West Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in West Hills, California.
- Location
- 7057 Shoup Ave, West Hills, California 91307
- CMS Provider Number
- 055443
- Inspections on file
- 65
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 63
Citation history
Health deficiencies cited at West Valley Post Acute during CMS and state inspections, most recent first.
A resident with DM and neurologic deficits had a physician order for blood glucose monitoring before meals and at bedtime, with instructions to notify the physician for values below 70 mg/dl or above 300 mg/dl. An LVN documented a blood glucose of 335 mg/dl but did not notify the physician, later stating they became busy and failed to make the call. The DON confirmed there was no documentation of physician notification or nursing interventions for hyperglycemia, despite facility policy requiring prompt notification and documentation of changes in condition.
A resident with multiple serious conditions was admitted and prescribed several essential medications, which were not available for administration as ordered. Nursing staff documented the issue and contacted the pharmacy, but did not notify the physician about the missed doses, contrary to facility policy requiring prompt physician notification when medications are unavailable.
Two residents with cognitive and behavioral challenges were involved in a physical altercation after a dispute over television use, resulting in injuries to both. The facility did not implement interventions or care planning to address known behavioral triggers and roommate incompatibility, failing to follow its abuse prevention policy and leaving both residents unprotected from physical abuse.
A facility did not create a comprehensive care plan to address a resident's known behavioral triggers, such as sensitivity to noise and roommates' televisions, despite a history of severe cognitive impairment and psychosis. This omission led to a physical altercation between two residents, resulting in injuries, as no specific interventions were in place to prevent or manage the resident's behavioral outbursts.
Staff failed to provide privacy during indwelling urinary catheter care for two residents, leaving them exposed to the hallway or others during personal care. Both a CNA and an LVN admitted to not closing privacy curtains before care, despite facility policy and DON statements emphasizing the importance of resident dignity and privacy.
Residents were not given easy access to view survey results or to communicate with advocate agencies, as required. This deficiency was identified through observations that the necessary information was not made available to residents.
The facility did not keep copies of advance directives in the medical records for two residents with complex medical conditions, despite documentation in their POLST forms indicating such directives existed. During record reviews, staff were unable to locate the required documents, contrary to facility policy that mandates advance directives be readily accessible in the medical chart.
Staff failed to properly dispose of documents containing PHI, such as meal tickets with residents' names, room numbers, diet orders, and allergies, by discarding them in regular trash instead of a confidential shredding bin. This practice was confirmed by dietary staff and acknowledged as improper by the DON, who was previously unaware of the issue.
The facility did not develop care plans for two residents receiving antibiotics and failed to implement an existing diabetes care plan for another resident, resulting in unmanaged medication use and repeated elevated blood glucose levels. These deficiencies were confirmed through record reviews and staff interviews.
A resident did not receive the necessary care to maintain or improve ROM, limited ROM, or mobility, and the facility did not ensure appropriate interventions were in place unless a decline was medically unavoidable.
Staff failed to maintain straight, unobstructed urinary catheter tubing for two residents with indwelling catheters, resulting in dependent loops and urine backflow. Despite facility policy requiring unobstructed urine flow and frequent checks, observations and staff interviews confirmed that catheter tubing was not properly positioned, leading to improper drainage.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating a failure to maintain proper accuracy in medication administration.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Staff failed to use approved portion control utensils during meal service, resulting in some residents receiving less than the required amount of vegetables and others receiving more than the prescribed portion of sweet potato fries. The Dietary Supervisor confirmed that the correct procedures and equipment were not used, leading to inaccurate serving sizes.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature.
The facility did not prepare pureed foods, such as bread and beef, to the required consistency and shape for residents on a puree/level 4 diet. Instead, these foods were flat and did not hold their shape on the plate, as confirmed by the Dietary Supervisor and review of facility policies and recipes. This affected multiple residents who rely on pureed diets, making it more difficult for them to eat and potentially impacting their nutritional intake.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as observed by surveyors.
Surveyors found that a dumpster was overfilled, not fully covered, and surrounded by trash, including food spills and paper products. The DS and DON both confirmed that the dumpster should be kept closed and the area clean to prevent pests and contamination, in accordance with facility policy and the Food Code.
Staff failed to accurately and promptly document care for two residents, including urinary catheter care and the application of prescribed splints. In one case, an LVN provided catheter care but did not record it until hours later, and in another, a restorative nursing assistant documented splint application incorrectly. These actions resulted in medical records that did not accurately reflect the care provided, contrary to facility policy.
Staff failed to date oxygen tubing for a resident on oxygen therapy and did not label a urinary catheter system for another resident, contrary to facility protocols. Additionally, a CNA provided catheter care to a resident on enhanced barrier precautions without wearing the required isolation gown. These actions were confirmed by staff interviews and direct observation, with facility policies specifying the need for proper labeling and PPE use.
A resident with dementia, dysphagia, and a history of falls was found with their call light out of reach, despite care plan instructions and facility policy requiring accessibility. The CNA acknowledged forgetting to place the call light within reach, and the DON confirmed the importance of call light accessibility, especially for residents at risk of falls.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, resulting in a deficiency related to communication and notification procedures.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Diclofenac Gel for pain, but the facility did not act on the consultant pharmacist's recommendation to clarify the specific application site with the physician. As a result, nurses lacked essential information for proper pain management, contrary to facility policy.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery for residents.
Multiple rooms in the facility were found to provide less than the required 80 square feet per resident, with 28 three-bed rooms offering only about 78.5 square feet per resident. Despite this, residents and staff did not report concerns, and observations showed adequate space for movement and care. The deficiency was identified through measurement and record review, and the facility had submitted a waiver request acknowledging the shortfall.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents did not receive pain management services in accordance with professional standards. One resident was given acetaminophen outside the prescribed pain scale range without physician consultation, while another was administered PRN hydrocodone-acetaminophen without documented attempts at nonpharmacological interventions, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for daily activities was found in bed with the call light inaccessible, as it was tucked between the mattress and pillow. An LVN confirmed the call light was not within reach, contrary to facility policy requiring accessibility for safety.
A resident with multiple medical conditions and moderate cognitive impairment had a care plan meeting that did not include the required IDT members such as a physician, RN, or CNA. Instead, only the POA, an LVN, an occupational therapist, social services, and dietary staff attended. Facility staff confirmed this practice did not follow the facility's own policy, which mandates participation from a physician, RN, and CNA in such meetings.
A resident with multiple myeloma and bone cancer did not receive their prescribed Lenalidomide as ordered due to a transcription error, resulting in the medication being administered only once instead of daily for 21 days. The error occurred when a nurse misunderstood the hospital discharge instructions and was not caught during the required verification process by the RN supervisor.
The facility did not ensure that the attending physician completed and documented an H&P within 72 hours of admission for two residents with moderate cognitive impairment and significant care needs. In both cases, the H&Ps were completed several days late, resulting in incomplete medical records.
A resident with multiple myeloma did not receive their prescribed Lenalidomide chemotherapy as ordered due to a transcription error by a nurse, resulting in only one dose being administered during a 21-day cycle. The error was not caught by medication administration checks or supervisory review, and was ultimately discovered by the resident's family member.
A resident with severe cognitive impairment and multiple diagnoses had their missing bilateral hearing aids reported, but the facility failed to promptly investigate the issue. The social service assistant did not receive proper endorsement from the previous director, leading to a delay in addressing the resident's right to retain personal property, contrary to the facility's policy.
The facility failed to ensure the designated Administrator (DADM) held a current and active NHA license and did not complete the background check prior to employment. The DADM began working without an active license, and the background check was completed after the hire date, contrary to facility policies.
The facility failed to maintain copies of advance directives in the medical records of three residents, leading to potential confusion regarding their healthcare wishes. Residents with severe cognitive impairments and various medical conditions, including cerebral vascular disease and epilepsy, had advance directive acknowledgment forms but lacked the actual documents in their records. The absence of these directives was confirmed by the ADON and DON, despite facility policy requiring them to be accessible in the medical record.
A LTC facility failed to follow professional standards by not measuring a resident's heart rate before administering Losartan and not rotating insulin injection sites for another resident. These actions were contrary to physician orders and facility policies, placing residents at risk for adverse health outcomes.
The facility did not label various food items with a use-by date, as observed during an inspection with the Dietary Director. This oversight was acknowledged by both the Dietary Director and the DON, who emphasized the importance of labeling to prevent spoilage. The facility's policy requires dry foods to be labeled and dated when stored in bins.
A resident with intact cognition and a history of surgical amputation was prescribed Trazadone and Vraylar without documented informed consent, violating their right to be informed and make decisions about their medical care. The facility's policy required informed consent for psychotropic medications, which was not obtained, as confirmed by a registered nurse during a review of the resident's medical chart.
A facility failed to create a comprehensive person-centered care plan for a resident's activity needs. The resident, with conditions including hypertension, diabetes, and legal blindness, was dependent on staff for daily care. Despite this, no care plan was developed to address their activity preferences, as confirmed by the Activity Director, which is against the facility's policy.
A resident admitted with hypertension and long-term anticoagulant use received a physician's order for Apixaban, but the care plan for anticoagulant use was delayed by 30 days. The ADON confirmed the care plan should have been initiated when the medication was ordered, as per facility policy, to address the serious safety risks associated with the medication.
A facility failed to reassess a resident's pain level after administering oxycodone for moderate to severe pain. The resident, with a history of lower back pain and a spinal fracture, received the medication but lacked a documented pain reassessment within the required 30 to 60 minutes. Interviews with staff confirmed the oversight, which was against the facility's pain management policy.
A resident with chronic conditions and intact cognition did not receive necessary dental services, including fillings and a crown, due to a lack of timely follow-up and documentation. Despite a physician order for dental consult and treatment, the facility failed to adhere to its policy on providing routine and emergency dental services.
The facility failed to prepare pureed egg noodles according to its recipe for 14 residents on a pureed diet. A staff member used chicken broth and an unmeasured amount of milk, contrary to the recipe, and added an incorrect amount of stabilizer. The Dietary Director found the noodles unpalatable, and the DON highlighted the importance of following recipes to ensure nutritional value and palatability.
A facility failed to transmit a resident's Discharge MDS within the required 14 days after completion, as per CMS guidelines. The resident, admitted with a leg fracture, was discharged shortly after admission. The MDS was completed on the discharge date but submitted nearly two months later. The MDSN and DON acknowledged the delay, which could interfere with the resident's admission to another facility.
The facility failed to meet the federal regulation requirement of 80 square feet per resident in 27 out of 49 rooms, each accommodating three residents with a total area of 235.7 square feet. Despite the deficiency, residents had sufficient space for mobility and the use of assistive devices. The facility submitted a Room Variance Waiver, indicating no obstructions in the rooms.
A resident's room was found in an unclean state with various items scattered on the floor, including plastic wrappers and a soiled washcloth. Despite the resident's intact cognition and need for assistance with daily activities, the facility failed to maintain a clean and homelike environment, as confirmed by a CNA and the DON. This deficiency had the potential to impact the resident's quality of life and increase the risk of infection and accidents.
Failure to Notify Physician of Elevated Blood Glucose per Order
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of an elevated blood sugar level as required by the physician’s order and facility policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and had moderately impaired cognition. The Minimum Data Set indicated the resident could make self-understood and understand others but was dependent on staff for multiple activities of daily living. A physician order dated 1/2/2026 directed staff to monitor blood sugar before meals and at bedtime and to notify the physician if blood sugar was less than 70 mg/dl or greater than 300 mg/dl. On 1/19/2026, the Weights and Vitals Summary and the Medication Administration Record documented that an LVN recorded the resident’s blood sugar as 335 mg/dl at approximately 9:00–9:30 p.m., which exceeded the threshold for required physician notification. During interviews and concurrent record reviews, the DON confirmed there was no documentation of any nursing intervention for monitoring hyperglycemia symptoms or of physician notification regarding the elevated blood sugar. The LVN acknowledged awareness of the order to notify the physician for blood sugars greater than 300 mg/dl and stated that they became busy and did not notify the physician when the 335 mg/dl result was obtained. The facility’s policy on “Change in a Resident’s Condition or Status” required prompt notification of the attending physician and documentation of changes in the resident’s condition, which was not followed in this instance.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify a resident's physician when several critical medications—methimazole, albuterol sulfate, and ipratropium bromide—were unavailable for administration upon the resident's admission. The resident had multiple significant diagnoses, including fractures, acute respiratory failure with hypoxia, and anxiety disorder, and was determined to lack capacity for decision-making. Medication orders for these drugs were in place, but the medications were not available at the scheduled administration times. Licensed nursing staff documented the unavailability of the medications in the resident's medical record and followed up with the pharmacy, which indicated the medications would be delivered the following day. However, the physician was not notified of the missed doses. The LVN involved stated that he reported the issue to RN supervisors and documented the situation but did not contact the physician because he did not receive instructions to do so from the supervisors. Further review and interviews confirmed there was no documented evidence that the physician was informed about the medication unavailability. Facility policy required prompt notification of the physician and resident representative regarding changes in the resident's condition or status, including when medications are not available. The Assistant Director of Nursing confirmed that the physician should have been notified to determine an alternative plan.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions
Penalty
Summary
The facility failed to protect two residents from physical abuse when a physical altercation occurred between them. One resident, who had a history of not tolerating noise and demonstrated roommate incompatibility, became involved in a confrontation with their roommate over the use of a television. The altercation escalated when one resident turned off the other's TV, leading to a series of physical exchanges, including hitting with a closed fist and striking with a wheelchair footrest. Both residents sustained injuries, including scratches, cuts, and reported pain, requiring first aid and further medical evaluation. The facility did not follow its own policy and procedure regarding abuse prevention, which mandates protecting residents from abuse by anyone, including other residents. There was a lack of interventions in place to prevent the altercation, despite documented behavioral triggers and incompatibility between the two residents. Staff interviews confirmed that the altercation was avoidable and that the facility should have implemented measures to ensure a safe environment, particularly given the known behavioral history of one of the residents. Record reviews revealed that one resident had moderate cognitive impairment and required assistance with daily activities, while the other had severe cognitive impairment with psychotic disturbances. The care plan for the resident with behavioral triggers did not address these triggers or provide specific interventions to prevent outbursts. Staff acknowledged that a care plan should have been developed to address these issues, and the absence of such planning contributed to the occurrence of the physical abuse.
Failure to Develop Person-Centered Care Plan for Behavioral Triggers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the behavioral triggers of a resident with severe cognitive impairment and a history of behavioral disturbances. The resident, who was readmitted with diagnoses including unspecified dementia with psychotic disturbance and unspecified psychosis, was known to have anger triggered by environmental factors such as roommates' televisions being on or loud noises. Despite this, the care plan did not include specific interventions or measurable objectives to address these triggers, as confirmed by the Director of Nursing during record review and interview. An incident occurred in which the resident with behavioral triggers became involved in a physical altercation with his roommate. The altercation began after the resident turned off his roommate's television, leading to a series of escalating actions that resulted in both residents sustaining injuries. Staff interviews and documentation indicated that the resident's behavioral response was directly related to his known triggers, yet no individualized care plan interventions had been implemented to prevent such incidents. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, the interdisciplinary team did not create a care plan specific to the resident's behavioral triggers, and no interventions were in place to address or mitigate these behaviors, contributing to the occurrence of the altercation.
Failure to Provide Privacy During Catheter Care
Penalty
Summary
Facility staff failed to provide privacy during indwelling urinary catheter care for two residents, resulting in a lack of dignity and potential psychosocial impact. In the first instance, a certified nurse assistant provided catheter care to a resident with Alzheimer's disease, aphasia, and neuromuscular bladder dysfunction without closing the curtain or door, leaving the resident exposed to the hallway. The resident was dependent on staff for all activities of daily living and was able to communicate her needs. The CNA acknowledged forgetting to provide privacy and recognized its importance for resident dignity. The Director of Nursing confirmed that privacy should have been ensured by closing the curtain or door before care. In the second instance, a licensed vocational nurse performed catheter care for another resident with hypertension, depression, and neuromuscular bladder dysfunction without closing the privacy curtain. The resident was capable of understanding and making decisions. The nurse admitted that privacy should have been provided and acknowledged the potential for exposure to others. The Director of Nursing reiterated that all residents have the right to privacy and that failure to provide it could cause embarrassment or impact psychological wellbeing. Facility policies reviewed confirmed the requirement to protect resident privacy and dignity during care.
Lack of Access to Survey Results and Advocate Communication
Penalty
Summary
Residents were not provided with easy access to view the facility's survey results and were not given the means to communicate with advocate agencies. This deficiency was identified based on observations that the required information was not made readily available to residents as mandated.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that copies of residents' Advance Directives (ADs) were maintained in their medical charts and were easily retrievable, as required by facility policy. For two residents, documentation in the Physician Order for Life-Sustaining Treatment (POLST) indicated the existence of an AD, but during concurrent interviews and record reviews, the Medical Records Assistant was unable to locate physical copies of these ADs in the residents' medical records. The Director of Nursing confirmed that a copy of the AD should be present in the physical chart for staff access. Both residents involved had significant medical histories, including conditions such as congestive heart failure, dementia, diabetes, Parkinson's disease, and epilepsy. Assessments indicated that these residents required varying levels of assistance with activities of daily living and were generally able to understand and communicate with others. The facility's policy, last reviewed in June 2025, specified that copies of executed advance directives must be obtained and maintained in a designated section of the medical record, but this was not followed in these cases.
Failure to Protect Resident PHI During Meal Ticket Disposal
Penalty
Summary
The facility failed to protect the confidentiality of residents' personal and medical information by not ensuring that documents containing protected health information (PHI) were properly shredded before disposal. During an observation of the dishwashing process, a dietary aide was seen discarding residents' meal tickets, which included names, room numbers, diet orders, and food allergies, directly into the trash. The dietary supervisor confirmed that this was the standard practice and acknowledged that the meal tickets contained sensitive resident information. The supervisor also stated that these documents should have been placed in a confidential bin for shredding, as disposing of them in regular trash exposed residents' information and violated privacy regulations. Further interviews with the Director of Nursing (DON) revealed that the DON was unaware that kitchen staff were discarding diet tickets in this manner. The DON confirmed that such documents contain PHI and should be disposed of securely, either by shredding or by blocking out identifying information. A review of the facility's policies indicated that all personnel are responsible for protecting PHI and that health information should not be disclosed except as permitted by law. The observed practice of discarding meal tickets in the trash was inconsistent with these policies and resulted in a failure to safeguard residents' confidential information.
Failure to Develop and Implement Comprehensive Care Plans for Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to medication management and monitoring. For two residents with orders for antibiotics—one for Bactrim for infection prophylaxis and another for amoxicillin following a tooth extraction—there were no care plans created to address the use of these medications. The Infection Preventionist Nurse confirmed that care plans should be developed for each antibiotic order to identify treatment goals and interventions to monitor for potential side effects or adverse effects, but this was not done for either resident. Additionally, a third resident with diabetes mellitus had a care plan in place to manage blood glucose levels, including specific interventions such as administering insulin per sliding scale, monitoring blood sugar, and notifying the physician if levels were outside set parameters. However, the care plan was not consistently implemented or followed, as evidenced by multiple instances of blood sugar readings above 300 mg/dL documented in the Medication Administration Record over two months. The Director of Nursing acknowledged that the care plan should have been followed to address the resident's elevated blood sugars. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident, to be developed and revised as resident conditions change. Despite this, the facility did not ensure that care plans were developed for antibiotic use or that the diabetes care plan was properly implemented and followed, as confirmed by record reviews and staff interviews.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Maintain Proper Urinary Catheter Positioning and Drainage
Penalty
Summary
Facility staff failed to ensure proper urinary catheter care for two residents with indwelling catheters, resulting in catheter tubing being observed with dependent loops and backflow of urine. For one resident with Alzheimer’s disease, aphasia, and neuromuscular bladder dysfunction, the catheter tubing was found hanging below the bed with a large dependent loop containing yellow liquid and sediment that back flowed toward the urine drainage port. Staff interviews confirmed that the tubing was not straight and that urine was not draining properly into the collection bag. A second resident, diagnosed with hypertension, hyperlipidemia, depression, neuromuscular bladder dysfunction, and a history of urinary tract infection, was also observed with a dependent loop in the catheter tubing. Staff, including an LVN and RN, acknowledged that the tubing was not straight, urine was present in the loop, and urine was not able to drain into the collection bag. Both staff members stated that dependent loops or kinks could prevent proper drainage and potentially cause urine to backflow into the resident. The facility’s policy and procedure for urinary catheter care, reviewed by surveyors, required staff to maintain unobstructed urine flow and to check frequently that residents were not lying on the catheter and that tubing was free of kinks. Despite this policy, observations and staff interviews confirmed that the required practices were not followed for both residents, resulting in improper catheter positioning and urine backflow.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Menu and Portion Control Procedures During Meal Service
Penalty
Summary
The facility failed to follow its established menu and portion control procedures, resulting in improper serving of vegetables and sweet potato fries to residents. During lunch service, a staff member used a perforated spoon, which was not an approved utensil, to portion carrots and broccoli. This method did not ensure the correct portion size was served, as confirmed by the Dietary Supervisor, who stated that the correct utensil should have been a perforated spoodle. The use of the incorrect utensil meant that residents may have received less than the required amount of vegetables. Additionally, another staff member overfilled a number 8 scoop with sweet potato fries by mashing them in, resulting in servings that exceeded the prescribed 1/2 cup portion size. The Dietary Supervisor acknowledged that this practice was incorrect and could lead to residents receiving more than the intended portion. The facility's policy and procedure on portion control required the use of specific portion control equipment to ensure accurate serving sizes, but these procedures were not followed during the observed meal service.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Prepare Pureed Foods to Required Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree/level 4 diet. During observation and interview, it was noted that puree bread and puree beef served to these residents were flat and did not hold their shape on the plate, contrary to the requirements outlined in the facility's diet manual and IDDSI guidelines. The Dietary Supervisor confirmed that the puree foods should be of a pudding-like consistency, smooth, and able to hold their shape, but acknowledged that the items in question were not prepared to these standards. The facility's recipes and policies specify that pureed foods must be smooth, free of lumps, and able to hold their shape, and must pass IDDSI level 4 testing requirements, which was not achieved in this instance. This deficiency affected 18 out of 101 residents on a puree/level 4 diet, as the improperly prepared foods could impact their ability to eat using silverware and potentially result in decreased food intake. The facility's documentation and staff interviews confirmed that the pureed foods did not meet the required consistency and presentation, as they were runny and did not maintain their shape, which could make them less appetizing and more difficult for residents to consume.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or the condition of individuals at the time of the deficiency are provided in the report.
Improper Disposal and Maintenance of Garbage Dumpster
Penalty
Summary
Surveyors observed that one of three dumpsters used for garbage disposal was overfilled, not completely covered, and had trash, including salsa drippings, plastic cans, paper towels, and empty cups, scattered on the floor around it. The Dietary Supervisor confirmed during the observation that the dumpster should always be kept closed to prevent flies, insects, and rodents from approaching the facility and to avoid trash spilling onto the ground. The supervisor acknowledged the presence of salsa spills and other refuse on the floor and stated that such conditions could allow insects, rodents, and flies to access the facility and potentially contaminate residents' food. The Director of Nursing also confirmed that the dumpster cover was not closed and that trash was present on the ground around the dumpster. The DON stated that the dumpster cover should be kept closed and the area kept clean to prevent flies, rodents, and unauthorized individuals from accessing the trash and potentially spreading infection to residents. A review of the facility's policies and the Food Code 2022 indicated that outside dumpsters must be kept closed and free of surrounding litter to minimize odors, prevent attraction and breeding of pests, and avoid contamination of food and food service areas.
Failure to Maintain Accurate and Timely Medical Records for Resident Care
Penalty
Summary
The facility failed to maintain timely and accurate medical records in accordance with accepted professional standards for two residents. For one resident with a history of hypertension, hyperlipidemia, depression, and neuromuscular bladder dysfunction, there was an active physician order for urinary catheter care every shift. On one occasion, the assigned LVN provided urinary catheter care in the morning but failed to document the care at the time it was provided. The care was later documented in the electronic treatment administration record several hours after the actual provision of care, resulting in an inaccurate record of when the care was performed. Both the LVN and the Director of Nursing acknowledged that this inaccuracy could lead to confusion for subsequent shifts and did not reflect the care as ordered by the physician. For another resident with diagnoses including hemiplegia, dysphagia, muscle weakness, contracture, and dementia, there were physician orders and care plans for the application of a left resting hand splint and left elbow extension splint, as well as passive range of motion (PROM) exercises. Observations and interviews confirmed that the restorative nursing assistant performed PROM and applied the splints as ordered. However, the documentation in the RNA Documentation Survey Report inaccurately indicated that splints were applied to both arms, when in fact only the left arm required splinting. The Assistant Director of Nursing confirmed that the documentation was inaccurate for the dates reviewed and emphasized the importance of accurate records to reflect the care provided. The facility's policy and procedure on charting and documentation required that all treatments and services performed be documented objectively, completely, and accurately, including the date and time of the procedure or treatment. In both cases, the failure to document care accurately and in a timely manner resulted in medical records that did not reflect the actual care provided, as required by facility policy and professional standards.
Failure to Date Medical Equipment and Adhere to PPE Protocols During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. For one resident receiving oxygen therapy, the nasal cannula oxygen tubing was not labeled with a date, contrary to facility protocol which requires tubing to be dated and replaced regularly. The Infection Preventionist Nurse confirmed that the tubing was undated and stated that dating is necessary for staff to know when to replace it, as part of infection prevention measures. In another case, a resident with an indwelling urinary catheter system did not have the catheter tubing and urine collection bag labeled with the date, time, and initials at the time of placement. The Licensed Vocational Nurse acknowledged the omission and explained that proper labeling is important to track when the catheter and bag were last changed, in accordance with physician orders and facility policy. The Director of Nursing also confirmed that the equipment should have been dated and initialed at the time of placement. Additionally, a Certified Nurse Assistant was observed providing urinary catheter care to a resident on enhanced barrier precautions without donning an isolation gown, as required by the facility's policy for residents with indwelling medical devices. The CNA admitted to forgetting to wear the gown and recognized the importance of following enhanced barrier precautions to reduce the risk of infection. Facility policy and signage were in place to remind staff of the required personal protective equipment for such care activities.
Call Light Not Accessible to Resident with Fall Risk
Penalty
Summary
A deficiency was identified when a resident with diagnoses including unspecified dementia, dysphagia, and a history of falls was found to have their call light out of reach. The resident's care plan specifically required that the call light be kept within reach and that the resident be encouraged to use it for assistance. During an observation, the resident was seated in a wheelchair near the foot of the bed, while the call light was wrapped and hung on the opposite side rail, making it inaccessible to the resident. When interviewed, the CNA responsible for the resident admitted to forgetting to place the call light within reach and acknowledged that it should not have been left on the opposite side of the bed. The DON confirmed that all call lights should be accessible to residents at all times and noted the resident's increased risk due to a history of falls. The facility's policy also required staff to ensure call lights are accessible to residents, but this was not followed in this instance.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Clarify Medication Order Location Following Pharmacist Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation during the monthly Medication Regimen Review (MRR) for a resident who was prescribed Diclofenac Gel for pain management. The pharmacist's review specifically requested clarification from the physician regarding the exact location where the Diclofenac Gel should be applied. Despite this recommendation, the order remained unclarified, and the location of application was not specified in the resident's medical record. The resident involved had significant medical conditions, including diabetes mellitus and contact dermatitis, and was severely cognitively impaired, requiring total assistance with personal hygiene. The lack of clarification on the medication order meant that licensed nurses did not have the necessary information to know where to apply the medication, which was important for effective pain management. The facility's policy required timely communication and documentation of such recommendations, but these procedures were not followed in this instance.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide at least 80 square feet of space per resident in multiple resident bedrooms, as required by federal regulations. Specifically, 28 rooms housing three residents each were found to have only 235.7 square feet per room, resulting in approximately 78.5 square feet per resident, which is below the required minimum. This was confirmed through observation, interviews, and record review, including a waiver request letter from the Administrator acknowledging the deficiency. The rooms in question were equipped with beds, side tables, and resident care equipment, and allowed for freedom of movement and care provision, but did not meet the minimum space requirement. During the survey, no concerns were raised by residents or staff regarding the adequacy of room size, and general observations indicated that residents could move freely and that staff had sufficient space to provide care. The deficiency was identified based on the measured square footage and the number of residents per room, not on complaints or observed negative outcomes. The facility had previously submitted a written request for a continued waiver of the room size requirement.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Deficient Pain Management and Documentation for Two Residents
Penalty
Summary
Two deficiencies were identified regarding pain management for two residents. For the first resident, who had diagnoses including generalized arthritis, syncope, and chest pain, the facility failed to administer acetaminophen as prescribed. The physician's order specified acetaminophen for mild pain (pain scale 1-3), but the medication was administered when the resident reported a pain level of four. The Assistant Director of Nursing (ADON) confirmed that the medication should not have been given for a pain level outside the prescribed range and that the physician should have been contacted for an alternative order appropriate for the resident's pain level. For the second resident, who had diagnoses including Parkinson's disease, encephalopathy, and low back pain, the facility failed to ensure that licensed nurses attempted and documented nonpharmacological interventions before administering as-needed hydrocodone-acetaminophen for severe pain. The resident's care plan included non-medication interventions such as repositioning and distraction, but the Medication Administration Record (MAR) showed that these interventions were not documented as attempted prior to administering the narcotic medication on multiple occasions. The ADON acknowledged that nonpharmacological interventions should have been implemented and documented first, in accordance with facility policy. Both deficiencies were found to be inconsistent with the facility's policies on pain assessment and medication administration, which require medications to be given as prescribed and nonpharmacological interventions to be considered prior to administering narcotic pain medications.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident's needs and preferences by not ensuring that the call light was within reach for a resident who was dependent on staff for all activities of daily living and had severely impaired cognitive skills. During an observation, the resident was found in bed with the call light tucked between the mattress and pillow, making it inaccessible. This was confirmed during a concurrent interview and observation with a Licensed Vocational Nurse, who acknowledged that the call light was not within reach and stated it should always be accessible for safety. The resident involved had a history of intervertebral disc degeneration, muscle wasting and atrophy, limitations in activity due to disability, and adult failure to thrive. The Minimum Data Set assessment indicated the resident was dependent on staff for eating, hygiene, toileting, bathing, dressing, and mobility, and had severely impaired decision-making abilities. Facility policies reviewed indicated that staff are required to ensure call lights are accessible to residents in bed, on the toilet, in the shower, and on the floor, but this was not followed in this instance.
Failure to Ensure Required Interdisciplinary Team Attendance at Care Plan Meeting
Penalty
Summary
The facility failed to implement its policy and procedure regarding care planning by not ensuring that the required interdisciplinary team (IDT) members, including a physician, a registered nurse (RN), and a certified nurse assistant (CNA), were present during a scheduled care plan meeting for a resident. The care plan meeting, held within seven days of the resident's admission as required, was attended only by the resident's power of attorney (POA), an MDS nurse (who was a licensed vocational nurse), an occupational therapist, a social services staff member, and the dietary services supervisor. The absence of the physician, RN, and CNA was confirmed through interviews and review of the IDT Conference Notes. The resident involved had been admitted with multiple diagnoses, including generalized arthritis, syncope, type 2 diabetes mellitus, and depression. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for varying levels of staff assistance with activities of daily living such as eating, oral hygiene, showering, personal hygiene, and mobility. Despite these complex needs, the care plan meeting did not include the clinical staff members responsible for the resident's direct care and medical management. Interviews with facility staff, including the Social Services Director, Assistant Director of Nursing, and Administrator, confirmed that the facility's practice was not in alignment with its own policy, which requires the attendance of a physician, RN, and CNA at IDT meetings. The Administrator acknowledged the importance of having these disciplines present to address medical questions, discuss clinical progress, and provide input on daily care routines. The facility's policy, last reviewed shortly before the incident, clearly outlined the required IDT composition, but this was not followed during the resident's care plan meeting.
Failure to Accurately Transcribe and Administer Chemotherapy Medication Order
Penalty
Summary
The facility failed to provide resident-centered care by not accurately transcribing a physician's order for Lenalidomide, a medication prescribed for a resident with multiple myeloma and bone cancer. The resident, who had moderate cognitive impairment and required significant assistance with daily activities, was admitted with discharge instructions from a general acute care hospital to receive Lenalidomide 20 mg by mouth once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed as Lenalidomide 20 mg every 21 days instead of daily for 21 days on and seven days off. As a result of this transcription error, the resident received the medication only once during the specified period, with the medication administration record showing it was not given on the other days. The error was discovered after the resident's family questioned the remaining medication supply. The facility's policy required accurate recording of medication orders, including type, route, dosage, frequency, and strength, but this was not followed, and the error was not identified or corrected by the RN supervisor responsible for verifying admission orders.
Failure to Complete Timely Admission History and Physicals
Penalty
Summary
The facility failed to ensure that the attending physician completed and documented a History and Physical (H&P) within 72 hours of admission for two residents. For the first resident, who was admitted with diagnoses including primary generalized arthritis, syncope, and chest pain, the H&P was completed seven days after admission, exceeding the required timeframe. This resident had moderate cognitive impairment and required varying levels of assistance with daily activities. The Medical Records Director confirmed that the H&P was not completed within the required 72-hour window. For the second resident, admitted with Parkinson's disease, encephalopathy, and low back pain, the H&P was documented as a late entry and was signed nine days after admission. This resident also had moderate cognitive impairment and required assistance with daily care. The facility's policy requires that a completed and signed H&P be present in the medical record within 72 hours of admission, and the Director of Nursing or designee is responsible for auditing new admission charts to ensure compliance. The failure to complete timely H&Ps resulted in incomplete medical records for both residents.
Failure to Administer Chemotherapy Medication as Ordered Due to Transcription Error
Penalty
Summary
A deficiency occurred when a resident with multiple myeloma and bone cancer did not receive their prescribed medication, Lenalidomide, as ordered. The resident was admitted with instructions from the discharging hospital to receive Lenalidomide 20 mg orally once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed by a desk nurse as 'one capsule by mouth one time a day every 21 days,' rather than daily for 21 days. As a result, the resident received only one dose of Lenalidomide during the period from 5/16/2025 to 5/31/2025, with the medication administered only on 5/22/2025 and not on the other days as required. The error was not identified by the facility's medication administration checks or by the RN supervisor responsible for verifying admission orders. The mistake was discovered when the resident's daughter questioned the number of capsules remaining in the medication bottle. The facility's policies required medications to be administered as prescribed and for orders to be accurately recorded, specifying type, route, dosage, frequency, and strength, but these procedures were not followed in this instance.
Failure to Investigate Missing Hearing Aids
Penalty
Summary
The facility failed to implement its grievance policy by not investigating a report regarding a resident's missing bilateral hearing aids. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction, had severely impaired cognition and was dependent on staff for various personal care activities. Despite the report of the missing hearing aids being documented, the investigation was not completed promptly, leading to a delay in addressing the resident's right to retain and use personal property. Interviews with facility staff revealed that the social service assistant was aware of the missing hearing aids but did not receive an endorsement from the previous social service director, resulting in a lack of immediate follow-up. The facility's policy required prompt response and investigation of theft or misappropriation complaints, but this was not adhered to, as evidenced by the delayed completion of the investigation. The failure to act promptly on the missing hearing aids was acknowledged by the social service assistant and director, who recognized the negative impact on the resident's well-being.
Failure to Ensure Administrator Licensing and Background Check
Penalty
Summary
The facility failed to ensure that the designated Administrator (DADM) held a current and active license from the State to serve as a nursing home administrator (NHA). The DADM began working at the facility on 9/9/2024, and signed the job description for an Administrator, which required maintaining licensing credentials. However, a review of the California Department Public Health (CDPH) Licensing and Certification (L&C) Verification Search Page revealed no active and current NHA license for the DADM. Interviews with the Director of Nursing (DON) and the DADM confirmed that the DADM's license was pending and that the Executive Director (ED) was aware of the inactive status at the time of hire. Despite this, the DADM was performing the duties of an Administrator. Additionally, the facility did not implement its policy and procedures for ensuring the background check of the DADM was initiated and completed prior to employment. The DADM's background check was requested on 9/18/2024 and completed on 9/19/2024, after the official hire date of 9/9/2024. The Director of Staff Development (DSD) confirmed that the background check should have been completed before employment, as per the facility's policy and procedures. The facility's policies and procedures, last revised in 8/2024, stated that a licensed administrator is responsible for the day-to-day functions of the facility, and in their absence, the assistant administrator or director of nursing services is authorized to act on their behalf. The hiring policy, last reviewed on 6/26/2024, required that certifications and licenses be considered in determining an applicant's qualifications. The failure to adhere to these policies resulted in the DADM operating the facility without an active NHA license and without a completed background check prior to employment.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that copies of advance directives were kept in the medical records of three residents, leading to potential confusion and conflict with the residents' healthcare wishes. Resident 83, admitted with cerebral vascular disease, chronic kidney disease, and type 2 diabetes, had severely impaired cognition and was dependent on staff for daily activities. Despite having an advance directive acknowledgment form, the actual document was missing from the resident's clinical record, as confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). Similarly, Resident 49, admitted with a displaced fracture, epilepsy, and dysphagia, also had severely impaired cognition and was dependent on staff for assistance. The resident's care plan indicated the presence of an advance directive, but the document was not found in the clinical record. Both the ADON and DON acknowledged the absence of the advance directive in the resident's chart, which should have been available to guide staff in respecting the resident's wishes. Resident 18, who was legally blind and had hypertension and type 2 diabetes, also had an advance directive acknowledgment form but lacked the actual document in both electronic and physical records. The ADON confirmed the absence of the advance directive, emphasizing the importance of having it readily accessible to ensure the resident's healthcare wishes are followed. The facility's policy requires advance directives to be placed in a prominent, accessible location in the medical record, but this was not adhered to for these residents.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that a resident's heart rate was measured before administering Losartan, a medication used to treat high blood pressure. This deficiency was observed when a Licensed Vocational Nurse (LVN) prepared and administered Losartan to a resident without checking their heart rate, despite a physician's order to do so. The resident had a history of hypertension and was at risk for bradycardia, which could lead to dizziness and falls. The Assistant Director of Nursing confirmed that the nurse should have followed the physician's order to check the heart rate before administering the medication. Additionally, the facility did not consistently rotate insulin injection sites for another resident, as required by professional standards. The resident, who had type 2 diabetes mellitus, received insulin injections in the same areas repeatedly over a period of time. This practice was contrary to the resident's care plan, which specified that injection sites should be rotated to prevent complications such as lipodystrophy. Medical Records staff and a Registered Nurse reviewed the resident's diabetic administration record and confirmed that the injection sites were not being rotated as required. The facility's policies and procedures for administering medications and insulin were not followed, leading to these deficiencies. The policy for administering medications required checking vital signs when necessary, and the insulin administration policy required rotating injection sites. These lapses in following established protocols placed the residents at risk for adverse health outcomes.
Failure to Label Food with Use-By Dates
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling food items with a use-by date. During an observation and interview with the Dietary Director, it was noted that various food items, including instant pudding mixes, cornbread mixes, brownie mixes, cheesecake mixes, premium topping, seedless raisins, and soup boxes, were stored without a use-by date label. The Dietary Director acknowledged that the absence of such labels could potentially affect residents' health. Additionally, the Director of Nursing confirmed that food should always be labeled with a use-by date to prevent spoilage. A review of the facility's policy on food receiving and storage, dated November 2022, indicated that dry foods stored in bins should be removed from their original packaging, labeled, and dated.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for a resident, violating their right to be informed and make decisions about their medical care. The resident, who was admitted with orthopedic aftercare following surgical amputation and had intact cognition, was prescribed Trazadone and Vraylar without documented consent. The resident's medical records indicated that they had the capacity to understand and make decisions, yet the facility did not secure the necessary consents for these medications. During a review of the resident's medical chart, it was confirmed by a registered nurse that there was no medication consent for the use of Trazadone and Vraylar. The facility's policy required informed consent to be obtained and documented before administering psychotropic medications, which was not adhered to in this case. The facility's policy also emphasized the resident's right to be informed of their medical condition and participate in care planning and treatment, which was not upheld in this instance.
Failure to Develop Person-Centered Care Plan for Resident Activities
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 18, specifically regarding their activity needs. Resident 18 was admitted with diagnoses including hypertension, type 2 diabetes mellitus, and legal blindness. The Minimum Data Set (MDS) assessment indicated that Resident 18 had impaired cognitive skills for daily decision-making and was totally dependent on staff for personal care activities such as toileting, showering, dressing, and personal hygiene. During a review of Resident 18's care plans, it was found that no care plan had been developed to address the resident's activity preferences, which is a requirement according to the facility's policy. The Activity Director confirmed that a person-centered care plan should have been created to set goals and interventions tailored to the resident's needs, such as including strolls in the facility patio. The absence of such a care plan meant there were no established objectives or timetables to meet Resident 18's psychosocial and functional needs.
Delayed Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident within the required timeframe. The resident, who was admitted with diagnoses including hypertension and long-term use of anticoagulants, received a physician's order for Apixaban, an anticoagulant medication, on June 23, 2024. However, the care plan addressing the use of anticoagulants was not developed until July 22, 2024, which was 30 days after the medication was ordered. This delay in care planning was identified during a review of the resident's records and confirmed by the Assistant Director of Nursing (ADON). The ADON acknowledged that the care plan should have been initiated when the Apixaban was first ordered, as the medication carries a black box warning requiring specific interventions to mitigate serious adverse effects. The facility's policy on comprehensive person-centered care plans, last reviewed on June 26, 2024, mandates that such plans include measurable objectives and timetables to meet the resident's needs. The failure to timely develop the care plan had the potential to impact the resident's care, particularly in managing the risks associated with anticoagulant therapy.
Failure to Reassess Pain After Oxycodone Administration
Penalty
Summary
The facility failed to reassess the pain level of Resident 156 after administering oxycodone, a medication used to treat pain. Resident 156, who was admitted with diagnoses including lower back pain and a wedge compression fracture of the third lumbar vertebra, was prescribed oxycodone 5 mg to be taken every six hours as needed for moderate to severe pain. On a specific date, the resident received oxycodone at 9:47 a.m., but there was no documented evidence that the resident's pain level was reassessed 30 minutes to one hour after administration, as required by the facility's policy. Interviews and record reviews with the Minimum Data Set Nurse (MDSN) and Licensed Vocational Nurse 4 (LVN 4) confirmed the lack of pain reassessment documentation. The facility's policy on pain assessment and management, last reviewed in June 2024, mandates that acute pain should be reassessed every 30 to 60 minutes until relief is obtained. The absence of a documented pain reassessment increased the risk of Resident 156 experiencing untreated and prolonged pain.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, which placed the resident at increased risk for deterioration of oral hygiene and gum disease. The resident, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease and essential hypertension, had intact cognition and required supervision for personal care activities, including oral hygiene. A physician order for a dentistry consult with follow-up treatment as needed was noted upon the resident's admission. However, despite a dental note indicating the need for fillings and a crown, there was no documentation of approval for these treatments after a certain date. Interviews with facility staff revealed a lack of timely follow-up on the resident's dental care needs. The Social Service Director confirmed the absence of documentation regarding the approval for the resident's dental treatments, and the Director of Nursing acknowledged the importance of timely dental visits to prevent oral health deterioration. The facility's policy on dental services, revised in June 2024, stated that routine and emergency dental services should be available to meet residents' oral health needs according to their assessment and care plan, which was not adhered to in this case.
Improper Preparation of Pureed Egg Noodles
Penalty
Summary
The facility failed to prepare pureed egg noodles according to its established recipe for 14 residents on a pureed diet. During an observation, a staff member, identified as C1, was seen preparing the noodles using chicken broth and an unmeasured amount of milk, contrary to the facility's recipe which specified the use of milk only and no chicken broth. Additionally, C1 used an incorrect amount of stabilizer, adding eight ounces instead of the recommended seven to twelve tablespoons. This deviation from the recipe was confirmed by the Dietary Director (DD) during a review of the facility's puree pasta recipe. The Dietary Director later sampled the prepared egg noodles and found them unpalatable, noting an excessive use of stabilizer. The Director of Nursing (DON) emphasized the importance of following recipes to ensure the nutritional value and palatability of food, as deviations could affect residents' nutrition and potentially lead to weight loss. The facility's policy, dated June 2024, mandates that each resident is provided with a nourishing, palatable, and well-balanced diet that meets their nutritional and special dietary needs.
Failure to Timely Transmit Discharge MDS
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) within the required 14 days after the completion date, as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified for one resident, who was admitted to the facility with a right lower leg fracture and was discharged shortly after admission. The MDS, which is a standardized assessment and care screening tool, was completed on the resident's discharge date but was not submitted to CMS until nearly two months later. During interviews, the MDS Registered Nurse (MDSN) acknowledged that the MDS was submitted late and could not provide a reason for the delay. The Director of Nursing (DON) confirmed that the MDS should have been submitted within the 14-day timeframe to ensure CMS had an accurate assessment of the resident's condition. The facility's policy, which aligns with CMS's Resident Assessment Instrument (RAI) Manual, also requires timely submission of MDS assessments. The delay in submission had the potential to interfere with the resident's admission to another facility.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 27 out of 49 resident rooms met the federal regulation requirement of 80 square feet per resident in multiple resident rooms. During the recertification survey, it was observed that these rooms, which had an application for variance, did not meet the required square footage. Each of these rooms was designed to accommodate three residents, with a total area of 235.7 square feet, falling short of the minimum requirement of 240 square feet for a three-bedroom setup. This deficiency was identified through observation, interviews, and record reviews conducted during the survey. Despite the deficiency in room size, it was noted that the residents in these rooms had sufficient space for mobility and the use of assistive devices such as wheelchairs, walkers, or canes. The room variance did not appear to affect the care and services provided by the nursing staff. The facility had submitted an application for a Room Variance Waiver, indicating that the rooms did not have any obstructions that would interfere with free movement or the provision of care, health, safety, and dignity for the residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for one of the residents, identified as Resident 1. On August 28, 2024, the floor of Resident 1's room was observed to be soiled with multiple plastic wrappers, two plastic containers, one plastic spoon, several pieces of paper, and a soiled washcloth around the bed. Resident 1, who has been residing in the facility for several years, was unsure how long the items had been on the floor. The resident's medical history includes chronic obstructive pulmonary disease, paraplegia, schizophrenia, major depressive disorder, and anxiety. Despite having intact cognition and the capacity to understand and make decisions, Resident 1 required assistance with various daily activities, including setup or clean-up assistance with eating and moderate assistance with personal hygiene. The observations were confirmed by a Certified Nursing Attendant (CNA 1) and the Director of Nursing (DON), who acknowledged that the room did not meet the standards of a clean and homelike environment as per the facility's policy. The facility's policy emphasizes providing a safe, clean, and comfortable environment that reflects a personalized, homelike setting. The failure to maintain cleanliness in Resident 1's room had the potential to negatively impact the resident's quality of life and increase the risk of infection and accidents, as confirmed by the DON.
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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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