Willow Creek Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clovis, California.
- Location
- 650 W. Alluvial, Clovis, California 93611
- CMS Provider Number
- 555652
- Inspections on file
- 35
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Willow Creek Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and previously intact cognition experienced an acute change in mental status, severe headache, lethargy, refusal of therapy, and refusal of all meals on a single day. The resident’s daughter reported these changes to an RN, who noted that the resident could nod and squeeze hands but had difficulty drinking and swallowing an oral medication. The RN placed a gloved hand in the resident’s mouth to check for the pill, did not remove or withhold the dose, and did not fully document or report the swallowing difficulty, meal refusals, or altered responsiveness to the physician. The ADON, called due to the daughter’s concern, only visually observed and did not perform an independent assessment. The SBAR completed by the RN omitted key assessment findings, resulting in incomplete information being relayed to the provider. Later in the evening, another RN documented profound lethargy and difficulty arousing the resident, notified the provider, and the resident was sent to the hospital, where a large intracranial hemorrhage and coma were diagnosed. Facility policies and staff interviews confirmed that these changes in condition should have been promptly recognized, thoroughly assessed, accurately documented, and clearly communicated to the physician.
A resident with multiple medical conditions was admitted without skin breakdown but developed a stage 2 pressure ulcer shortly after admission. Facility staff failed to consistently assess, measure, and document the wounds as required, leading to the progression of wounds to stage 4 pressure ulcers on both buttocks. The lack of timely intervention and inadequate wound management resulted in pain, loss of mobility, and the resident's inability to participate in rehabilitation, ultimately leading to discharge with ongoing wound care needs.
A resident with a history of sepsis and other chronic conditions did not receive IV antibiotics as prescribed, missing two doses and receiving ten doses late, with no documentation or monitoring for side effects or changes in condition. Nursing staff failed to report or document these medication errors as required by facility policy, and no audits or follow-up actions were recorded.
A resident with diabetes was admitted with a home medication list that included insulin, but nursing staff failed to verify or continue insulin therapy, did not communicate abnormal blood glucose readings or symptoms to the physician, and did not initiate change of condition protocols. The resident experienced several days of illness, developed DKA and sepsis, and required emergency hospitalization. Staff interviews and record reviews confirmed failures in medication reconciliation, documentation, and physician notification.
Multiple residents were found living in rooms with missing thresholds, unrepaired wall damage, torn wallpaper, blood stains, scuff marks, strong urine odors, and soiled curtains. Staff confirmed these conditions did not meet homelike standards, and some residents expressed frustration and emotional distress over unaddressed complaints. Several affected residents had significant medical and cognitive impairments, and the facility's own policy required a clean, orderly environment, which was not maintained.
Several residents did not have updated or individualized care plans to address their current medical needs, including discontinued isolation precautions, new medication regimens, high-risk pain management, and the safe coordination of oxygen therapy with smoking. Staff interviews and record reviews confirmed that care plans were either outdated or missing critical interventions, contrary to facility policy and professional standards.
Several deficiencies were identified, including a resident left with unattended medication without a self-administration assessment, incomplete oxygen therapy orders for another resident, missing required oxygen safety signage, improper insulin pen technique by an LPN for two residents, unlabeled and unprotected nebulizer tubing for a resident, and the lack of enhanced barrier precautions for a resident with an open wound. These actions and inactions by staff did not meet professional standards of quality.
Surveyors identified deficiencies in medication labeling and storage, including two residents' medications lacking required open dates, a resident's medication with an illegible label, and an unattended med cart left with keys and loose pills on top. Nursing staff and leadership confirmed these actions were not in line with facility policy, which requires proper labeling, dating, and secure storage of all drugs and biologicals.
Surveyors observed multiple failures in food storage and handling, including unlabeled and undated food items in the kitchen refrigerator, a cook not checking food temperature before serving, and a resident keeping perishable food at bedside for an extended period. Staff confirmed that these actions did not follow facility policy or food safety standards, potentially exposing residents to foodborne pathogens.
The facility did not follow its policy for food-related garbage and refuse disposal, as all outside trash bins were left uncovered and surrounded by litter. Staff interviews confirmed that bins should be closed and free of trash on the ground, in line with facility policy.
Several residents were not provided with adequate privacy during direct care activities, including blood pressure checks, blood sugar monitoring, insulin administration, and urinary catheter management. Staff failed to close privacy curtains or doors, leaving residents exposed to view by others, and a urinary catheter bag was left uncovered and visible. These actions were acknowledged by staff as violations of resident dignity and facility policy.
Two residents were involved in an altercation where one, diagnosed with dementia, caused a skin tear to another by throwing a metal object. The incident was reported to the Ombudsman and local law enforcement, but not to the state agency as required by federal regulations. Facility staff and leadership believed state guidance only required reporting to the Ombudsman and law enforcement when dementia was involved and no serious injury occurred, resulting in the failure to notify the state agency about the alleged abuse.
A resident's MDS assessment did not accurately reflect their use of antianxiety medication and a diagnosis of migraine, as these were not coded despite being present in the medical orders. The MDS nurse acknowledged the omissions, and both the DON and Administrator confirmed that it was the MDS nurse's responsibility to ensure all relevant medications and diagnoses were included in the assessment.
A resident with multiple diagnoses, including dementia and Parkinson's Disease, was admitted for hospice care, but the required PASRR assessment was not completed following this significant change in condition. Facility staff confirmed that it was their policy to conduct a PASRR assessment in such situations, but the assessment was missed.
A resident admitted with a lumbar fracture and bronchiectasis was observed receiving oxygen therapy and prescribed ciprofloxacin, but no baseline care plan was developed within 48 hours to address these immediate needs. Staff interviews and facility policy confirmed that care plans for oxygen and antibiotics were required but not implemented, resulting in a lack of documented interventions for the resident.
A resident with a history of congestive heart failure, polyneuropathy, and muscle weakness was observed smoking without being offered a required smoking apron, resulting in ashes falling on her clothing and wheelchair. Staff present did not follow the facility's smoking policy, which mandated supervision and the use of adaptive equipment to prevent burns, thereby placing the resident's safety at risk.
Two residents did not receive food prepared in the form required by their physician-ordered diets: one was served a banana that was not fully pureed despite a pureed diet order, and another was served minced meat instead of regular texture as ordered. Staff interviews and record reviews confirmed that the correct diet textures were not provided, contrary to facility policy and job expectations.
A resident with severe cognitive and physical impairments was found without access to a functioning call light, as the tap button was hanging from the bed rail and out of reach. Staff interviews and documentation confirmed that the call light should have been accessible at all times, especially for residents with mobility limitations, but this was not ensured in this case.
The facility failed to ensure call lights were accessible for two residents, as observed during a survey. One resident's call light was wrapped around the assist bar, making it unreachable, while another's was found on the floor. The DSD confirmed these issues and repositioned the call lights. Both residents' care plans and facility policy emphasized the importance of keeping call lights within reach, especially for those at high risk for falls.
The facility failed to maintain infection control in shower areas, with observations of used gloves, hair, and debris in drains, and feces on floors. Housekeeping staff admitted the areas were not clean, and the Administrator and DON acknowledged the risk of cross-contamination. Facility policies for daily cleaning and disinfection were not followed.
A resident in a LTC facility, who was cognitively intact, experienced abuse when a CNA checked his brief without consent, touching his genitals. Despite the resident's refusal, the CNA repeated the action, leading to feelings of violation and disrespect. The incident was not properly documented or reported by the LVN and ADON, contrary to facility policies on abuse prevention and reporting.
A resident reported feeling violated by a CNA, but the incident was not reported to authorities within the required 24-hour timeframe. The LVN and ADON failed to investigate or document the incident properly, leading to a delay in addressing the resident's complaint. The facility's policies and state regulations mandate timely reporting of such allegations, which was not followed in this case.
A resident experienced an acute change in mental status, loss of appetite, and weakness, which were reported by a CNA to an LVN. However, the LVN did not assess the resident or notify the physician, leading to a delay in medical intervention. The resident was later diagnosed with an acute ischemic stroke and placed on hospice care due to the delay in treatment.
A CNA in an LTC facility failed to wear proper PPE and perform hand hygiene while caring for a resident with COVID-19, immunodeficiency, and chronic myeloid leukemia. Despite the presence of a sign indicating enhanced barrier precautions, the CNA did not wear a gown or clean hands after handling dirty linen and repositioning the resident. The facility's policies require PPE use to prevent the spread of MDROs, but the CNA's actions showed a lapse in protocol adherence.
A facility failed to assess a resident for the risk of entrapment from bed rails prior to their installation. The resident had no entrapment risk assessment, physician order, or care plan in place for the use of the bed rails, despite facility policy and professional standards requiring these measures. This failure placed the resident at risk for decreased freedom of movement, entrapment, and/or injury.
A resident with chronic obstructive pulmonary disease and other conditions did not receive the prescribed oxygen flow rate due to an empty portable oxygen tank and incorrect settings. The LVN confirmed the error, and the DON acknowledged that the facility's policies were not followed.
Failure to Recognize and Report Acute Change in Condition and Swallowing Difficulty
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete physician notification and accurate assessment/documentation of a resident’s acute physical and mental status changes. An 81‑year‑old resident admitted for rehab after a motor vehicle accident had multiple diagnoses including diabetes mellitus II, hypertension, atrial fibrillation, hypothyroidism, neuromuscular bladder dysfunction, and multiple fractures. On admission and in subsequent assessments, she was documented as alert and oriented, with a Glasgow Coma Scale of 15 and a BIMS score of 13, indicating she was cognitively intact, able to speak in full sentences, make her needs known, and eat independently with tray setup. Therapy and nursing notes prior to the incident described her as motivated, vocal, and actively participating in PT/OT, with meal intake generally ranging from 26–100%. On the morning in question, the resident’s daughter arrived shortly after 10 a.m. and observed that the resident was not her usual self, reporting an excruciating headache, refusing therapy, and refusing to eat. The daughter stated the resident, normally eager to converse and participate in therapy, did not want to talk and later fell asleep around lunchtime. Documentation later showed the resident refused breakfast, lunch, and dinner that day, a change from her prior intake, but these refusals were not communicated to the RN by CNA staff and were not reported to the physician by the RN. When RN 1 entered the room before 2 p.m. to administer scheduled sodium chloride, the daughter voiced concerns about the resident’s condition. RN 1 attempted to wake the resident, noted that she could nod yes/no and squeeze hands on command, and proceeded to administer oral medication and soda via straw despite the resident’s difficulty drinking and swallowing. RN 1 documented that the resident sucked on the medication and did not swallow it, prompting RN 1 to place a gloved hand into the resident’s mouth to feel for the pill until she believed it was swallowed. This action was later described by the DON and ADON as not standard practice and not taught in the facility. RN 1 did not document or report to the physician that the resident had difficulty swallowing, that a mouth sweep was performed, or that meals had been refused. The SBAR completed by RN 1 that afternoon lacked a full assessment and omitted key findings such as altered mental status, swallowing difficulty, and meal refusals. The ADON, who was called to the room due to the daughter’s concern, only visually observed while RN 1 assessed the resident and did not perform an independent physical assessment. The DON, MD, and RN 1 all later acknowledged that the physician was not provided with a complete and accurate clinical picture of the resident’s change in condition, including the acute neurological and swallowing changes that represented a significant deviation from her baseline. The resident’s condition continued to decline throughout the day until the evening nurse (RN 2) performed a more detailed assessment, documented lethargy, difficulty arousing, decreased responsiveness, and abnormal oxygen saturation, and then notified the provider, who ordered transfer to the hospital, where the resident was diagnosed with a large intracranial hemorrhage and coma. The facility’s own policies required nurses to notify the physician for significant changes in physical, emotional, or mental condition, including refusal of treatment, and to gather and communicate detailed, pertinent information prior to notification. Policies and job descriptions also required licensed nurses and CNAs to identify, document, and report changes in condition, and for RNs to ensure nurses’ notes were informative and accurately reflected the resident’s response to care. Interviews with the LVN, CNA, MD, DON, and RN 2 confirmed that changes such as altered mental status, lethargy, refusal of meals, difficulty swallowing medications, and deviations from baseline communication and activity should be promptly assessed, documented, and reported using tools like SBAR. In this case, the facility failed to ensure that staff recognized and escalated the resident’s acute neurological and swallowing changes, failed to ensure accurate and complete documentation of those changes, and failed to ensure that the physician received a full and accurate description of the resident’s condition in a timely manner. Professional references cited in the report emphasized that altered mental status requires early recognition, thorough history and physical examination (including neurologic assessment), and close communication among healthcare providers, and that clear, complete nurse‑physician communication is essential for safe patient management. The DON also referenced a standard of practice document indicating that when a patient is unable to swallow medication and the nurse must retrieve or assess for medication in the mouth, the dose should be removed and withheld and the provider notified immediately. The DON stated this did not occur with RN 1, and that RN 1 failed to conduct and document a full neurological assessment and failed to provide the primary physician with a complete and accurate assessment of the resident’s acute change in condition on the day in question.
Failure to Prevent and Manage Pressure Ulcers Resulting in Harm
Penalty
Summary
A resident was admitted to the facility with multiple complex medical conditions, including a cervical vertebral fracture with surgical intervention, impaired mobility, idiopathic peripheral autonomic neuropathy, ankylosing spondylitis, cirrhosis of the liver, muscle weakness, and neuromuscular dysfunction of the bladder. Upon admission, a full body assessment was completed, and no open skin areas were noted on the buttocks. The resident was identified as being at mild risk for skin breakdown, and standard interventions such as turning and repositioning every two hours were implemented. Despite these interventions, a stage 2 pressure ulcer was identified on the resident's left buttock three days after admission. The facility failed to implement effective interventions to prevent the progression of the pressure ulcer, and weekly wound measurements and detailed documentation were not consistently performed as required by professional standards and facility policy. The treatment nurse did not measure the wound weekly, and there was a gap in wound assessment and documentation from late May to early June. During this period, the wound worsened, and a second wound developed on the right buttock. The wound specialist was not consulted until over a month after the initial wound was identified, and by that time, the left buttock wound had become unstageable and the right buttock had developed shearing and a new pressure ulcer. The lack of timely and thorough wound assessment, documentation, and intervention led to the progression of the resident's wounds to stage 4 pressure ulcers, resulting in pain, suffering, and loss of mobility. The resident reported that the wounds interfered with his ability to participate in physical therapy and rehabilitation, leading to a decline in his physical and emotional well-being. The resident ultimately decided to discharge home with ongoing wound care needs, including a wound vac, after expressing concerns that the facility did not act promptly to address his wounds or psychosocial needs.
Failure to Administer IV Antibiotics as Prescribed and Monitor for Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during their stay. The resident, who had a complex medical history including sepsis, chronic kidney disease, diabetes, and morbid obesity, was admitted from a hospital with orders for intravenous (IV) antibiotic therapy (ertapenem sodium) to be administered daily. Despite these orders, the resident missed two doses of the antibiotic and received ten doses more than an hour past the prescribed time. There was no documentation that these medication errors were reported to the Director of Nursing, the primary care physician, or the responsible party, as required by facility policy. Nursing staff did not document or monitor for side effects during the administration of the IV antibiotic, nor did they conduct or record change of condition assessments following the missed or late doses. The facility's policies required that all medication errors be documented, reported, and reviewed, and that any change in a resident's condition, including missed or late medication doses, be communicated to the appropriate parties and recorded in the resident's medical record. However, interviews with nursing staff and the DON confirmed that these steps were not taken, and no audits or follow-up actions were documented regarding the missed or late doses. The lack of timely administration and monitoring of the IV antibiotic, as well as the failure to follow established protocols for reporting and documenting medication errors and changes in condition, resulted in the resident not receiving antibiotics as prescribed. This had the potential to contribute to the resident's subsequent transfer to a general acute care hospital. The facility's failure to adhere to its own medication administration and change of condition policies was confirmed through interviews, record reviews, and policy examination.
Failure to Recognize and Act on Change in Condition for Diabetic Resident
Penalty
Summary
The facility failed to recognize and appropriately act on a change in condition for a resident with a known diagnosis of diabetes mellitus type II. Upon admission, the resident's family provided a list of home medications, which included insulin, to the admission nurse. However, the nursing staff did not verify or clarify the continuation of insulin therapy with the primary care provider, nor did they document any communication regarding the resident's medication regimen. As a result, the resident did not receive insulin during their stay, despite having a care plan that identified diabetes and the need for monitoring and management of blood glucose levels. Throughout the resident's stay, blood glucose checks were performed three times daily, revealing values ranging from 79 mg/dl to 389 mg/dl, which were outside the normal range for diabetic management. Despite these abnormal readings and the resident experiencing symptoms such as nausea and malaise, there was no documentation that the nursing staff notified the primary care provider or initiated a change of condition protocol. The facility's policies required notification of the physician for significant changes in condition and for abnormal blood glucose readings, but these procedures were not followed. The resident's condition deteriorated over several days, culminating in severe symptoms including hypotension, nausea, vomiting, and malaise. The resident was ultimately transferred emergently to an acute care hospital, where they were diagnosed with uncontrolled hyperglycemia, diabetic ketoacidosis (DKA), and sepsis, requiring a nine-day hospitalization. Interviews with facility staff, including the DON, LVN, RN, and ADON, confirmed that medication reconciliation was not completed, insulin orders were not clarified or administered, and abnormal blood glucose results were not communicated to the physician, all of which contributed to the resident's acute medical crisis.
Failure to Maintain a Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for eight of sixteen sampled residents. Observations revealed multiple deficiencies in resident rooms, including missing thresholds, unrepaired holes and dents in walls, torn and missing wallpaper, blood stains and scuff marks on walls, strong urine odors, and curtains with blood stains left hanging. These environmental issues were directly observed by surveyors and confirmed by staff interviews, with both the Infection Prevention Nurse and the Director of Maintenance acknowledging that these conditions did not meet homelike standards and posed potential hazards such as tripping and fire risks. Several residents affected by these deficiencies had significant medical and cognitive impairments. For example, one resident with a history of falls, fractures, diabetes, and severe cognitive deficit was exposed to persistent urine odors due to urine-soaked clothing left to dry in the bathroom. Another resident with muscle weakness, major depressive disorder, and severe cognitive deficit reported that her room always smelled like urine, even after cleaning. In another room, residents were exposed to a dangling electrical outlet, missing bathroom thresholds, and scuffed walls, with one resident expressing concern about the fire risk and not knowing repairs could be requested. Additional observations included a room with a large hole and dent in the walls behind residents' beds, and another room where blood splatter stains were present on both the wall and privacy curtain. One resident expressed frustration and emotional distress over repeated, unaddressed requests to have blood stains cleaned and curtains changed. Staff interviews confirmed that these conditions were not acceptable, with the Housekeeping Manager acknowledging that blood stains posed an infection issue and that the room was not cleaned to expectations. The facility's own policy required a clean, sanitary, and orderly environment in good condition, which was not maintained in these instances.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in deficiencies in meeting their individualized care needs. For one resident, the care plan was not updated after droplet isolation precautions for influenza were discontinued. Despite the resident no longer requiring isolation or a single room, the care plan continued to reflect outdated precautions, and staff interviews confirmed that the care plan should have been revised to accurately reflect the resident's current status. The facility's own policies and staff statements indicated that care plans must be updated as residents' conditions change, but this was not done in this case. Another resident was prescribed and administered divalproex for migraine headaches, but there was no care plan addressing the use of this medication or the associated diagnosis. Staff interviews revealed that a care plan should have been initiated for new medications and diagnoses to guide nursing staff in providing appropriate care. The absence of a care plan for this medication meant that staff lacked direction for monitoring and managing the resident's needs related to the new treatment. A third resident was receiving oxycodone for back pain, but the care plan did not include any interventions for the use of this high-risk pain medication. Staff acknowledged that oxycodone requires specific care planning due to its potential side effects, such as respiratory depression and constipation. Additionally, a fourth resident who required continuous oxygen therapy and also smoked did not have an individualized care plan that addressed the interaction between oxygen use and smoking. Staff interviews confirmed that the care plan lacked instructions for managing oxygen therapy during smoking, which was necessary for the resident's safety. In all cases, the facility did not follow its own policies and procedures for developing and updating comprehensive, person-centered care plans based on residents' current needs and conditions.
Multiple Failures in Medication Administration, Oxygen Therapy, and Infection Control
Penalty
Summary
The facility failed to maintain professional standards of quality for multiple residents in several key areas. One resident was found with a medication left unattended on her bedside table without a completed self-administration assessment and without nursing staff present. The medication, intended for blood pressure management, was not administered at the scheduled time, and the nurse responsible left the medication while retrieving an item and did not return. Both the Assistant Director of Nursing and the Director of Nursing confirmed that this was a medication error and a violation of facility policy, as medications should not be left unattended and self-administration assessments are required. Another resident receiving oxygen therapy had an incomplete physician order that did not specify the oxygen flow rate. The respiratory therapist and nursing staff acknowledged that the order should have included the specific rate to ensure proper administration. Additionally, a resident receiving continuous oxygen therapy did not have the required 'Oxygen in Use/No Smoking' signage posted inside or outside the room, as mandated by facility policy. Staff interviews confirmed that the absence of signage was a failure to follow established procedures and could have led to unsafe conditions. Further deficiencies included improper insulin pen administration by a licensed nurse for two residents, where the insulin pen tip was not disinfected with an alcohol wipe before and after use, contrary to facility policy and infection control standards. Another resident's nebulizer tubing was found unlabeled, unprotected, and touching the floor, with staff confirming that tubing should be labeled, changed weekly, and stored in a privacy bag. Lastly, a resident with an open wound did not have a physician order for enhanced barrier precautions upon admission, despite facility policy requiring such precautions for residents with wounds. Staff interviews indicated that the omission was due to a lapse in the admission assessment and order process.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. For one resident, a bottle of artificial saliva (eye medication) was found on the medication cart without an open date, and the Assistant Director of Nursing confirmed that the medication should have been dated when opened. Similarly, another resident's insulin pen was observed with a blank 'Date Opened' field, and the nurse stated that the open date should have been recorded. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that medications should be dated upon opening, and the facility's policy requires opened multidose vials to be dated and discarded within 28 days. A separate incident involved a resident's lorazepam, which was found without a legible medication label. The registered nurse present confirmed the label was not legible and stated that a new medication should be ordered in such cases. The Director of Nursing further clarified that medication labels must include specific information such as prescription number, physician's name, date filled, expiration date, medication name, and resident identification, and that labels must be legible. The facility's policy also requires that medications with missing or illegible labels be returned or destroyed per pharmacy instructions. Additionally, an unattended medication cart was observed in a hallway with a set of keys and a cup containing five unidentified, loose pills on top. The responsible nurse admitted that both the keys and medications should not have been left unattended and should have been secured. The Director of Nursing confirmed that leaving medications and keys unattended is unacceptable and poses a security risk. Facility policy states that medication carts must be locked when not in use and never left unattended if open or accessible.
Failure to Store, Label, and Monitor Food According to Professional Standards
Penalty
Summary
The facility failed to store and distribute food in accordance with professional standards for food service safety. During observations in the kitchen, surveyors found a large clear plastic container with a red gelatinous substance in the refrigerator that lacked any labels to identify the product, its open date, or expiration date. Additionally, a large opened container of mayonnaise was found in the same refrigerator without an open date or expiration date. The Dietary Manager confirmed that both items should have been labeled to prevent serving expired foods. During lunch tray line service, the cook did not take the temperature of a tray of cauliflower after removing it from the oven, which the Dietary Manager acknowledged should have been done to ensure food safety. In a resident's room, a bowl containing cooked, perishable cabbage and onions was found on the bedside table without any labeling or dating. The resident stated that the food had been brought in by a family member the previous day and had remained at the bedside since then. The resident was assessed as cognitively intact and had a medical history including generalized muscle weakness, unspecified fracture of the left pubis, history of falling, and vitamin D deficiency. Facility staff, including the Assistant Director of Nursing, Registered Dietitian, and Director of Nursing, all confirmed that perishable or cooked food should not be left out and should be discarded after consumption, as prolonged exposure could lead to bacterial growth and foodborne illness. Review of facility policies and state regulations indicated that all food should be stored in a manner to prevent contamination, with proper labeling, dating, and temperature control. The facility's policy for food brought in from outside sources required that prepared food be consumed within one hour after removal from temperature control, with any unused food disposed of immediately. Staff interviews confirmed that these policies were not followed in the instances observed, resulting in the deficiencies cited.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in accordance with its policy and procedure for food-related garbage and refuse disposal. During observations, all three outside trash bins were found uncovered, with paper and plastic bags littering the ground around them. Interviews with the Certified Dietary Manager, Registered Dietitian, and Director of Maintenance confirmed that the trash bins should always be closed and free of surrounding litter, and that the presence of open bins and trash on the ground was not in compliance with facility policy. A review of the facility's policy indicated that all food waste should be kept in containers and stored in a manner inaccessible to pests, with outside dumpsters kept closed and free of litter.
Failure to Maintain Resident Dignity and Privacy During Direct Care
Penalty
Summary
Multiple residents were not treated with dignity and respect, as required by facility policy and resident rights, during the provision of direct care. In one instance, a resident with a urinary catheter was observed lying in bed with the catheter bag uncovered and visible from the doorway while family members were present. The urinary bag, filled with urine, was not placed in a privacy bag as required, making it visible to anyone entering the room. Staff, including a Licensed Vocational Nurse (LVN), Certified Nurse Assistant (CNA), Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), all acknowledged that the catheter bag should have been covered to maintain the resident's dignity and privacy. In several other cases, staff failed to provide privacy during routine medical procedures. Blood pressure checks were performed on two residents without closing privacy curtains or doors, allowing other residents, visitors, and roommates to observe the procedures. Both the LVN and Registered Nurse (RN) involved admitted that privacy should have been provided. Similarly, blood sugar checks and insulin administration were conducted for multiple residents without ensuring privacy by closing doors or curtains, despite the presence of visitors and other residents in the vicinity. The staff involved recognized these lapses as dignity and privacy issues. Facility policies reviewed during the investigation emphasized the importance of treating residents with dignity and respect, including maintaining privacy during personal care and medical procedures. Staff interviews consistently confirmed that the observed actions did not align with facility expectations or policies. The deficiencies were observed across different shifts and involved multiple staff members, including agency and regular staff, indicating a pattern of failure to uphold resident dignity and privacy during care.
Failure to Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident-to-resident altercation to the California Department of Public Health (CDPH) as required. Two residents were involved in an incident where one resident, who had moderate cognitive impairment and a diagnosis of dementia, allegedly threw a metal object at another resident, resulting in a skin tear to the hand. The injured resident was alert, oriented, and able to answer questions appropriately at the time of the incident. The incident was reported to the police and the Ombudsman, but not to CDPH. Facility staff, including a CNA and LVN, described the process for handling resident-to-resident altercations, which included separating the residents, assessing for injuries, notifying physicians and resident representatives, and reporting to outside agencies. However, both the Administrator and the Director of Nursing stated that, based on their interpretation of state guidance (AB-1417 and AFL 24-09), incidents involving a resident with dementia and no serious bodily injury only required reporting to the Ombudsman and local law enforcement, not to CDPH. This interpretation was reflected in the facility's policies and procedures, which referenced following state law and reporting requirements. Despite these actions, federal regulations (42 CFR 483.12) require that all alleged violations involving abuse be reported to the State Survey Agency, regardless of the cognitive status of the residents involved. The facility's failure to report the incident to CDPH meant that the alleged violation involving resident-to-resident abuse was not reported within the required timeframe, and this had the potential for additional allegations of abuse to go unreported.
Inaccurate MDS Assessment Due to Omitted Medication and Diagnosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status. Specifically, for one resident, the MDS did not include the use of an antianxiety medication (lorazepam) and a diagnosis of migraine, despite both being present in the resident's medical orders. The MDS nurse acknowledged during interview and record review that these items should have been coded in the MDS assessment but were omitted. The nurse stated that she should have reviewed the resident's list of medications and diagnoses to ensure the MDS was accurate and complete. Further review with the Assistant Director of Nursing confirmed that the antianxiety medication was ordered when the resident was admitted to hospice care, and medication for migraine headache was also ordered, though a formal diagnosis of migraine was not found in the record. Both the Administrator and Director of Nursing stated their expectation that the MDS nurse is responsible for gathering all relevant information, including medications and diagnoses, to ensure accurate MDS coding. Professional guidelines require that physician-documented diagnoses and high-risk drug class medications be coded in the MDS when they have a direct relationship to the resident's current status.
Failure to Complete PASRR Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident who was admitted for hospice care. The resident, who had diagnoses including Parkinson's Disease, hypothyroidism, and dementia, was admitted and later readmitted to the facility. Upon review, it was found that the most recent PASRR assessment on file was dated several months prior to the resident's admission to hospice care, and no updated PASRR was completed at the time of this significant change in condition. Interviews with facility staff, including the Minimum Data Set Nurse (MDSN), Administrator, and Director of Nursing (DON), confirmed that it was the facility's practice and policy to complete a PASRR assessment annually, upon a change of condition, and when a resident is admitted to hospice care. The MDSN acknowledged that the assessment should have been completed at the time of hospice admission but was not. Facility documentation also indicated that a Resident Review PASRR should be conducted for significant changes in condition, which did not occur in this case.
Failure to Develop Baseline Care Plan for Oxygen and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, specifically neglecting to address the resident's use of oxygen therapy and the administration of ciprofloxacin, an antibiotic. Observation revealed the resident was receiving oxygen at 3 liters per minute via nasal cannula following a recent hospitalization. The resident's admission record documented diagnoses including a lumbar vertebra fracture and bronchiectasis, and the order summary confirmed an active prescription for ciprofloxacin. Interviews with facility staff, including the Infection Preventionist, LVN, and Director of Nursing, confirmed that care plans should have been created for both oxygen use and antibiotic therapy. The facility's policies and job descriptions also required the development of baseline care plans within 48 hours of admission to address immediate health and safety needs. However, no such care plan was found for the resident's oxygen or antibiotic use, resulting in a lack of documented interventions and instructions for staff regarding these treatments.
Failure to Provide Required Smoking Safety Equipment and Supervision
Penalty
Summary
A deficiency occurred when a resident was allowed to smoke in the facility's designated smoking area without being offered or wearing a smoking apron, as required by her care plan and the facility's smoking policy. During observation, the resident, who has diagnoses of congestive heart failure, polyneuropathy, and muscle weakness, was seen dropping ashes on her shirt and between her legs in her wheelchair while smoking two cigarettes. The activities assistants supervising the smoking break were present but did not offer the resident a smoking apron, and the resident brushed ashes off her body with her hand while still holding a lit cigarette. The resident's records indicated she was cognitively intact and required supervision and the use of a smoking apron for safety during smoking activities. The Smoking Observation/Assessment specifically noted that a smoking apron should be offered and that supervision was required to help prevent burns. Despite these documented requirements, staff failed to provide the necessary adaptive equipment and did not ensure that ashes were properly disposed of in the ashtray, as outlined in the facility's policy. Interviews with staff, including the activities assistants, Activities Director, ADON, and DON, confirmed that the expectation was for the resident to be offered a smoking apron and to be supervised to ensure safe smoking practices. Staff acknowledged that the resident's safety was put at risk due to the failure to follow the facility's smoking policy, which mandates direct supervision and the use of safety equipment for residents with smoking privileges who require monitoring.
Failure to Provide Physician-Ordered Diet Textures to Two Residents
Penalty
Summary
Two residents did not receive food prepared in the form required by their physician-ordered diets. One resident, who had a physician order for a pureed diet due to diagnoses including Alzheimer's disease, malnutrition, anorexia, and vitamin deficiency, was served a banana that was mashed with chunks rather than being fully pureed to a smooth, pudding-like consistency. Multiple staff, including a CNA, the cook, the Certified Dietary Manager (CDM), and the Registered Dietician (RD), confirmed that the banana was not pureed as required and that the resident was not served the correct texture as ordered. The resident's records and assessments indicated significant cognitive impairment, and the staff acknowledged that serving food with the wrong texture could pose a risk to the resident. Another resident, with a physician order for a bland diet with regular texture and thin liquids, was served minced meat instead of the regular textured meat as ordered. Observations and interviews with a CNA, an LVN, and the Dietary Manager confirmed that the meat was not of regular texture and that the resident did not receive the diet texture as ordered by the physician. The Dietary Manager and DON both stated that the expectation was for staff to check each food plate to ensure residents are served the correct diet before food is delivered. Review of job descriptions and facility policies showed that staff are expected to prepare and serve food according to physician orders and resident needs, and that therapeutic diets must be prescribed and followed as specified. The facility's recipe for pureed fruit and policy on therapeutic diets both emphasized the importance of preparing food to the correct texture and consistency as ordered by the physician.
Resident Unable to Access Call Light Due to Improper Placement
Penalty
Summary
A deficiency was identified when a resident with significant physical and cognitive impairments did not have access to a functioning call light system. During an observation, the resident was found asleep in bed with an air mattress and enteral feeding in progress. The tap button call light, designed for residents with limited finger strength, was hanging from the left handrail, three inches above the floor, and not within the resident's reach. The resident's medical history included left hemiplegia and hemiparesis following a cerebral infarction, dysphagia, generalized muscle weakness, gastrostomy status, and aphasia. The Minimum Data Set assessment indicated severe cognitive impairment. The resident's care plan specifically noted a high risk for falls and injuries, with interventions requiring the call light to be within reach and encouragement to use it for assistance as needed. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the call light should have been within the resident's reach, especially given the resident's mobility limitations. Staff acknowledged that the resident would not be able to call for help if the call light was not accessible. Facility policies and job descriptions reviewed also required staff to ensure call lights were within easy reach of residents, particularly those with mobility issues.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light was accessible for two residents, leading to a deficiency in care. During an observation, it was noted that one resident's call light was wrapped around the assist bar on the left side of the bed, making it unreachable. The resident expressed the need for the call light to request help but was unable to find it. The Director of Staff and Development (DSD) confirmed the issue and repositioned the call light within the resident's reach. Another resident's call light was found on the floor, out of reach, while the resident was asleep. The DSD again confirmed the issue and placed the call light within reach, acknowledging the importance of accessibility for residents who require assistance. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both emphasized the necessity of keeping call lights within reach, as outlined in the residents' care plans and the facility's policy. The care plans for both residents, who were identified as high risk for falls, specifically included the intervention to keep the call light accessible. The facility's policy also mandates that call lights be within easy reach when residents are in bed or confined to a chair. These observations and interviews highlight the facility's failure to adhere to its own policies and care plans, potentially compromising resident safety and care.
Inadequate Infection Control in Shower Areas
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control procedures in four sampled shower areas. Observations revealed that the women's shower in Station 1 had used gloves and a washcloth with a brown substance in the soap bar holder, and the drains had loose hair and paper debris. The men's shower had a brown substance on the grab bar near the toilet, an uncovered toilet plunger with a white dried substance, and an open package of wipes on the floor. Housekeeping staff acknowledged that the showers were not clean and should have been disinfected immediately. In Station 2, both the men's and women's shower drains contained dark and grey hair and debris, and the women's shower floor had brown tracks identified as feces. Housekeeping staff stated that showers should be cleaned before and after resident use, and any presence of bodily fluids should be reported for immediate cleaning. However, no notification of feces in the shower areas was received on the day of observation. Similarly, Station 3's shower drains had hair and debris, and the housekeeping staff admitted that the conditions did not meet infection control standards. In room [ROOM NUMBER], the shower drain had hair and debris, and the bedside commode had chipped paint with a brown substance. The ceiling vent was also dirty. The CNA reported the shower and commode conditions but had not yet alerted maintenance. The Administrator and Director of Nursing confirmed the cleanliness issues and acknowledged the risk of cross-contamination and potential infection control problems. The facility's policies required daily cleaning and immediate disinfection of soiled areas, but these were not adhered to, leading to the deficiencies observed.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident 1 from abuse, as evidenced by an incident involving Certified Nursing Assistant (CNA) 1. On the morning of June 7, 2024, Resident 1, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, explicitly refused care from CNA 1, stating he did not want his brief checked. Despite this refusal, CNA 1 proceeded to check Resident 1's brief twice, physically touching his genitals, which Resident 1 described as a violation of his personal space and dignity. This action was against Resident 1's expressed wishes and could be considered physical and sexual abuse. The incident was not properly addressed by the facility staff. CNA 1 reported the incident to Licensed Vocational Nurse (LVN) 1, who failed to investigate or document the incident adequately. LVN 1 did not report the incident to the abuse coordinator or the Administrator, which delayed the investigation and potentially caused emotional distress to Resident 1. Assistant Director of Nursing (ADON) 1 was informed of the incident but did not read CNA 1's written statement or discuss the matter with Resident 1 or LVN 1 on the day of the incident. This lack of immediate action and failure to follow the facility's abuse reporting policy contributed to the deficiency. The facility's policies and procedures, including those on abuse prevention, resident rights, and unusual occurrence reporting, were not adhered to by the staff involved. Both LVN 1 and ADON 1 had received training on their responsibilities as mandated reporters but did not fulfill these duties. The Director of Nursing (DON) and the Administrator acknowledged that the staff did not follow the established policies for reporting and investigating the incident, which compromised Resident 1's right to be free from abuse and to have grievances addressed promptly.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a Certified Nursing Assistant (CNA) to the appropriate authorities within the required 24-hour timeframe. On June 7, 2024, a resident, who was cognitively intact as per their Minimum Data Set assessment, reported to a Licensed Vocational Nurse (LVN) that a CNA had violated him. The resident described an incident where the CNA, despite being told not to, checked his brief in a manner that he found inappropriate and violating. The resident expressed feeling awful, mad, and violated by the CNA's actions. The LVN, upon being informed by the resident, did not investigate the matter further or report it to the abuse coordinator, who is the Administrator. Instead, the LVN merely switched the CNA's assignment without documenting the incident or the reason for the change. The Assistant Director of Nursing (ADON) was also informed by the CNA about the resident's anger over the brief check but did not read the CNA's written statement or discuss the incident with the resident or LVN. The ADON admitted to not following the facility's policy for reporting abuse, which contributed to the delay in addressing the resident's complaint. The facility's policies and procedures, as well as state regulations, require that allegations of abuse be reported to the appropriate agencies within 24 hours. However, the incident went unreported until June 17, 2024, ten days after the initial report by the resident. The Director of Nursing and the Administrator acknowledged that both the LVN and ADON failed to adhere to the reporting policy, which could have caused emotional distress to the resident.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident, leading to a delay in medical intervention. On 5/14/24, the resident exhibited an acute change in mental status, loss of appetite, weakness, fatigue, and was difficult to arouse. Despite these symptoms being communicated by CNA 4 to the licensed nurse, the nurse did not assess the resident or notify the physician and the Responsible Party about the change in condition. This oversight resulted in a delay in transferring the resident to a hospital, where a CT scan revealed an acute ischemic stroke. Interviews with staff revealed that CNA 4 noticed the resident's unusual behavior and reported it to LVN 2, who attributed the symptoms to a side effect of an antibiotic and did not notify the physician. LVN 1, who took over the afternoon shift, was informed of the change in condition but also did not notify the physician. The facility's policy required nurses to notify the physician of significant changes in a resident's condition, but this was not followed. The resident's condition worsened the following day, prompting LVN 2 to finally notify the physician and other relevant parties. The delay in physician notification and subsequent transfer to a hospital resulted in the resident being unable to receive timely treatment for the stroke. The resident was eventually placed on hospice and palliative care due to the decline in mental and physical abilities. The facility's failure to adhere to its policy on notifying physicians of significant changes in condition directly contributed to the resident's deteriorating health and the inability to provide timely medical intervention.
Inadequate Infection Control Practices by CNA
Penalty
Summary
The facility failed to ensure an effective infection control and prevention program for a resident when a Certified Nursing Assistant (CNA) was observed not wearing proper personal protective equipment (PPE) and not performing hand hygiene while providing care. The CNA was seen wearing a mask and gloves but not a gown while attending to the resident, who had a diagnosis of COVID-19, immunodeficiency, and chronic myeloid leukemia. The CNA left the resident's room multiple times without performing hand hygiene, even after handling dirty linen and repositioning the resident. The Infection Preventionist (IP) confirmed that all staff must clean their hands and wear gloves and gowns when providing care, especially for residents with open wounds and infections who are placed under enhanced barrier precautions. The IP noted that the resident had a deep tissue injury and was at high risk for Methicillin-resistant Staphylococcus aureus (MRSA). Despite the presence of a sign indicating the need for PPE, the CNA did not adhere to these precautions, stating a lack of understanding of the purpose of wearing a gown. The Director of Nursing (DON) reiterated that staff and visitors are expected to wear PPE when there is a sign next to the resident's door, and that staff are trained on infection control during orientation and annually. The facility's policies and procedures emphasize the importance of PPE and infection control to prevent the spread of multidrug-resistant organisms (MDRO) and other infections. However, the CNA's actions demonstrated a lapse in following these protocols, potentially increasing the risk of infection transmission within the facility.
Failure to Assess Entrapment Risk for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails prior to their installation. During an observation, it was noted that the resident was lying in bed with two bed rails up. The Certified Nursing Assistant (CNA) confirmed that the resident had two bed rails up and could not ambulate by himself due to hip surgery. However, there was no entrapment risk assessment, physician order, or care plan in place for the use of the bed rails, as confirmed by the Registered Nurse (RN) and the Director of Nursing (DON). The DON stated that it was the licensed nurses' responsibility to create a care plan for bed rails and that an entrapment risk assessment should have been completed prior to their use. The facility's policy and procedure titled 'Bed Safety and Bed Rails' indicated that bed rails should not be used unless specific criteria were met, including an interdisciplinary evaluation, resident assessment, and informed consent. The policy also required that bed frames, mattresses, and bed rails be checked for compatibility and size prior to use. Despite these requirements, the resident had no care plan or physician order for the bed rails, and no entrapment risk assessment had been conducted. The DON acknowledged that the resident should have had a physician order and care plan for the side rails and that the entrapment risk assessment should have been completed. The Administrator (ADM) stated that while the facility policy did not explicitly require a physician order and care plan for bed rail use, it was a professional standard of practice to have them. A review of professional references from the FDA indicated that patients with certain conditions must be carefully assessed for the best ways to keep them from harm, including the potential risks associated with bed rails. The facility's failure to conduct an entrapment risk assessment, obtain a physician order, and develop a care plan for the bed rails placed the resident at risk for decreased freedom of movement, entrapment, and/or injury.
Failure to Administer Oxygen According to Physician's Order
Penalty
Summary
The facility failed to provide services that met professional standards for Resident 2 when the resident's oxygen flow rate was not administered according to the physician's order. Resident 2, who was admitted with diagnoses including essential hypertension, chronic obstructive pulmonary disease, and obstructive sleep apnea, was observed with a portable oxygen tank set at 3 liters per minute instead of the prescribed 4 liters per minute. The portable oxygen tank was also found to be empty. The Licensed Vocational Nurse (LVN) confirmed that the oxygen flow rate should have been set at 4 liters per minute and acknowledged the error. The Director of Nursing (DON) stated that the physician's orders and the facility's Oxygen Administration policy were not followed for Resident 2. The facility's policies and procedures, including those for administering medications and oxygen, were reviewed and found to require that medications and treatments be administered according to prescriber orders. The LVN admitted that it is the nurse's responsibility to ensure the oxygen tank is full and the flow rate is correct. The DON emphasized the importance of checking oxygen flow rates during shift changes and medication administration rounds to prevent shortness of breath and ensure proper oxygen saturation levels. The failure to adhere to these protocols resulted in Resident 2 not receiving the prescribed oxygen flow rate, which could lead to respiratory distress.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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