatment Nurse confirmed that the GT site dressing changes should be done daily and as needed to maintain skin integrity and prevent infection. The Director of Nursing also stated that the GT site should be clean and covered with a dressing as ordered. The facility's policy on feeding tube site care emphasized daily inspection and appropriate dressing application to prevent irritation and infection, which was not adhered to in this case.
Failure to Implement Policy on Grab Bars Use
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of grab bars for Resident 237, who was admitted with diagnoses including congestive heart failure and muscle weakness. The facility did not ensure that appropriate alternative interventions were attempted and found insufficient before installing grab bars. Additionally, there was no documented evidence of informed consent being obtained from Resident 237 or their representative, nor was there an individualized care plan developed to address the specific needs of the resident concerning the use of grab bars. During observations and interviews, it was noted that Resident 237 had intact cognition and was using grab bars for bed mobility without prior attempts of alternative interventions. The facility's Director of Nursing and Minimum Data Set Coordinator confirmed the lack of documentation for alternative interventions, informed consent, and a care plan. The facility's policy required an assessment of alternatives, informed consent, and an updated care plan, none of which were followed, placing Resident 237 at risk for entrapment and injury.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident who had been taking Lexapro, a medication used to treat depression, since February 2024. Despite recommendations for a GDR in the resident's monthly Medication Regimen Review (MRR) dated August 2024, the facility did not attempt a GDR from February 2024 to January 2025. The Director of Nursing (DON) acknowledged that the GDR was overlooked due to hospital transfers and emphasized the importance of completing a GDR to reduce potential side effects of Lexapro. The resident, who was admitted to the facility with diagnoses including major depressive disorder, had no documented depressive behavior from September 2024 to January 2025. The resident was assessed as having a low risk in a psychiatric evaluation and was cognitively intact with the capacity to understand and make decisions. The facility's policy required the attending physician to review the drug regimen monthly and attempt a GDR unless clinically contraindicated, which was not adhered to in this case.
Failure to Follow Enhanced Barrier Precaution Protocol
Penalty
Summary
The facility failed to adhere to infection prevention guidelines for an Enhanced Barrier Precaution (EBP) room, which is an infection control measure requiring the use of gloves and gowns during high-contact patient care. This deficiency was observed when a private caregiver (PC) was inside the room of a resident, identified as Resident 78, assisting with a bed bath without wearing a gown. The resident had been admitted with diagnoses including hypertension and a stage 3 pressure ulcer, which necessitated the EBP to prevent the spread of bacteria. The PC acknowledged not wearing a gown during the bed bath, despite the EBP signage posted at the door and the understanding that the measure was to protect both the resident and caregivers from cross infections. The Infection Preventionist Nurse (IPN) confirmed that Resident 78 was on EBP due to a stage 2 pressure ulcer and that the PC should have worn a gown during close contact care activities, such as bathing. The facility's policy and procedure on Standard and Enhanced Precautions, dated April 2024, indicated that EBP should be used during high-contact resident care activities, including dressing, bathing, and showering. The physician's order summary also confirmed the requirement for EBP due to the resident's pressure ulcer. This oversight in following the infection control protocol had the potential to spread infections from the resident to the PC, staff members, and other residents in the facility.
Unsanitary Electric Fan Poses Health Risk to Resident
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident, which had the potential to affect the resident's quality of life and overall health. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD) and a history of myocardial infarction, was found to have a standing white electric fan in their room with dirty and dusty blades. This observation was made during a concurrent observation and interview with the Registered Nurse Supervisor, who acknowledged that the dirt and dust on the fan blades were not good and might cause allergies to the resident. Further interviews with the Maintenance Supervisor and the Director of Nursing confirmed that the dirt and dust on the fan could lead to respiratory illnesses. The facility's policy and procedure on housekeeping indicated that all equipment inside the resident's room should be cleaned and maintained daily to prevent infection. However, the failure to adhere to this policy resulted in the unsanitary condition of the fan, posing a risk to the resident's respiratory health.
Failure to Follow Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) for pressure ulcer prevention and care for a resident who was at high risk for developing pressure ulcers. The resident, who was on a low air loss (LAL) mattress, was observed with multiple layers on the mattress, including a flat sheet, a folded flat sheet, and a disposable chux pad. This setup contradicted the facility's guidelines, which specified that only one flat sheet and a chux pad should be used to maintain the effectiveness of the LAL mattress. Interviews with Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed that the additional layers could interfere with the mattress's function and potentially worsen the resident's condition. The resident had a history of multiple pressure ulcers, including a Stage 3 ulcer and several unstageable ulcers, and was dependent on staff for various activities, including repositioning. The facility's P&P emphasized the importance of identifying residents at risk and implementing measures to prevent pressure ulcer development, such as frequent repositioning and the use of support surfaces. However, the failure to follow these guidelines and the improper use of the LAL mattress compromised the resident's care and increased the risk of further skin breakdown.
Failure to Follow Controlled Medication Storage Procedures
Penalty
Summary
The facility failed to follow its policy and procedures on controlled medication storage in one of the medication storage rooms. Specifically, two licensed nurses were not present when checking the Controlled Substance II Emergency Kit (CS II E-kit), leading to the discovery that five tablets of 10 mg Percocet and two tablets of 5 mg Percocet were missing. The incident was reported by LVN 5, who noticed that the plastic covering of the CS II E-kit was carefully ripped and the red tags were cut and placed back to make it appear intact. This discrepancy was not reported immediately to the Director of Nursing (DON) as required by the facility's policy and procedures (P&P). Additionally, the Cart 1 Controlled Drug Reconciliation (CDR) form was not filled out correctly, indicating a failure to properly document and monitor the controlled medications, which could lead to drug diversion. The facility's P&P mandates that two licensed nurses conduct a physical inventory of all controlled medications at each shift change and document it on the controlled medication accountability record. However, interviews with various licensed nurses revealed that it was common practice for only one nurse to check the CS II E-kit, contrary to the facility's P&P. This practice increased the risk of discrepancies and potential drug diversion, as evidenced by the missing Percocet tablets. The facility's Pharmacy Consultant emphasized the importance of monitoring controlled substances like Percocet due to their high potential for misuse and severe consequences such as overdose or death. The DON confirmed that the staff did not follow the P&P, and the failure to properly document and monitor the controlled medications posed a significant risk for errors and drug diversion.
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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