Westgate Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 4525 W. Tulare Ave., Visalia, California 93277
- CMS Provider Number
- 555208
- Inspections on file
- 42
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westgate Gardens Care Center during CMS and state inspections, most recent first.
A resident was found to be sleeping on a low air flow therapeutic mattress with a dark brown circular stain. An LVN reported that the stain did not look appealing and that the mattress should have been changed. The DON and DOH later reviewed a photograph of the mattress and confirmed the dark brown stain, acknowledging it should have been removed and replaced. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
A resident with Parkinson's Disease, panic disorder, and severe cognitive impairment (BIMS score of 3) did not have a comprehensive, person-centered care plan addressing cognition. The DON confirmed that such a care plan was required but had not been developed, contrary to facility policy.
A resident with end stage renal disease missed a scheduled dialysis session due to transportation issues, and staff did not notify the attending physician as required by facility policy. Multiple staff interviews confirmed the lack of notification, despite established procedures for reporting missed treatments.
A resident with End Stage Renal Disease missed a scheduled hemodialysis treatment because transportation was not provided, and staff did not notify the transportation company as required by facility policy. Nursing staff either did not realize the resident was not picked up or failed to follow the expected procedure to address the missed transport.
A resident who required partial assistance for transfers was moved from a wheelchair to bed by a CNA and LVN without the use of a gait belt, contrary to facility policy. The improper transfer resulted in the resident landing face down on the bed. Staff interviews and documentation confirmed that the required gait belt was not used during the transfer.
A resident with dementia and hemiplegia reported being struck on the head by a CNA, an incident witnessed by a family member during a phone call. Although the CNA was removed from care and an internal investigation was started, facility staff did not report the abuse allegation to the Ombudsman, law enforcement, or state licensing agency as required by policy.
Staff did not follow the care plan for a resident with a history of verbally abusive behavior, resulting in the resident verbally and physically abusing another resident. Despite observing aggressive behavior, staff failed to intervene, allowing the situation to escalate and leading to physical harm and distress for the affected resident.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident was discharged home without home health services being arranged in advance, despite physician orders and discharge documentation specifying the need for physical therapy, occupational therapy, nursing, and durable medical equipment. The referral to home health was not sent until several days after discharge, and there was no evidence that the required services were coordinated prior to the resident leaving the facility.
A resident was found with lidocaine at the bedside without having been evaluated for self-administration, as required by facility policy. Nursing staff confirmed the medication was left accessible and that no physician orders or lock box were in place. The facility's policy mandates an interdisciplinary assessment before allowing self-administration, which was not completed in this instance.
A resident was issued a 30-day discharge notice for non-payment, but the facility did not notify the Ombudsman as required. The administrator stated notification was not needed since the resident did not dispute the discharge, and the Ombudsman confirmed they were unaware of the notice. Facility policy requires simultaneous notification to the Ombudsman when a discharge notice is given.
The facility failed to ensure Advance Directives (ADs) were offered and completed for two residents, potentially leading to their healthcare wishes not being honored. Resident 19 had no AD on file, and there was no documentation of it being offered or discussed. Resident 103 expressed interest in an AD, but no follow-up was documented. The facility's policy requires providing information about ADs, which was not followed in these cases.
The facility's arbitration agreement failed to explicitly state that residents or their representatives had the right to rescind the agreement within 30 days of signing. This was discovered during a review with the Admissions Director, revealing that 92 out of 138 residents had signed such agreements. The Administrator confirmed the omission, despite the facility's policy indicating a 30-day rescission period.
The facility did not document attendance for ten out of twelve QAPI meetings in 2024, as required. While meetings were held monthly, attendance records were only available for November and December. The facility's policy assigns the responsibility of maintaining meeting documentation to the QAPI Administrator, but this was not followed for most of the year.
Three residents experienced significant delays in having their call light requests answered, leading to discomfort and emotional distress. One resident waited up to two hours for assistance with changing a soiled brief, while two others waited over 15 minutes for toileting help. The facility's policies on prompt response and dignity were not adhered to, as indicated by ongoing issues noted in Resident Council Minutes.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their ability to call for assistance. Observations revealed that one resident's call light was tied to the bed rail, and another's was attached to the bed but not reachable. CNAs confirmed the call lights should be within reach, as per facility policy.
A facility failed to provide a functioning overhead light for a resident, compromising their right to a safe and comfortable environment. The resident, with moderate cognitive impairment, was unable to use the light due to a detached string. Despite being reported and marked as corrected in the maintenance log, the issue persisted, as confirmed by staff interviews.
A resident with mobility issues was not assisted by CNAs to attend scheduled smoking breaks, as outlined in their care plan. Despite being ready, the resident remained in bed without receiving the necessary help to reach the designated smoking area, contrary to facility policy.
A facility failed to properly label medications for a resident, leading to potential medication errors. A resident prescribed two types of insulin had mislabeled insulin pens, with one pen labeled with another resident's name. The DON confirmed that labels should match to prevent errors. The facility's policy requires correct labeling and contacting the pharmacy for mislabeled items.
The facility failed to accurately document meal consumption for two residents, leading to potential weight changes. One resident expressed dissatisfaction with the food and left most of the meal uneaten, yet it was recorded as 76-100% consumed. Another resident also left parts of the meal uneaten, but the consumption was similarly overestimated. The DSD and IPC confirmed the inaccuracies, noting only 25% was consumed in both cases.
The facility failed to report an allegation of sexual abuse between two residents to the proper authorities. A CNA observed inappropriate touching, but the required SOC 341 form was not sent to the Ombudsman. The DON admitted to not completing the form, and the Administrator could not provide evidence of notification. The facility's policy required immediate reporting, which was not followed.
A facility failed to implement a care plan intervention for a resident who had fallen in the restroom. The care plan required non-skid strips on the restroom floor, but they were not present during an observation. A CNA confirmed their absence, and the Maintenance Director, responsible for placing them, was unaware of the requirement. The ADON acknowledged the strips should have been placed. The facility's policy emphasizes ongoing assessments and revisions to care plans, which was not followed.
A resident with moderate cognitive impairment expressed discomfort with a specific CNA and requested that the CNA not return to his room. This request was reported to the LVN on duty but was not communicated to the oncoming staff, resulting in the CNA being reassigned to the resident. The facility's policy required immediate reassignment of staff in such cases, which was not followed.
A facility failed to notify a physician of a change in a resident's discharge plan, resulting in the physician being unaware of the resident's transfer to a hospital. The resident was initially planned for discharge with home health services, but the plan changed to a hospital transfer after a Medicare appeal was denied. The facility's policy required physician notification, but no documentation was found. Both the Administrator and DON acknowledged the oversight.
A resident with a history of falls and cognitive impairment experienced a fall resulting in a head injury and spinal fracture. Despite multiple falls, the facility failed to adequately revise the care plan, relying on insufficient interventions like bed positioning and call light accessibility. The only new measure added was placing mattresses beside the bed, which did not prevent further incidents.
The facility failed to implement a care plan for a resident at risk for falls by not ensuring the call light was within reach. The call light was found clipped to the wall, out of the resident's reach, contrary to the care plan and facility policies.
Failure to Provide a Clean Therapeutic Mattress
Penalty
Summary
Surveyors identified that the facility failed to provide a clean mattress for one of six sampled residents. On 2/8/26, a Licensed Vocational Nurse (LVN) observed that this resident’s low air flow therapeutic mattress had a dark brown circular stain and stated the stain did not look appealing and the mattress should have been changed. During a subsequent interview, the Director of Nursing (DON) and Director of Housekeeping (DOH) reviewed a photograph of the mattress taken on 2/8/26 and confirmed the presence of the dark brown stain, agreeing that the mattress should have been removed and replaced. As a result of this inaction, the resident slept on a stained mattress, with the report noting potential for skin irritation and respiratory issues. Review of the facility’s “Homelike Environment” policy dated 2001 indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance. The deficiency centers on the facility’s failure to ensure the resident’s mattress was clean and appropriately maintained in accordance with its own policy and procedure for providing a safe and clean environment.
Failure to Develop Care Plan for Cognition in Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing cognition for a resident with severe cognitive impairment. The resident had diagnoses of Parkinson's Disease and panic disorder, and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, a review of the resident's admission record and care plan revealed that no care plan had been created to address the resident's cognitive needs. During an interview and record review, the DON confirmed that a care plan should have been developed for the resident's cognitive impairment, but none was present. The facility's policy requires the interdisciplinary team to create and implement a comprehensive care plan with measurable objectives and timeframes for each resident, including those with cognitive issues. This process was not followed for the resident in question.
Failure to Notify Physician of Missed Dialysis Treatment
Penalty
Summary
The facility failed to notify the attending physician when a resident with end stage renal disease missed a scheduled dialysis treatment. The resident was scheduled for hemodialysis three times a week, and on one occasion, did not attend the treatment because transportation did not arrive. Review of the resident's clinical records confirmed the missed dialysis session, and interviews with nursing staff and the Director of Nursing revealed that the attending physician was not informed of the missed treatment, despite facility practice and policy requiring such notification. Interviews with multiple staff members, including two LVNs and an RN, confirmed that it was standard practice to notify the attending physician of any missed dialysis treatments. However, documentation and staff statements indicated that this notification did not occur. The facility's policy on changes in a resident's condition or status specifically required physician notification in the event of significant changes, such as missed treatments, but this protocol was not followed in this instance.
Failure to Ensure Transportation for Dialysis Appointment
Penalty
Summary
A resident with a diagnosis of End Stage Renal Disease, requiring hemodialysis three times weekly, missed a scheduled dialysis treatment due to a failure in transportation arrangements. The resident's clinical records and progress notes confirmed that the resident did not attend the scheduled dialysis session because the transportation service did not arrive to pick up the resident. Interviews with nursing staff revealed that the transportation company was not notified when the resident was not picked up, and staff were either unaware of the missed pickup or did not follow the facility's practice of contacting the transportation provider to determine the cause. The Director of Nursing confirmed that the expectation was for nurses to notify the transportation company in such situations, but this was not done. Review of the facility's policy indicated that the facility is responsible for helping arrange transportation for residents as needed. The failure to ensure transportation resulted in the resident missing a critical dialysis treatment.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of a gait belt during resident transfers for one of three sampled residents. According to the resident's Minimum Data Set, the individual required partial/moderate assistance for chair/bed-to-chair transfers. During a transfer from wheelchair to bed, the resident reported that the CNA and LVN did not transfer her correctly, resulting in her landing face down on the bed. Multiple interviews with facility staff, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that a gait belt was not used during the transfer, and the transfer was performed inappropriately. A review of the facility's policies indicated that a gait belt must always be used for any resident who is not completely independent, with no exceptions. The staff involved did not adhere to this policy, as confirmed by their own statements and the investigation findings. The incident was documented in the Facility Reported Event and progress notes, and the resident expressed that the staff were rough and did not transfer her correctly, leading to the incident.
Failure to Report Abuse Allegation to Required Agencies
Penalty
Summary
The facility failed to implement its own policy regarding the reporting of an abuse allegation involving a resident with multiple medical conditions, including metabolic encephalopathy, dementia, hemiplegia, and hemiparesis. The resident, who had moderate cognitive impairment, reported an incident where a CNA struck her on the head, causing her head to hit the bed's side rail. This incident was witnessed indirectly by a family member during a phone call and subsequently reported to facility staff. Upon learning of the allegation, facility staff, including the Director of Staff Development (DSD), Infection Preventionist (IP), Director of Nursing (DON), and the Administrator, were informed. The CNA involved was immediately removed from resident care, and an internal investigation was initiated. However, the staff did not report the allegation to any external agencies, such as the Ombudsman, law enforcement, or the state licensing agency, as required by the facility's policy and regulatory guidelines. The facility's policy clearly states that all allegations of abuse must be reported to the appropriate external agencies immediately, defined as within two hours for abuse allegations or those resulting in serious bodily injury. Despite this, the staff acknowledged during interviews that the required external reporting did not occur. The failure to follow the established reporting procedures constituted a deficiency in the facility's abuse prevention and response protocols.
Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
Staff failed to implement the care plan for a resident with a history of verbally abusive behaviors related to poor impulse control. The care plan included interventions such as gentle redirection when applicable. On the day of the incident, staff observed the resident invading another resident's personal space, appearing angry and aggressive, but did not intervene. This inaction allowed the resident to escalate, resulting in cussing at and physically hitting the other resident on the leg, as well as throwing the resident's belongings on the floor. Documentation and interviews confirmed that the resident had a moderately impaired cognitive status and had previously exhibited similar behaviors, including yelling and becoming upset with the roommate. Staff members present at the time either did not intervene or delayed intervention, despite being aware of the resident's behavioral history and the care plan interventions. The facility's policy required individualized behavioral interventions to address such behaviors, but these were not implemented during the incident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were arranged prior to the discharge of a resident. Physician orders indicated that the resident was to be discharged home with home health services, including physical therapy, occupational therapy, nursing, and durable medical equipment. The discharge summary also documented that these services and equipment were to be provided upon discharge. However, a review of the resident's progress notes revealed that the referral to home health was not sent until six days after the resident had already been discharged. During an interview and record review with the Social Service Director, it was confirmed that there was no evidence of home health being notified of the resident's discharge orders before the resident left the facility. The facility's policy required that discharge planning ensure the resident's health and safety needs were met and that arrangements for community care and support services were made prior to discharge. This process was not followed, resulting in the resident being discharged without the necessary home health services in place.
Medication Left at Bedside Without Self-Administration Evaluation
Penalty
Summary
A deficiency occurred when a resident was found with lidocaine, a medication used to relieve pain, left at the bedside without having been evaluated for self-administration. During observation, the resident was seen holding a washcloth to her mouth in apparent pain, with a medication cup containing a clear gel substance on her over-bed table. The resident reported that the nurse provided the lidocaine so she could use it when in pain. Licensed nursing staff confirmed that the medication was left at the bedside and acknowledged that an evaluation is required before a resident is permitted to self-administer medication. However, the resident had not been evaluated for this, nor were there physician orders or a lock box present as required by facility policy. Further interviews with nursing staff and the Director of Nursing confirmed that the resident did not have physician orders to self-administer medications and that the lidocaine should not have been left at the bedside. Review of the facility's policy indicated that an interdisciplinary team assessment is necessary to determine if self-administration is safe and appropriate, considering the resident's cognitive and physical abilities. In this case, the required assessment and procedures were not followed, resulting in the medication being accessible to the resident without proper authorization or safeguards.
Failure to Notify Ombudsman of Resident Discharge for Non-Payment
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when a resident was issued a 30-day notice of discharge for non-payment. The Notice of Proposed Transfer/Discharge (NPTD) was provided to the resident, citing non-payment of the share of cost assigned by Medi-Cal as the reason for discharge. The notice was signed by both the facility representative and the resident. However, the Ombudsman was not informed of the impending discharge, as required by facility policy and federal regulations. During interviews, the facility administrator stated that the Ombudsman was not notified because the resident did not dispute the discharge. The Ombudsman confirmed that their office was unaware of the discharge notice. Review of the facility's policy indicated that a copy of the discharge notice should be sent to the Ombudsman at the same time it is provided to the resident and their representative. This omission resulted in a failure to follow required notification procedures for resident discharge.
Failure to Ensure Advance Directives Offered and Completed
Penalty
Summary
The facility failed to ensure that Advance Directives (ADs) were offered and completed for two residents, which could potentially lead to their healthcare wishes not being honored. During an interview and record review, it was found that there was no documentation of an AD being offered or discussed with Resident 19 or their responsible party. The Nursing Consultant confirmed the absence of an AD on file for Resident 19. For Resident 103, the AD indicated interest in executing an AD, but there was no follow-up documentation. The Social Services staff acknowledged that Resident 103 had expressed interest in an AD, but no further action was documented. The facility's policy requires that residents or their representatives be provided with information about their rights to accept or refuse treatment and to formulate an AD, but this was not adhered to in these cases.
Arbitration Agreement Rescission Rights Not Explicitly Stated
Penalty
Summary
The facility failed to ensure its arbitration agreement explicitly stated that residents or their representatives had the right to rescind the agreement within 30 calendar days of signing. This oversight was identified during an interview and record review with the Admissions Director, where it was found that 92 out of 138 residents had signed arbitration agreements. The facility's Arbitration Agreement mentioned the possibility of rescission within 30 days but did not explicitly state the right to do so. The Administrator acknowledged that the agreement should have clearly indicated this right. Additionally, the facility's policy on Binding Arbitration Agreements, dated November 2023, stated that residents or their representatives are provided 30 days to review and rescind any agreement not understood at the time of admission.
Failure to Document QAPI Meeting Attendance
Penalty
Summary
The facility failed to document the attendance of required members at the Quality Assurance and Performance Improvement (QAPI) committee meetings for ten out of twelve meetings in 2024. During an interview and record review with the Administrator, it was revealed that while the facility held monthly QAPI meetings throughout 2024, attendance records were only available for the meetings in November and December. There was no documentation of attendance for meetings from January to October 2024. The facility's policy indicated that the QAPI Administrator is responsible for maintaining documentation of meeting minutes, but this was not adhered to for the majority of the year.
Delayed Response to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity, as they experienced significant delays in having their call light requests answered. Resident 97 reported waiting up to two hours for assistance with changing her soiled brief, which required the help of two staff members. This delay caused her discomfort and emotional distress. Resident 97 had a diagnosis of long-term complications from a stroke and required substantial assistance with hygiene. Similarly, Resident 34, who had Parkinson's Disease, reported waiting more than 15 minutes for assistance with toileting, which left him feeling upset. Resident 13, diagnosed with spinal stenosis, also experienced a delay of more than 15 minutes for help with changing her brief, resulting in discomfort and anger. The facility's Resident Council Minutes from the past few months indicated ongoing issues with CNAs not responding promptly to call lights, with residents expressing concerns about staff availability and willingness to assist. The facility's policy on answering call lights emphasized the importance of responding to residents' needs as soon as possible, and the dignity policy highlighted the prohibition of practices that compromise residents' dignity, including delays in toileting assistance. Despite these policies, the facility's failure to adhere to them resulted in residents experiencing discomfort and emotional distress.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could potentially result in their needs not being met. During an observation and interview, it was noted that Resident 42's call light was tied to the right side rail near the top of the bed, making it unreachable for the resident. Both Resident 42 and a Certified Nursing Assistant (CNA) confirmed that the call light was out of reach. Similarly, in Resident 101's room, the call light was attached to the bed but not within reach of the resident. CNA 2 also acknowledged that the call light should be within reach. The facility's policy, dated 2010, states that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Provide Functioning Overhead Light for Resident
Penalty
Summary
The facility failed to ensure a functioning overhead light was available for a resident, identified as Resident 37, which compromised the resident's right to a safe and comfortable environment. During an observation and interview, it was noted that the string to turn on the light above the resident's bed was detached, rendering the light unusable for personal use. The resident reported that the string had been broken for a couple of weeks, indicating a prolonged period without access to adequate lighting. The resident's Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment with a BIMS score of 11. Interviews with a Licensed Vocational Nurse and a Maintenance Assistant confirmed that the string should have been longer to allow the resident to operate the light. A review of the facility's Maintenance Log showed that the issue was reported by another LVN and was marked as corrected the day before the observation, suggesting a discrepancy between reported maintenance actions and the actual condition of the light.
Failure to Assist Resident with Scheduled Smoking Breaks
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as Resident 103, regarding smoking breaks. The care plan specified that Resident 103, who has muscle weakness and mobility issues, required assistance to and from the designated smoking area. However, on the day of observation, Resident 103 was not offered assistance to attend the scheduled smoking breaks. Despite being dressed and ready, the resident remained in bed and expressed that no staff had come to help him prepare for the smoke break. The facility's policy outlined specific smoking times and locations, and it was the responsibility of the CNAs to assist residents to these areas. During interviews, it was confirmed that the CNAs did not offer the smoking break to residents in the relevant hallway, including Resident 103. The facility's policy mandates that smoking is only permitted in designated areas outside the building, and the care plan emphasized the need for assistance, which was not provided, leading to a failure in meeting the resident's psychosocial needs.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medications for one of its residents, identified as Resident 83, which led to a potential risk of medication errors. During a review of Resident 83's records, it was found that the resident was prescribed two types of insulin: Insulin Lispro, a fast-acting insulin to be administered before meals, and Insulin NPH, an intermediate-acting insulin to be administered at bedtime. However, during an observation, a Licensed Vocational Nurse (LVN) discovered that the insulin pen intended for Resident 83 was mislabeled. The plastic bag containing the insulin pen was labeled with Resident 83's name but indicated Insulin NPH, while the pen inside was labeled as Insulin Lispro. Furthermore, a replacement insulin pen obtained from the medication room was also mislabeled, with the pen inside labeled with another resident's name. The Director of Nursing (DON) confirmed that the labels on insulin bags and pens should match to prevent residents from receiving the wrong type of insulin or another resident's medication. The facility's policy on medication labeling and storage requires that medications dispensed by the pharmacy be labeled in accordance with federal and state requirements and accepted pharmaceutical practices. The policy also states that if medication containers have incorrect labels, the dispensing pharmacy should be contacted for instructions on returning or destroying these items. This incident highlights a failure in the facility's medication management system, specifically in ensuring that medications are correctly labeled to prevent potential medication errors.
Inaccurate Meal Consumption Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document meal consumption percentages for two residents, Resident 93 and Resident 103, which could potentially lead to unplanned weight changes. During an observation and interview, Resident 93 expressed dissatisfaction with the food, stating she never ate 80% of her meals. Observations showed that Resident 93 left most of her meal uneaten, yet her meal consumption was inaccurately recorded as 76-100% consumed. The Director of Staff Development (DSD) and Infection Preventionist Consultant (IPC) reviewed the meal and agreed that only 25% was consumed. Similarly, Resident 103's meal consumption was inaccurately documented. Observations revealed that Resident 103 ate only a portion of the meal, leaving the salad and apple juice untouched. However, the meal consumption was recorded as 76-100% consumed. The DSD and IPC, upon reviewing the meal, concurred that only 25% was consumed. The facility's Dietary Intake Guide and policy on charting and documenting emphasize the need for accurate and complete documentation, which was not adhered to in these instances.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide a written report of an allegation of sexual abuse to the proper authorities for two residents. During an interview, the Ombudsman stated they did not receive the required SOC 341 form from the facility regarding the allegation of sexual abuse between the two residents. The incident was documented in Resident 2's Progress Notes, indicating that a CNA observed Resident 2 inappropriately touching Resident 1. The Licensed Vocational Nurse confirmed the observation, stating that the CNA saw Resident 2 with his hands on Resident 1's peri area. The Director of Nurses admitted to not filling out or sending the SOC 341 form to the Ombudsman. The Administrator, upon reviewing the mandated reporter pathway, acknowledged that law enforcement and the Ombudsman should have been notified immediately or as soon as practically possible by phone and with a written report within 24 hours of the alleged abuse. However, the Administrator could not provide documented evidence that the written SOC 341 was sent to the Ombudsman. The facility's policy and procedure required verbal and written notices to be submitted via special carrier, fax, email, or telephone, which was not adhered to in this case.
Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who had experienced a fall in the restroom. The care plan, dated January 11, 2024, specified that non-skid strips should be placed on the restroom floor to prevent further falls, with the intervention initiated on December 23, 2024. However, during an observation and interview on January 2, 2025, it was found that the non-skid strips were not present on the restroom floor. A Certified Nursing Assistant confirmed the absence of the strips, and the Maintenance Director, who was responsible for placing them, stated he was unaware of the requirement. The Assistant Director of Nursing acknowledged that the strips should have been placed following the care plan update. The facility's policy on comprehensive, person-centered care plans emphasizes the need for ongoing assessments and revisions to ensure residents' well-being, which was not adhered to in this instance.
Failure to Address Resident's Grievance Regarding CNA Assignment
Penalty
Summary
The facility failed to promptly address a grievance raised by a resident who expressed discomfort with a specific Certified Nursing Assistant (CNA). On August 26, 2024, after receiving care from CNA 1, the resident reported feeling uncomfortable and requested that CNA 1 not return to his room. This request was immediately communicated by CNA 2 to the Licensed Vocational Nurse (LVN) on duty. However, the LVN did not relay this information to the oncoming staff or take any action to ensure the resident's request was honored. As a result, when CNA 1 returned to work on August 30, 2024, he was again assigned to care for the resident, leading to the resident expressing his discomfort vocally. The Director of Staff Development (DSD) confirmed that the facility's policy required immediate reassignment of staff when a resident expressed discomfort, which was not followed in this case. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was entitled to have his grievances addressed promptly according to the facility's policy on resident rights.
Failure to Notify Physician of Change in Discharge Plan
Penalty
Summary
The facility failed to notify the physician when there was a change in the discharge plan for a resident, resulting in the physician being unaware of the resident's transfer to the hospital. The physician order dated two days prior to the discharge indicated that the resident was to be discharged with home health services, including physical therapy, occupational therapy, a registered nurse, a wound nurse, a home health aide, and a master of social work. However, the resident's responsible party was informed that the appeal for the Notice of Medicare Non-Coverage was denied, and the discharge plan was changed to transfer the resident to a hospital. The resident was transferred to the hospital via ambulance, and the responsible party signed the transfer discharge, discharge summary, and inventory of personal items. During interviews, both the Administrator and the Director of Nursing acknowledged that the physician should have been notified of the change in the discharge plan and that a new discharge order should have been written. The facility's policy and procedure for transfer or discharge indicated that the resident's attending physician should be notified in such cases, but there was no documentation of this notification in the resident's clinical record.
Failure to Revise Fall Care Plan for Resident
Penalty
Summary
The facility failed to revise and implement an appropriate plan of care for falls for a resident, which had the potential to cause serious harm. The resident, who had a history of falls and was generally confused, experienced a fall on 3/16/24, resulting in a head injury and a fracture of the L3 vertebra. Despite previous falls in the facility, the care plan was not adequately updated to address the resident's high risk of falling. The resident's medical records indicated a high fall risk score and cognitive impairment, as evidenced by an unassessable score on the Brief Interview for Mental Status. The resident required partial moderate assistance for various movements and had a history of attempting to get up independently, which was not effectively managed by the facility. The interventions in place, such as keeping the bed in the lowest position and ensuring the call light was within reach, were not sufficient to prevent further falls. The facility's Interdisciplinary Team (IDT) met multiple times to discuss the resident's falls but failed to implement new or effective interventions. The only new measure added to the care plan since January 2024 was placing mattresses on either side of the bed. The Director of Nursing acknowledged that the care plan should have been revised and suggested that moving the resident closer to the nurse's station could have been a more effective intervention.
Failure to Implement Care Plan for Call Light Accessibility
Penalty
Summary
The facility failed to ensure the care plan was implemented for a resident at risk for falls when the call light was not within reach. The care plan, dated 1/5/24, specified that the call light should be kept within reach of the resident. However, during an observation on 4/17/24, the call light was found clipped to the wall, out of the resident's reach. A Certified Nursing Assistant (CNA) had to unclip the call light and place it on the resident's abdomen for accessibility. The resident confirmed that the call light was used to call for help, and the CNA acknowledged that it should have been on the bed for easy access. The Director of Nursing (DON) also confirmed that the call light should have been close to the resident. A review of the facility's policy and procedure (P&P) on answering call lights, dated 10/10, indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. Additionally, the facility's P&P on comprehensive, person-centered care plans, dated 3/22, emphasized that care plans should describe services to help residents attain or maintain their desired level of wellbeing. The failure to follow these policies resulted in the resident's inability to call for assistance when needed.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
