Westlake Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 316 S Westlake Avenue, Los Angeles, California 90057
- CMS Provider Number
- 056242
- Inspections on file
- 24
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Westlake Convalescent Hospital during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. The form lacked required selections and signatures from the legally recognized decision maker, and was signed only by the provider. Both nursing staff and the DON confirmed that the POLST was incomplete and not in accordance with facility policy, resulting in the resident's care preferences not being properly documented.
A resident with severe cognitive impairment and complex medical needs was transferred to a general acute care hospital, but staff failed to document the transfer in the medical record. The Clinical Manager confirmed the absence of required documentation, including the resident's clinical condition and vital signs at the time of transfer, resulting in incomplete records despite facility policy requiring thorough documentation of all services and changes.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Only a baseline care plan was created, and facility staff confirmed that no interdisciplinary team care plan was in place to address the resident's complex wound care needs, contrary to facility policy and regulatory requirements.
A resident with multiple Stage 4 and unstageable pressure ulcers did not receive weekly reassessments and documentation of their wounds as required by professional standards. The treatment nurse confirmed that scheduled weekly evaluations, including measurements and descriptions, were missed, and facility policies lacked clear guidance on reassessment frequency. This failure occurred despite the resident's high risk and dependence on staff for care.
The facility failed to provide proper catheter care for three residents, leading to potential health risks. One resident's urinary collection bag was not emptied as ordered, another's catheter bag was improperly placed above bladder level, and a third resident was not assessed for catheter removal after wound healing. These deficiencies were acknowledged by the facility's staff, highlighting risks of infection.
The facility failed to store Tuberculin PPD according to the manufacturer's recommendation, keeping it refrigerated after opening instead of at room temperature. Additionally, a vial of Latanoprost lacked an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within 60 days of opening, contrary to facility policy. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to follow food production recipes and fortified diet guidelines during lunch service. Fortified diets were not prepared or served to 10 residents, and six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles as per the menu. Interviews revealed a lack of a written fortified diet menu and an oversight in preparing pureed items, potentially leading to meal dissatisfaction.
The facility failed to maintain safe food storage practices, with improperly labeled thawing meats and significant ice buildup in the walk-in freezer. The Dietary Supervisor confirmed the labeling errors, and the Maintenance Supervisor acknowledged the potential contamination risk from the leaking freezer.
A resident with multiple health conditions, including hemiplegia and impaired cognition, was found to have their call light out of reach, potentially preventing them from calling for assistance. The care plan required the call light to be within reach, but during an observation, it was found hanging off the bed. A CNA and the DON confirmed the deficiency, acknowledging the risk of the resident being unable to call for help.
A facility failed to include a resident's advance directive in their medical chart, despite the resident having chronic respiratory failure, end-stage renal disease, and dementia. The resident lacked decision-making capacity, and the absence of the directive was confirmed by the Director of Social Services and the DON. Facility policy required advance directives to be in the clinical record, but this was not followed.
A resident with Korean as their primary language was unable to effectively communicate their needs due to the facility's failure to provide a Korean communication board within reach. Despite the care plan's directive, the board was placed in a bin by the room entrance, not at the bedside. Staff interviews confirmed the oversight, and the resident expressed difficulty in communicating with staff, often using gestures.
A resident who was ventilator-dependent and had severe cognitive impairment did not receive adequate oral care, as required by physician orders and care plans. Observations showed dry, flaky lips and crusty patches on the tongue, indicating neglect. Staff interviews confirmed the lack of consistent oral care, which is crucial to prevent infections, especially ventilator-associated pneumonia.
The facility failed to implement seizure precautions for two residents with epilepsy, as required by their care plans and physician's orders. Observations revealed that the residents' bedrails were not padded, despite the need for such precautions to prevent injury. Staff confirmed the absence of required safety measures, and the Director of Nursing acknowledged the oversight, which could lead to injuries during seizure activity.
A resident with chronic respiratory failure did not have their oxygen tubing changed weekly as required by their care plan and physician's order. Observations showed the tubing was overdue for replacement, posing a risk of infection. Interviews with staff confirmed the oversight, which was contrary to facility policies aimed at maintaining infection control.
A facility failed to ensure timely in-person visits by a physician for a resident, as required by regulations. The attending physician did not conduct an initial visit within 30 days of readmission, and subsequent visits were not alternated with a Nurse Practitioner every 60 days after the first 90 days. This resulted in incomplete care, as confirmed by the DON.
The facility failed to enforce its infection control policy, leading to deficiencies in hand hygiene and IV catheter management for two residents. A nurse did not perform hand hygiene between glove changes during skin care for a resident with severe cognitive impairment and multiple health conditions. Another resident's IV catheter was not labeled or clamped, increasing the risk of contamination. These actions violated the facility's infection prevention protocols, which emphasize hand hygiene as crucial to preventing infection spread.
A resident with multiple diagnoses, including dysphagia and severe protein-calorie malnutrition, experienced a delay in receiving a modified barium swallow study (MBSS) due to the facility's failure to follow up on insurance authorization in a timely manner. Miscommunication and errors in transportation arrangements further contributed to the delay, causing the resident to become angry and refuse meals.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete the Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was admitted with multiple complex medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was determined to lack capacity to make medical decisions, as documented in both the History and Physical and the Minimum Data Set, which indicated severely impaired cognitive skills and total dependence on staff for daily activities. Upon review, the resident's POLST form was found to be incomplete. Key sections of the form, including those addressing cardiopulmonary resuscitation, medical interventions, artificially administered nutrition, and the information and signatures section, were not filled out. The form was signed only by the provider and not by the resident's legally recognized decision maker, as required when the resident lacks capacity. The responsible registered nurse confirmed that the POLST should not have been signed by the provider alone and that all sections must be completed for the document to be valid. The Director of Nursing stated that it was the responsibility of the social worker and licensed nursing staff to ensure the POLST was fully completed. Facility policy also required that the provider confirm the orders with the resident or, if incapacitated, the legally recognized decision maker before signing. The failure to complete the POLST as required resulted in the resident's medical wishes not being properly documented or available to guide care in the event of an emergency.
Plan Of Correction
F-578 Corrective Action On 9/8/25, the Director of Nursing (DON) gave the Social Service Designee (SSD) an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
A deficiency occurred when the facility failed to document the transfer of a resident to a general acute care hospital (GACH) in the resident's medical records. The review of the resident's records showed that there was no documentation by facility staff indicating the transfer, despite a physician's telephone order for the transfer being present. The Clinical Manager confirmed during an interview and record review that the medical records were incomplete and not accurate, specifically noting the absence of documentation regarding the resident's transfer. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube placement. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities such as oral hygiene, toileting, and dressing. The resident did not have the capacity to understand or make decisions, as indicated in the history and physical and the Minimum Data Set (MDS) assessment. Facility policy and procedure documents reviewed indicated that all services provided, progress toward care plan goals, and any changes in the resident's condition should be documented in the medical record. However, in this instance, the licensed nurse did not document the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. This lack of documentation resulted in incomplete medical records for the resident.
Plan Of Correction
F-628 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. On 9/9/25, the Director of Nursing (DON) gave the transferring RN for Resident 1 an inservice about the facility's policy on discharge process. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. Identification of Others On 9/11/25, the DON and Clinical Manager assessed other discharge charts. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers. The resident was admitted with several stage 4 and unstageable pressure ulcers, as well as other significant medical conditions including a urinary tract infection and a gastrostomy tube. The resident was assessed as having severely impaired cognitive skills and was totally dependent on staff for daily care activities. Despite these complex needs, only a baseline care plan was created upon admission, and no comprehensive care plan was developed more than two months after admission. Interviews with facility staff confirmed the absence of a comprehensive care plan. The Clinical Manager acknowledged that while a baseline care plan was in place, there was no comprehensive care plan addressing the resident's multiple pressure ulcers. The Clinical Manager emphasized the importance of such a plan for guiding the monitoring and treatment of the wounds, noting that without it, there was no specific guidance for wound care. The Director of Nursing also confirmed that the baseline care plan is only valid for 14 days and that a comprehensive care plan should have been developed by the interdisciplinary team within that timeframe. A review of the facility's policy and procedure on comprehensive care plans indicated that care plans should be created for skin alterations, including pressure ulcers, and that goals should be realistic, measurable, and include a timeframe for re-evaluation. The failure to develop a comprehensive care plan for the resident's pressure ulcers was contrary to both regulatory requirements and the facility's own policy, resulting in a lack of documented, coordinated interventions for the resident's wound care needs.
Plan Of Correction
F -656 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Perform Weekly Pressure Ulcer Reassessments
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers did not receive care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers, was found to have not had their pressure ulcers reassessed and documented on a weekly basis as required. The treatment nurse confirmed that a scheduled weekly reassessment and documentation of the pressure ulcers, including type, location, measurement, and description, was not completed for one week. This omission was acknowledged during an interview and record review, where the nurse stated that such reassessments are necessary to determine the status and progression of the ulcers and to make any needed adjustments to the wound care plan. The resident in question had significant medical issues, including severely impaired cognitive skills, total dependence on staff for daily activities, and a history of pressure ulcers present upon admission. The baseline care plan and Minimum Data Set (MDS) documented the presence of multiple pressure ulcers and the resident's high risk for developing additional ulcers. Despite these risk factors and the need for close monitoring, the required weekly wound assessments were not consistently performed or documented. Further review of facility policies and the treatment nurse's job description revealed gaps in guidance regarding the frequency and documentation of pressure ulcer reassessments. The facility's policy did not specify the need for scheduled weekly reassessments to monitor the progression of pressure ulcers, and the job description did not require the treatment nurse to review and revise the care plan as needed for accurate wound care guidance. These omissions contributed to the failure to provide care consistent with professional standards for pressure ulcer management.
Plan Of Correction
F-686 Corrective Action On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. Identification of Others On 9/11/25, the DON and Treatment nurse reviewed other residents' weekly wound assessments and documentation. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the DON and/or designee will review 5 random charts of residents with wounds and review if they have completed their weekly wound assessment; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Deficient Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide proper care for residents with indwelling catheters, leading to potential health risks. For one resident, the staff did not empty the urinary collection bag as ordered by the physician. The resident reported that the bag had not been emptied since the previous day, and a CNA confirmed that the bag was full and had not been checked or emptied during the current shift. The Director of Nursing acknowledged this as a deficient practice, noting the potential for infection. Another resident's urinary catheter bag was improperly maintained above the level of the bladder, contrary to the facility's policy. An LVN confirmed the incorrect placement and acknowledged the risk of urinary tract infection due to potential backflow of urine. The Director of Nursing reiterated that the catheter bag should be placed below the bladder level to prevent infection. A third resident had an indwelling catheter placed for wound management, but there was no assessment for its removal after the wound had healed. An LVN stated that the catheter was no longer appropriate as the resident's pressure sore had resolved. The Director of Nursing confirmed that the resident should have been assessed for catheter removal to avoid unnecessary infection risk.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store Tuberculin purified protein derivative (Tuberculin PPD) according to the manufacturer's recommendation. During an observation, a vial of Tuberculin PPD was found in the medication refrigerator with an open date of 5/29/2024, despite the manufacturer's instructions to store it at room temperature after opening. This oversight was confirmed by RN 2, who acknowledged the discrepancy between the storage practice and the manufacturer's guidelines. Additionally, the facility did not adhere to proper labeling and disposal protocols for other medications. An open vial of Latanoprost was found without an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within the 60-day period after opening, as required by the facility's policy. LVN 5 and LVN 6 confirmed these lapses during interviews, and the Director of Nursing reiterated the importance of following the facility's policy and manufacturer's recommendations to ensure medication efficacy.
Failure to Follow Fortified and Pureed Diet Guidelines
Penalty
Summary
The facility failed to ensure that staff followed food production recipes and fortified diet guidelines during lunch service. Specifically, fortified diets, which are designed to increase caloric intake for residents who cannot consume adequate calories or protein, were not prepared or served to 10 residents who were on such diets. During a tray line observation, it was noted that the dietary aide communicated the fortified diet orders, but the staff member serving the food did not add any additional food items as per the fortified menu. Interviews with the dietary aide and the dietary supervisor revealed that there was no written fortified diet menu, and extra butter or gravy, which are typically added to increase calorie density, were not included in the meals served that day. Additionally, the facility did not adhere to the menu for residents on a pureed diet. Six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles with their meal as specified in the menu. During the tray line observation, it was found that only pureed hamburger, bread, and corn were served. An interview with the dietary supervisor and the staff member serving the food confirmed that there was a mistake, and the pureed items were not prepared or served as required. This oversight had the potential to result in meal dissatisfaction for residents on a pureed diet.
Deficiencies in Food Storage and Freezer Maintenance
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices, as observed during a survey. Two previously cooked and frozen roast pork items were found thawing in the walk-in refrigerator without a pull-out or thaw date, and a large turkey was labeled with the wrong thaw date. The Dietary Supervisor confirmed that the roast pork was removed from the freezer to thaw but was not dated correctly, and the turkey was mislabeled. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, which was not adhered to in these instances. Additionally, the walk-in freezer had significant ice buildup on the ceiling, condenser, and pipes, with icicles hanging above the food. A large pan filled with solid ice and water was observed, indicating a leak from above. The floor of the freezer was slippery with ice. The Dietary Supervisor acknowledged the issue and stated that an outside company was expected to fix it. The Maintenance Supervisor was informed of the problem and recognized the potential for contamination from the leaking water. The facility's sanitation policy requires equipment to be maintained in good repair, which was not the case here.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 22, which could potentially prevent the resident from calling for assistance when needed. Resident 22 was admitted with multiple diagnoses, including hemiplegia, blindness in one eye, and dependence on a wheelchair, and had moderately impaired cognition. The resident required substantial assistance with daily activities, including toileting and personal hygiene. The care plan for Resident 22 specified that the call light should be kept close and within reach to ensure the resident could call for help. During an observation, it was noted that Resident 22's call light was hanging off the bed and not within reach, and the resident was unable to locate it. A CNA confirmed the call light was not accessible and acknowledged the potential risk of the resident being unable to call for help. The Director of Nursing also stated that call lights should always be within reach to prevent residents from being unable to call for assistance. The facility's policy indicated that call lights should be easily accessible to residents when they are in bed or confined to a chair.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the resident's medical chart. This deficiency was identified for a resident who was admitted with chronic respiratory failure, end-stage renal disease, and dementia. The resident's physician history and physical indicated that the resident lacked the capacity to understand and make decisions, and the Minimum Data Set assessment showed moderately impaired cognition and dependence on multiple helpers for daily activities. During interviews, the Director of Social Services acknowledged that the resident's advance directive was not found in the clinical record, despite an acknowledgment form indicating its existence. The Director of Nursing confirmed that the advance directive should have been in the resident's chart to guide staff in honoring the resident's medical decisions. The facility's policy required that advance directives be placed in the clinical record when provided by the resident or their representative, but this was not adhered to in this case.
Failure to Provide Accessible Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to accommodate the communication needs of a resident whose primary language is Korean. The resident, admitted with conditions such as osteomyelitis, type 2 diabetes, and muscle weakness, required a Korean communication board to effectively communicate with staff. Despite the care plan indicating the need for a visual communication board at the resident's bedside, the board was found in a folder placed in a bin secured to the wall by the entrance of the resident's room, out of the resident's reach. This oversight was confirmed during observations and interviews with staff, including a Licensed Vocational Nurse and the Social Services Director, who acknowledged the importance of having the communication board accessible to the resident. Interviews with the resident, facilitated by translation services, revealed that the resident experienced difficulty communicating with staff due to the language barrier, often resorting to gestures. The Director of Nursing also confirmed that the communication board should have been near the resident's bedside to ensure easy access and facilitate communication. The facility's policy on accommodating communication deficits emphasized the need for care plans to reflect accurate and current assessments related to communication needs, which was not adhered to in this case.
Failure to Provide Oral Care for Ventilator-Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident who was completely dependent on staff for all activities of daily living, including oral hygiene. The resident, who had severe cognitive impairment and was dependent on a ventilator due to chronic respiratory failure, was observed with dry, flaky lips and off-white crusty patches on the tongue, indicating a lack of oral care. Despite physician orders and care plans specifying the need for oral care every shift to prevent infection, observations and staff interviews revealed that oral care was not consistently provided. Interviews with staff, including a CNA, a respiratory therapist, the Director of Staff Development, and the Director of Nursing, confirmed that the resident had not received proper mouth care for some time. The facility's policy required oral care to maintain oral hygiene and prevent infections, especially important for residents on ventilators to avoid ventilator-associated pneumonia. The deficiency was identified through observations and staff admissions that oral care was neglected, putting the resident at risk for infection.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to implement necessary seizure precautions for two residents, both diagnosed with epilepsy, which placed them at risk for injury. Resident 2, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a care plan that required padded side rails as a precaution against seizures. However, during an observation, it was noted that Resident 2's bedrails were not padded, contrary to the physician's orders and the care plan. Licensed Vocational Nurse 4 confirmed the absence of padding and acknowledged that it was required to protect the resident from harm. Similarly, Resident 20, who had moderate cognitive impairment and required substantial assistance for daily activities, also had a care plan that included seizure precautions such as padded side rails. Observations revealed that Resident 20's bedrails were not padded, and there were no pillows or wedge pillows in place as required. Licensed Vocational Nurse 1 confirmed the lack of padding despite having documented that the precautions were in place. The Director of Nursing acknowledged the failure to implement the physician's orders, which could lead to injuries during seizure activity. The facility's policy emphasized the importance of implementing interventions to reduce accident risks, which were not followed in these cases.
Failure to Change Oxygen Tubing as Per Care Plan
Penalty
Summary
The facility failed to adhere to the care plan and physician's order for Resident 2, who required oxygen therapy due to chronic respiratory failure and other conditions. The care plan specified that the resident's oxygen tubing should be changed every seven days to prevent infection and maintain cleanliness. However, observations revealed that the oxygen tubing had not been changed as scheduled, with the tubing dated 6/14/2024, indicating it was overdue for replacement by the time of the surveyor's observation on 6/21/2024 and 6/22/2024. Interviews with the respiratory therapist and the Director of Nursing confirmed that the tubing should have been changed weekly, and the failure to do so posed a risk of infection. The facility's policy and procedure documents supported the requirement for regular changes to maintain infection control. Despite these guidelines, the oversight in changing the oxygen tubing as per the care plan and physician's order resulted in a deficiency, highlighting a lapse in the facility's adherence to prescribed care protocols.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a physician completed in-person visits in a timely manner for a resident, as required by regulations. Specifically, the attending physician did not conduct an initial comprehensive visit within 30 days after the resident's readmission. Instead, a Nurse Practitioner (NP) completed the History and Physical (H&P) assessment. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the attending physician was required to perform the initial visit personally. Additionally, the facility did not adhere to the required schedule of alternating physician and NP visits every 60 days after the first 90 days of the resident's admission. The resident's progress notes from November 2023 to March 2024 were all completed by an NP, with no documented visits from the attending physician. The DON confirmed that the attending physician had not visited the resident since November 2023, which could lead to incomplete care. The facility's policy mandates that the attending physician must visit residents at least once every 30 days for the first 90 days and then at least every 60 days thereafter, with alternate visits by an NP allowed only after the initial 90 days.
Infection Control Deficiencies in Hand Hygiene and IV Management
Penalty
Summary
The facility failed to enforce its infection prevention and control policy, resulting in deficiencies related to hand hygiene and intravenous catheter management for two residents. For Resident 29, who was admitted with severe cognitive impairment and multiple health conditions including sepsis and chronic kidney disease, the facility did not ensure proper hand hygiene between glove changes during skin care procedures. Licensed Vocational Nurse 2 was observed changing gloves multiple times without performing hand hygiene, which is against the facility's policy and increases the risk of spreading infectious microorganisms. Resident 10, who had intact cognition and required assistance with daily activities, was receiving intravenous antibiotic treatment. The facility failed to label the intravenous catheter with the date of insertion and did not clamp the needleless lock system after use. This oversight was confirmed by Registered Nurse 1, who acknowledged that the open system could lead to cross-contamination. The Director of Nursing also confirmed that the facility's protocol requires labeling and clamping to prevent contamination. The facility's policy emphasizes hand hygiene as the primary means to prevent infection spread, stating that gloves do not replace the need for handwashing. The policy outlines specific instances when hand hygiene should be performed, such as between glove changes and after contact with a resident's skin or contaminated equipment. The failure to adhere to these protocols for both residents highlights a significant lapse in maintaining a safe and sanitary environment, as required by the facility's infection prevention and control policies.
Failure to Timely Follow Up on Insurance Authorization for MBSS
Penalty
Summary
The facility failed to follow up on insurance authorization for a modified barium swallow study (MBSS) in a timely manner for a resident, leading to a delay in service. The resident, who had multiple diagnoses including hemiplegia, COPD, dysphagia, and severe protein-calorie malnutrition, was admitted with a g-tube for feeding. Despite a physician's order for an MBSS, the facility did not ensure the authorization process was completed promptly, causing the resident to become angry and refuse meals. The resident's appointment for the MBSS was initially scheduled, but due to miscommunication and errors in transportation arrangements, the appointment was missed. The facility's business office assistant (BOA) faced difficulties in obtaining the necessary authorization from the insurance company, experiencing a runaround between the insurance company and the medical group. Despite multiple follow-up attempts, the authorization process was delayed, and the resident was not informed of the status in a timely manner. The resident expressed frustration and anger due to the delay in receiving the MBSS, which was necessary for evaluating the removal of the g-tube. The resident's refusal to eat the provided puree diet and the ongoing issues with the authorization process contributed to the resident's deteriorating mental state and increased agitation. The facility's failure to follow its own policy and procedures for timely follow-up on authorizations led to a significant delay in the resident's care and exacerbated the resident's distress.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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