West Pico Terrace Healthcare & Wellness Centre Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 6070 W. Pico Boulevard, Los Angeles, California 90035
- CMS Provider Number
- 055119
- Inspections on file
- 33
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Pico Terrace Healthcare & Wellness Centre Lp during CMS and state inspections, most recent first.
The facility did not ensure that informed consent documentation for psychotropic medications was complete for two residents. Consent forms lacked the prescriber's name and did not confirm that the physician obtained consent from the resident or responsible party, despite being signed. Both the RNS and DON acknowledged the forms were incomplete and did not meet policy requirements.
The facility failed to store boxed food items off the floor, risking contamination and foodborne illnesses. Observations revealed that a box of thickened dairy drink, a box of thickened lemon-flavored water, and a 25-pound bag of sugar were placed directly on the floor. Staff acknowledged the items should be stored at least 6 inches off the floor, as per facility guidelines.
A facility failed to properly cohort a resident who tested negative for COVID-19 with another who tested positive, and did not update transmission-based precautions for a resident no longer requiring them. These actions were against facility policy and CDC guidelines, increasing infection risk.
The facility failed to update and follow up on the advance directives for two residents. One resident's POLST form was incomplete, lacking documentation of their wishes regarding CPR and other medical interventions. Another resident's AHCD was not followed up on, with no evidence that the facility requested or obtained a copy of the directive. The Director of Nursing confirmed these oversights, which were not in compliance with the facility's policy.
A facility failed to ensure a resident was free from physical restraints by not having a physician's order for bilateral bed siderails, as required by policy. The resident, with conditions like cerebral infarction and Parkinson's, was observed with siderails up, but no order or care plan was documented. The DON confirmed that siderails should have an order and care plan, as they can limit movement and be considered a restraint.
A facility failed to provide a written bed hold notification to a resident or their representative during a hospital transfer for hypotension evaluation. The Bed Hold Agreement form was incomplete, and the resident or their representative was not informed of their right to have the bed held. The facility's policy requires such notification, but it was not followed in this instance.
A facility failed to document a Change of Condition (COC) for a resident with dementia and other medical conditions, who exhibited aggressiveness and combativeness, and refused a urine sample collection. Despite the facility's policy requiring timely COC documentation, no evidence of such documentation was found, potentially delaying necessary care.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, with dementia and hearing loss, lacked a documented activity care plan and a personalized treatment strategy for hearing. Staff interviews confirmed the absence of these plans, potentially affecting the resident's care and social engagement.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including cerebral infarction and Parkinson's disease. The resident used bilateral bed siderails, but no care plan was developed for their use. Additionally, no care plans were created following the resident's hospitalizations for altered mental status, chest pain, and productive cough. Staff confirmed the absence of necessary care plans, which are required by facility policy.
A facility failed to update the enteral feeding care plan for a resident with severe cognitive impairment and total dependence on staff. The resident's care plan did not reflect the current physician's order for Jevity 1.5 at 65 ml/hr, instead showing an outdated order of 40 ml/hr. This discrepancy was confirmed by the RN Supervisor and the DON, who acknowledged the importance of updating care plans to ensure proper care. The facility's policy mandates regular review and revision of care plans by the interdisciplinary team.
A resident with dementia and other health issues exhibited aggressive behavior, potentially indicating a UTI. Despite physician orders to collect a urine sample, the facility failed to notify the physician after unsuccessful attempts, as required by their policy.
A facility failed to provide necessary audiology services for a resident with hearing difficulties, despite a physician's order. The resident, who had dementia and other health issues, was not referred to an audiologist as required by the facility's policy. Interviews with staff confirmed the oversight, which resulted in a significant delay in care.
A resident's exit pathway was obstructed by geri-chairs, creating a potential fire hazard and causing discomfort. Despite the resident's concerns and the facility's policies for a safe environment, the Maintenance Supervisor did not remove the obstruction. The DON acknowledged the importance of clear pathways for emergencies.
A resident with severe cognitive impairment and dysphagia had their enteral feeding bottle left unchanged for over 24 hours, contrary to facility policy. The LVN confirmed the oversight, and the DON stated that bottles should be changed daily for infection control. The facility's policy requires feeding formula and tubing changes every 24-48 hours, but this was not adhered to, risking complications.
A facility failed to change and label nasal cannula tubing and humidifier for a resident's oxygen therapy as per policy. The resident, with conditions like acute bronchospasm and pulmonary embolism, was on oxygen therapy. Staff interviews confirmed the oversight, and the facility's policy required weekly changes and labeling for infection control.
The facility failed to label an open date on a resident's ipratropium-albuterol inhalation solution, contrary to manufacturer guidelines, and left another resident's medications unattended at the bedside. The LVN acknowledged the labeling oversight, and the DON confirmed that leaving medications at the bedside is unacceptable due to potential risks. Facility policies require proper labeling and administration of medications by the nurse who prepared them.
A resident's levalbuterol inhalation solution was improperly stored, with the opened medication not used within the manufacturer's recommended timeframe. The medication was observed in a medication cart with an opened foil pouch, contrary to guidelines that require use within two weeks of opening the pouch. The resident had acute respiratory failure, CHF, and acute kidney failure, requiring moderate assistance for daily activities. The DON confirmed the importance of following manufacturer guidelines for medication effectiveness.
The facility was found deficient for not providing the required minimum square footage per resident in three multiple resident bedrooms. Despite the deficiency, observations indicated that residents had ample space to move freely, and staff reported no concerns regarding room sizes. The facility had submitted a request for a room size waiver, asserting that the room sizes did not impede resident care.
A resident with severe cognitive impairments did not receive prescribed Ciprofloxacin Otic Solution for a suspected ear infection due to it being out of stock. The delay in obtaining an alternative medication led to worsening symptoms, including severe pain and maggots in the ear, requiring hospital transfer. The facility's policies on medication availability and condition change notification were not effectively followed.
A resident with acute respiratory failure, hypertension, and dementia was not readmitted to the facility after hospitalization due to an expired bed hold. Despite an available female bed, the Admission Coordinator reserved it for another resident, violating the facility's policy. This resulted in the resident staying in the hospital longer than necessary.
Incomplete Documentation of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents by not verifying that the physician obtained informed consent prior to initiating psychotropic medications. For one resident with anxiety disorder and moderate cognitive impairment, the Verification of Informed Consent for Buspirone did not indicate the prescribing physician's name or confirm that the prescriber obtained informed consent from the resident. The form was signed by the resident but lacked documentation of the prescriber's involvement in the consent process. For another resident with major depression, dementia, and severe cognitive impairment, the Verification of Informed Consent for Mirtazapine, Quetiapine, and Buspirone did not indicate the prescriber and, although signed by the next of kin, did not confirm that the prescriber obtained informed consent from the responsible party. Both the registered nurse supervisor and the director of nursing confirmed that the consent forms were incomplete and did not meet facility policy requirements, which specify that documentation must confirm the physician obtained informed consent and that no blank spaces are left on forms.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that boxed food items were not stored directly on the floor, which could potentially lead to food contamination and place residents at risk for foodborne illnesses. During an observation in the dry storage area, it was noted that a box of thickened dairy drink, a box of thickened lemon-flavored water, and a 25-pound bag of sugar were stacked directly on the floor. The Cook (CK1) acknowledged that these items had been delivered earlier in the day and had not yet been placed on the racks. CK1 confirmed that the boxes should be stored at least 6 inches off the floor to prevent contamination. The Dietary Supervisor (DS1) and the Director of Nursing (DON) both stated that food should be stored in a sanitary manner, adhering to the facility's storage guidelines, which require shelving to be at least 6 inches from the floor.
Inadequate Cohorting and Precaution Updates in Infection Control
Penalty
Summary
The facility failed to ensure proper cohorting of residents in relation to COVID-19 infection control. Resident 4, who tested negative for COVID-19, was placed in the same room as Resident 29, who tested positive for the virus. Despite Resident 4's refusal to move, there was no documentation explaining the risks or the decision-making process. This practice was against the facility's policy and CDC guidelines, which recommend separating residents with confirmed infections from those without. Additionally, the facility did not update the transmission-based precaution orders for Resident 30. Although the resident was no longer on antibiotic therapy for pneumonia, the precautionary measures were not discontinued in a timely manner. This oversight was confirmed by both the RN and the Infection Preventionist, who acknowledged the failure to update the physician's order. The facility's policies and procedures were not followed, as evidenced by the lack of documentation and failure to adhere to infection control guidelines. These deficiencies had the potential to increase the risk of infection transmission among residents, staff, and visitors.
Failure to Update and Follow Up on Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records for two residents were updated according to the facility's policy and procedure. For Resident 3, the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, lacking documentation of the resident's wishes regarding cardiopulmonary resuscitation (CPR), medical interventions, and artificially administered nutrition. Additionally, the POLST form did not have the necessary signatures from the resident or their legally recognized decision-maker, indicating whether the form had been discussed and reviewed. For Resident 29, the facility did not follow up on the resident's Advance Healthcare Directives (AHCD). Although the resident's Advance Directive Acknowledgement (ADA) form indicated that an AHCD had been executed, there was no evidence that the facility requested or obtained a copy of the actual AHCD. The Director of Nursing confirmed that the facility should have followed up to ensure the residents' wishes were documented and honored, as per the facility's policy and procedure.
Failure to Obtain Physician's Order for Bed Siderails
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not having a physician's order for the use of bilateral bed siderails, as required by the facility's policy and procedures. The resident, who was admitted with conditions including cerebral infarction, Parkinson's disease, Type II Diabetes Mellitus, and muscle wasting, was observed in bed with both siderails up. Despite the resident's cognitive skills being intact and requiring maximal assistance for activities of daily living, there was no documented physician's order or care plan for the use of these siderails. During an interview, the Director of Nursing acknowledged that bed siderails are used as enablers and should have a physician's order and care plan, as they can limit a resident's movement and be considered a restraint. The facility's policy, reviewed in 2024, states that bed rails are classified as a physical restraint when used to limit a resident's freedom of movement, and a detailed order by a healthcare provider is required before any restraints can be utilized. This oversight had the potential to result in entrapment and injury for the resident.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold notification to a resident or their representative at the time of transfer to a hospital, which is a requirement when a resident is transferred for therapeutic leave or hospitalization. This deficiency was identified for one resident, who was transferred to a hospital for evaluation of hypotension. The resident's Admission Record indicated they were initially admitted and later readmitted with diagnoses including metabolic encephalopathy, bladder cancer, and chronic kidney failure. The Bed Hold Agreement form, which should have been completed upon transfer, was only partially filled out, with the sections regarding notification upon transfer and the 24-hour notification of bed hold decision left incomplete and unsigned. During interviews, the Registered Nurse Supervisor confirmed that the facility did not notify the resident or their responsible party of the bed hold option during or after the transfer. The Director of Nursing stated that the facility's policy is to inform residents of their right to a bed hold upon transfer. The facility's policies and procedures require written notification of the bed hold option whenever a resident is transferred to an acute care hospital or requests therapeutic leave. However, in this case, the required notification was not provided, resulting in the resident or their representative being uninformed of their right to have the bed held during the hospital stay.
Failure to Document Change of Condition for a Resident
Penalty
Summary
The facility failed to complete a Change of Condition (COC) assessment for a resident, identified as Resident 23, in accordance with its policy and procedures. Resident 23 was admitted with diagnoses including dementia, a history of transient ischemic attack, cerebral vascular accident without residuals, and hypertension. The Minimum Data Set (MDS) indicated that Resident 23 had cognitive impairment and required extensive staff assistance with activities of daily living. On a specific date, Resident 23 exhibited aggressiveness, combativeness, and refused to allow staff to collect a urine sample ordered by the physician. Despite these changes, there was no documented evidence that a COC was completed. During interviews, the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a COC documentation for Resident 23. They acknowledged that a COC is essential to monitor residents and involve the interdisciplinary team in providing necessary care. The facility's policy, reviewed in June 2024, emphasized the importance of informing residents, family, legal representatives, and physicians of changes in a resident's condition in a timely manner. The lack of a COC documentation for Resident 23 could potentially delay the care needed to address the resident's condition changes.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy and procedures. Specifically, the facility did not address the inclusion of activity programs tailored to the resident's interests and cognitive, physical/functional, and social abilities. This omission was identified during a record review and interviews with facility staff, who acknowledged the absence of a documented activity care plan for the resident. The lack of an activity care plan meant that staff were unaware of the resident's activity preferences, which could affect the resident's social engagement and overall well-being. Additionally, the facility did not outline a personalized treatment strategy for the resident's hearing loss within the required timeframe. The resident, who was admitted with diagnoses including dementia, generalized weakness, and adult failure to thrive, was noted to have moderate difficulty with hearing and severely impaired vision. Despite a physician's order for an audiology consult, the facility did not implement a care plan to address the resident's hearing needs. Interviews with staff confirmed that the resident was hard of hearing, requiring staff to speak loudly and close to the resident's ear. The absence of a care plan for the resident's hearing loss potentially impacted the delivery of necessary care and services.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, identified as Resident 10, which resulted in a deficiency. Resident 10 was admitted with multiple diagnoses, including cerebral infarction, Parkinson's disease, Type II Diabetes Mellitus, and muscle wasting and atrophy. Despite these conditions, the facility did not develop a care plan for the use of bilateral bed siderails, which were observed in use during a facility tour. Additionally, there were no care plans developed following Resident 10's hospitalizations due to altered mental status, chest pain, and productive cough with generalized weakness. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of care plans for the use of siderails and for the resident's changes of condition that led to hospitalizations. The facility's policy requires comprehensive, person-centered care planning, which should be reviewed and revised with the onset of new problems or changes in condition. The lack of a care plan for these critical aspects of Resident 10's care had the potential to negatively impact the resident's health and safety.
Failure to Update Enteral Feeding Care Plan
Penalty
Summary
The facility failed to update the enteral feeding care plan for Resident 22, who was admitted with diagnoses including cerebrovascular accident, dysphagia, and heart failure. The resident's Minimum Data Set indicated severely impaired cognition and total dependence on staff for various activities, including eating. A physician's order dated 1/16/25 specified that Jevity 1.5 should be administered at 65 ml/hr via a gastrostomy tube. However, the care plan, initiated on 10/9/24, still reflected an outdated order of 40 ml/hr, which was not aligned with the current physician's order. During a review, the Registered Nurse Supervisor confirmed that the care plan had not been updated to reflect the current enteral feeding order, acknowledging that this oversight could lead to the resident not receiving proper care. The Director of Nursing also confirmed that care plans should be updated with any changes in the resident's care, medication, or enteral feeding. The facility's policy on comprehensive person-centered care planning requires that care plans be reviewed and revised by the interdisciplinary team after each assessment and upon changes in the resident's condition.
Failure to Notify Physician of Unsuccessful Urine Sample Collection
Penalty
Summary
The facility failed to notify the physician when they were unable to collect a urine sample for urinalysis, culture, and sensitivity (UA and C&S) for a resident, as per the physician's orders. The resident, who was admitted with diagnoses including dementia, a history of transient ischemic attack, cerebral vascular accident without residuals, and hypertension, exhibited aggressive and combative behavior during activities of daily living care. This behavior was potentially indicative of a urinary tract infection (UTI), for which the physician had ordered a urine sample to be collected via straight catheter. Despite the facility's process requiring three attempts to collect the urine sample before notifying the physician, there was no documented evidence that the physician was informed after the unsuccessful attempts. The Director of Nursing confirmed that the urine sample should have been collected as soon as possible and that the physician should have been notified if the sample could not be collected after three consecutive shifts. The facility's policy indicated that the attending physician should be notified of refusal of treatment based on the resident's condition and potential serious consequences, but this was not adhered to in this case.
Failure to Provide Audiology Services as Ordered
Penalty
Summary
The facility failed to provide necessary outside services as required by physician orders for a resident, identified as Resident 6, who was admitted with diagnoses including dementia, generalized weakness, and adult failure to thrive. The physician's order dated 11/23/2024, indicated a need for an audiology consult due to the resident's hard of hearing condition. However, there was no documented evidence that the referral to an audiologist was made, despite the facility's policy and procedures requiring such referrals to be coordinated by the Director of Social Services. Interviews with facility staff, including a CNA, Registered Nurse Supervisor, and the Social Services Director Interim, confirmed that the referral was not made, and it had been 13 weeks since the order was given. The deficiency was further highlighted during interviews with the Director of Nursing, who stated that the facility's process involved notifying social services of the order, who would then notify the audiologist. The failure to notify the audiologist resulted in a delay in care and evaluation for Resident 6, who had moderate difficulty with hearing and severely impaired vision. This delay had the potential to negatively affect the delivery of necessary care and services for the resident, as confirmed by the staff interviews and the facility's policy review.
Obstructed Exit Pathway Poses Safety Risk
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident by not ensuring that the exit pathway was clear of geri-chairs and clutter. This deficiency was identified during an observation and interview with the resident, who expressed concerns about the obstruction caused by six geri-chairs outside her door. The resident, who was admitted with conditions such as pneumonia, acute respiratory failure, and hemiplegia following a cerebral infarction, required maximal to total assistance for activities of daily living. Despite the resident's intact cognitive skills, she felt uncomfortable and unsafe due to the blocked exit pathway, which also obstructed her view to the outside. The Maintenance Supervisor acknowledged the placement of the geri-chairs outside the resident's room due to recent rains and was aware of the resident's complaint but had not moved the equipment. The Director of Nursing confirmed that the exit pathway should be clear in case of emergencies such as fire or earthquake, and acknowledged that a blocked pathway might make residents feel unsafe. The facility's policies emphasized providing a safe and hazard-free environment, and staff were instructed to notify supervisors of any unsafe situations. However, these policies were not adhered to in this instance, leading to the deficiency.
Failure to Change Enteral Feeding Bottle Within 24 Hours
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding bottle was changed after 24 hours, as required by the facility's policy and procedures. Resident 22, who was admitted with diagnoses including cerebrovascular accident, dysphagia, and heart failure, was observed with a feeding tube that had not been changed within the 24-hour timeframe. The resident's care plan indicated the need for monitoring for signs or symptoms of infection and adherence to physician orders for feeding. However, during an observation, it was noted that the feeding bottle was dated from the previous day, exceeding the recommended hang time. Licensed Vocational Nurse (LVN) 1 confirmed that the tube feeding had been hanging for more than 24 hours, acknowledging that this could lead to infection. The Director of Nursing (DON) stated that staff are expected to change enteral feeding bottles daily for infection control, following the manufacturer's instructions. The facility's policy indicated that feeding formula and tubing should be changed every 24-48 hours, depending on manufacturer guidelines. Despite this, the feeding bottle for Resident 22 was not changed within the specified time, posing a risk of tube feeding-associated complications.
Failure to Change and Label Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not adhering to its policy on changing nasal cannula (NC) tubing and humidifier for oxygen therapy. The resident, who was admitted with conditions including acute bronchospasm, pulmonary embolism, Type II Diabetes Mellitus, and chronic kidney disease, required oxygen therapy. The physician's order specified that the NC tubing and humidifier should be changed every Monday, labeled, and dated. However, during an observation, it was found that the NC tubing and humidifier bottle lacked a written label with the date, and the staff was unaware of when it was last changed. Interviews with the staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed the oversight. The RN stated that the NC tubing and humidifier should be changed every seven days and labeled with the date. The Director of Nursing (DON) reiterated that the equipment should be replaced weekly and labeled for infection control purposes. The facility's policy on oxygen therapy, reviewed in 2024, also indicated that the humidifier and tubing should be changed every seven days and labeled. This deficiency had the potential to cause complications associated with oxygen therapy.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to properly label the open date on a resident's ipratropium-albuterol inhalation solution, which is necessary to ensure the medication is used within the manufacturer's recommended timeframe. During an observation, it was noted that the medication was stored in a medication cart with an opened foil pouch, but without a label indicating when it was first opened. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been labeled upon opening. The manufacturer's guidelines specify that once removed from the foil pouch, the vials should be used within two weeks. The facility's policy also requires that medications be labeled with the date opened and adhere to the manufacturer's expiration guidelines. Additionally, the facility did not ensure that a resident's medications were not left unattended at the bedside. During an observation, a medication cup containing various medications was found on a resident's bedside table. The resident confirmed the medications were left there, and the LVN admitted that it was not acceptable to leave medications at the bedside. The Director of Nursing (DON) stated that medications should not be left unattended as it poses a risk of other residents taking them, potentially leading to accidents or interactions with other medications. The facility's policy requires that medications be administered by the nurse who prepared them and that any refusal by a resident should be documented, with attempts made to administer the medication again.
Improper Storage of Levalbuterol Inhalation Solution
Penalty
Summary
The facility failed to properly store a resident's levalbuterol inhalation solution medication according to manufacturer guidelines. The medication, which is used to prevent or relieve symptoms of lung disease, was observed in a medication cart with an opened foil pouch. The medication box was labeled with the date it was first opened, but the manufacturer's guidelines specify that once the foil pouch is opened, the vials should be used within two weeks, and individual vials should be used within one week once removed from the pouch. This discrepancy was noted during an observation and interview with an LVN, who confirmed the date labeled was when the medication was first opened. The resident involved had been admitted with diagnoses including acute respiratory failure, congestive heart failure, and acute kidney failure. The resident's cognitive skills for daily decisions were mildly impaired, and they required moderate assistance from staff for activities of daily living. The Director of Nursing acknowledged that manufacturer guidelines must be followed to ensure medication effectiveness. The facility's policy indicated that medications should be dated when opened and used within the manufacturer's recommended timeframe, which was not adhered to in this case.
Room Size Deficiency in Resident Bedrooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, three resident rooms were identified as not meeting the minimum requirement of 80 square feet per resident. Room 7, Room 14, and Room 15 were each found to have less than the required space for three residents, with measurements of 217.21, 217.68, and 220 square feet respectively, whereas the regulation requires at least 240 square feet for a three-bedroom. This deficiency was identified during a recertification survey, where it was noted that the facility had previously submitted a request for a room size waiver, indicating that the rooms did not pose any risk to resident care. Observations and interviews conducted during the survey period revealed that residents had ample space to move freely within the rooms, and there was sufficient space for nursing staff to provide care. The maintenance supervisor demonstrated the method used to measure the rooms, which involved measuring from the window to the door for length and from the wall to the start of the closet for width. Despite the room size deficiency, staff interviews indicated no concerns regarding the room sizes, and the Vice President of Operations confirmed the facility's request for a continued room waiver, asserting that the room sizes did not impede resident care.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services as ordered for a resident with severe cognitive impairments and multiple diagnoses, including cerebral palsy and severe intellectual disabilities. The resident was prescribed Ciprofloxacin HCI Otic Solution for a suspected ear infection, but the medication was not administered for two days due to it being out of stock at the pharmacy. The delay in obtaining an alternative medication, Ofloxacin Otic Solution, contributed to the resident's condition worsening. The resident experienced increased redness, swelling, and severe pain on the right side of the face, along with a cream-colored foreign body in the right ear, which was later identified as maggots. This condition necessitated the resident's transfer to a General Acute Care Hospital for further evaluation. The facility's Director of Nursing acknowledged the delay in medication administration and the lack of timely follow-up with the pharmacy and physician. The facility's policies on unavailable medications and change of condition notification were not effectively followed, leading to a failure in ensuring the resident's needs were met. The Director of Nursing admitted that the ENT specialist should have been informed after the resident's repeated ear infections, and the nursing staff should have identified the worsening symptoms sooner.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the readmission of a resident after hospitalization, resulting in a deficiency. A resident, who was admitted with acute respiratory failure, hypertension, and dementia, was not allowed to return to the facility after a hospital stay. The resident's bed hold had expired, and the facility's Admission Coordinator informed the family that no female beds were available, despite the facility's census indicating otherwise. This led to the resident remaining in the hospital longer than necessary. The facility's policy stated that residents eligible for Medi-Cal/Medicaid should be readmitted to their previous room or the first available bed in a semi-private room if their hospital stay exceeded seven days. However, the Admission Coordinator admitted to reserving an available female bed for another resident, who also exceeded the bed hold period. This action was contrary to the facility's policy, which contributed to the resident's extended hospital stay and potential impact on her psychosocial wellbeing.
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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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