Willows Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Willows, California.
- Location
- 320 North Crawford Street, Willows, California 95988
- CMS Provider Number
- 555151
- Inspections on file
- 27
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Willows Post Acute during CMS and state inspections, most recent first.
A resident with multiple medical conditions but no documented cognitive, mood, or behavior problems was asked by the BOM and SSA to transfer her funds into a resident fund management service account and explicitly declined, stating she wished to manage her own bank account. Despite facility policy requiring a signed delegation before opening such an account, the BOM later signed an authorization agreement to transfer the resident's funds without the resident's signature. The resident reported that she had not agreed to facility management of her funds and was very angry and upset about losing control of her money.
Multiple residents who required staff assistance for ADLs reported that staff frequently ignored call lights, failed to provide timely help, and behaved in a rude or uncommunicative manner. These actions led to residents experiencing incontinence, embarrassment, and emotional distress. Despite complaints to management and staff awareness of problematic behavior by a CNA, residents perceived that their concerns were not addressed.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a history of cerebrovascular disease and diabetes did not receive adequate nail care, as required by the facility's policy. Despite documentation of personal hygiene being provided, observations showed the resident's nails were soiled. Staff interviews revealed a lack of adherence to the expected nail care routine, highlighting a deficiency in the facility's care practices.
The facility failed to maintain kitchen equipment in accordance with professional standards, as evidenced by a slimy substance in the icemaker, improper drainage from the dishwasher, and a missing kick plate on an oven/stove unit. These issues were identified during a review of the facility's policies and through direct observations and interviews with staff.
The facility failed to maintain a sanitary, comfortable, and homelike environment, with worn-off varnish on wooden handrails and scratched or disrepaired wall paint in several rooms. The Environmental Services Director acknowledged the difficulty in maintaining infection control on these surfaces, and the Director of Maintenance confirmed the disrepair of walls and curtains.
The facility failed to maintain proper grooming and personal hygiene for three residents. One resident had an unkempt beard and dirty nails, while two others had matted hair. Despite their needs and preferences, the staff did not provide the necessary care, and there was a lack of proper documentation and communication.
A resident with diabetes and hypertension experienced a six-month delay in receiving cataract treatment due to inadequate follow-up by social services. The delay was acknowledged by the DON, who noted that social services responsibilities had been inconsistently managed.
A resident with chronic pain and dental issues experienced ongoing discomfort due to the facility's failure to document pain location consistently and administer a prescribed dental rinse. The resident reported daily tooth pain and felt neglected by the facility staff, who did not follow the care plan or place the necessary medication orders.
The facility failed to arrange dental and vision services for a resident with multiple health issues, leading to the resident feeling neglected and like giving up on addressing his problems. Despite having no cognitive impairment, the resident's dental and vision needs were not followed up on, and social services were inconsistent in the previous three months.
The facility failed to ensure accurate labeling of medications for two residents. One resident's clonidine label was incomplete, lacking instructions to hold the medication for a low heart rate, while another resident's Visine eye drops were labeled with only initials, risking confusion and cross-contamination.
The facility failed to ensure timely dental services for a resident experiencing tooth pain. Despite multiple complaints and a documented need for dental treatment, no appointment was made, leading to continued pain and frustration for the resident. The process for dental service authorization was delayed, and the responsibility for coordinating care had been inconsistently managed.
The facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). Records showed inconsistent RD coverage, issues with labeling, maintenance, and the absence of a written policy to honor resident preferences. Further inspection revealed a lack of Quality Assurance (QA) processes, outdated skill checks for food service workers, and improper food storage practices.
The facility failed to consistently incorporate resident dietary preferences, leading to dissatisfaction with food quality and availability. Residents reported receiving disliked food items, limited snack options, and a lack of fresh fruit. The facility also did not have a Dining Committee and had an inadequate food supply based on licensed bed capacity.
The facility failed to implement an effective infection prevention and control program. Medical supplies and equipment in the medication room were found dirty, a resident was allowed to wash soiled laundry in a shared bathroom, and a CNA did not perform hand hygiene between assisting two residents, increasing the risk of cross-contamination.
The facility failed to ensure safe medication administration for four residents. An LVN did not check expiration dates before administering medications, another LVN did not confirm resident identities before giving medications, and a resident received the wrong eye drops. The DON confirmed these lapses in protocol.
Unauthorized Transfer of Resident Funds to Managed Account
Penalty
Summary
The facility violated a resident's right to manage her own financial affairs by arranging for her pension checks to be deposited into a resident fund management service account without her written authorization. The facility's Resident Trust Account Policy, dated 1/1/2023, required that no account be opened until a Delegation of Responsibility for the Management of Personal Funds was signed by the resident or their representative. The resident, who had diagnoses including diabetes, peripheral vascular disease, osteoporosis, hypertension, delusional disorder, and cognitive/communication deficits, had an MDS dated 10/9/25 indicating no memory, recall, thinking, reasoning, mood, or behavior problems. On 12/6/23, a Business Office Activity Note documented that the Business Office Manager (BOM) and Social Service Assistant (SSA) approached the resident and asked her to have her funds transferred into a resident fund management service bank account, and the resident declined, stating she wanted to continue managing her own bank account. Despite this refusal, an Authorization Agreement to Handle Resident Funds showed that on 6/5/25 the BOM signed the authorization to have the resident's funds transferred into the resident fund management service account, without the resident's signature. In an interview on 10/17/25, the resident stated she understood the facility believed she was not competent but asserted that she was competent, wanted to manage her own bank account, had not agreed to the facility managing her funds, and was very angry and upset over no longer having control of her money.
Failure to Ensure Resident Dignity and Timely Assistance
Penalty
Summary
Direct care staff failed to respond to and assist residents who were dependent on staff for activities of daily living (ADLs), resulting in multiple residents feeling afraid, uncomfortable, and unwanted. Residents reported that staff ignored call lights, walked by without assisting, or answered call lights but left without providing help. This led to episodes of incontinence, embarrassment, humiliation, and physical discomfort for residents. Several residents expressed fear of asking for help, frustration with frequent staff turnover, and the need to repeatedly explain their care needs to new staff. Residents also described staff as being rude, uncommunicative, and engaging in inappropriate behavior such as gossiping during care. Interviews and record reviews indicated that residents had reported these issues to management multiple times, but perceived that no changes were made. One resident described a specific incident where his wife cried and yelled for help at night without receiving assistance. Staff interviews corroborated concerns about a particular CNA's behavior, including rudeness and lack of teamwork, with reports made to management but no apparent resolution. The DON stated he was unaware of grievances or staffing issues, though documentation showed at least one CNA had received corrective action for care deficiencies.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #119, who was admitted with a medical history of cerebrovascular disease, weakness, and type 2 diabetes mellitus. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) due to a self-care performance deficit. Despite documentation showing that personal hygiene and bed baths were provided on specific dates, observations revealed that the resident's fingernails were soiled on multiple occasions. Interviews with staff, including a CNA and an LVN, confirmed that nail care was expected to be part of the ADL routine, yet the resident's nails remained dirty. The facility's policy on nail care, revised in 2018, required daily cleaning and regular trimming to prevent infections. However, the CNA responsible for the resident admitted to checking the resident's nails daily but did not ensure they were clean. The LVN and Interim Director of Nursing also acknowledged the expectation for nail care but were unsure of the documentation process. The Interim Administrator confirmed that nail care should be performed during showers, baths, and as needed, yet the resident's nails were not maintained according to these standards.
Failure to Maintain Kitchen Equipment in Accordance with Professional Standards
Penalty
Summary
The facility failed to maintain kitchen equipment in accordance with professional standards for food service safety. A slimy, brown-pink substance was found inside the holding tray of the facility's icemaker, despite the Director of Maintenance (DM) stating that the icemaker had been sanitized recently. Additionally, dirty dishwasher water from the dishwasher's air gap was splashing onto floor tiles next to the drain, which was confirmed by the Registered Dietitian (RD A) during an observation. The DM was unaware of this issue and only fixed the air gap after it was pointed out during the survey. Furthermore, a kick plate at the bottom of an oven/stove unit was missing, exposing wires and other internal parts, which was acknowledged by RD A, who stated that Maintenance was aware of the issue and had ordered the part. These deficiencies were identified during a review of the facility's Infection Prevention and Control Program (IPCP) and Sanitation policy, as well as through direct observations and interviews with staff. The presence of the slimy substance in the icemaker, the improper drainage of the dishwasher, and the missing kick plate all indicate lapses in the facility's adherence to its own policies and professional standards for maintaining a safe and sanitary kitchen environment. These failures created safety issues for staff and had the potential to cause avoidable food- or waterborne illness for all 68 facility residents.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment, as evidenced by worn-off varnish on wooden handrails in Unit 1 and scratched or disrepaired wall paint in several rooms. Specifically, the varnish on the handrails between Rooms 27-34 and the hallway between Station 1 nurses' desk and the patio was worn off, making it difficult to maintain infection control on these porous surfaces. The Environmental Services Director acknowledged that the increased frequency of cleaning during the COVID pandemic contributed to the deterioration of the varnish. Additionally, the wall paint in Rooms 6, 10, 30, and 37 was scratched or in disrepair, and curtains were missing in one of the rooms, further compromising the homelike environment for residents. During an observational tour, it was noted that there were no curtains in one of the rooms, and a significant portion of paint was peeled off the wall, revealing the drywall. The Director of Maintenance confirmed that the walls and curtains in the affected rooms were in disrepair and that the handrails were in the process of being revarnished. These deficiencies violated the residents' rights to a clean, comfortable, and homelike environment, diminishing their quality of life and increasing the potential risk for infection from exposure to uncleanable surfaces.
Failure to Maintain Resident Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for three residents. Resident 6 had an unkempt beard and mustache, with long and dirty nails. Despite expressing his desire to be shaved and have his nails cut, these needs were not addressed. The CNA responsible for Resident 6's care did not inquire about his grooming preferences, and there was no care plan indicating his preference to be clean-shaven. The Director of Staff Development confirmed the lack of documentation and care planning for Resident 6's grooming needs. Resident 56, who was on comfort care and required full assistance with personal hygiene, was observed with matted and unkempt hair. Despite documentation indicating that personal care was provided earlier in the day, her hair remained unbrushed. Similarly, Resident 22, who was on hospice care and required full assistance with personal hygiene, was also observed with matted hair. The Licensed Vocational Nurse confirmed that both residents' hair needed attention, but these grooming needs were not met. The facility's policy on Activities of Daily Living (ADLs) indicated that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and personal hygiene. However, the observations and interviews revealed that the facility staff did not adhere to this policy, resulting in unmet grooming needs for Residents 6, 22, and 56. The lack of proper documentation and communication among staff contributed to these deficiencies.
Failure to Ensure Timely Vision Services
Penalty
Summary
The facility failed to ensure timely vision services for a resident, resulting in continued vision issues and feelings of frustration. Resident 416, who has diagnoses including diabetes and hypertension, was admitted over a year ago and had a cataract in his left eye that required treatment. Despite an ophthalmology consultation recommending cataract treatment for quality of life enhancement, no appointment was made for six months. The delay in referral was confirmed during an interview with the Director of Nursing (DON), who acknowledged that social services should have followed up on the issue. The deficiency was further highlighted by the fact that the social services responsibilities had been inconsistently managed. The Administrator had delegated social services work to the desk nurse and MDS nurse three months prior, but the follow-up on the ophthalmology consultation was still delayed. The facility's job description for the Social Worker clearly states that they are responsible for coordinating social services activities and obtaining resources to meet residents' needs, which was not adequately done in this case.
Failure to Document Pain Location and Administer Dental Prescription
Penalty
Summary
The facility failed to consistently document the location of pain for Resident 416, who had a history of chronic pain, COPD, diabetes, and dysphagia. Over a four-month period, the facility missed 52 out of 70 opportunities to document the location of the resident's pain while administering pain medications. This lack of documentation prevented the facility from recognizing and addressing the resident's dental pain in a timely manner. Additionally, the facility failed to administer a prescribed dental rinse, Chlorhexidine, which was ordered to help manage the resident's oral health issues. The order for Chlorhexidine was not placed in June or July of 2023, despite being indicated in the resident's hygiene notes. The resident reported experiencing daily tooth pain, which varied in intensity, and expressed frustration over the lack of dental care provided by the facility. Interviews with the resident and facility staff, including the Director of Nursing (DON), confirmed these deficiencies. The DON acknowledged that the location of the resident's pain was not consistently documented and that the Chlorhexidine order was never placed. The resident's care plan indicated a risk for oral health problems and required staff to assess for signs of pain and report them to the medical doctor, but these steps were not followed. The resident felt that his complaints about tooth pain were not being heard by the facility staff, leading to ongoing discomfort and a sense of neglect.
Failure to Arrange Dental and Vision Services
Penalty
Summary
The facility failed to ensure that social services arranged for dental and vision services for Resident 416, who had been admitted with multiple diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease, Diabetes, and Dysphagia. Despite having no cognitive impairment, as indicated by a BIMS score of 14, Resident 416 reported feeling neglected regarding his dental and vision needs. He had a cataract in his left eye and required dental work, but no appointments had been made for these issues, leading him to feel like giving up on getting his problems addressed. The records showed that dental x-rays were completed on 11/30/23, but no follow-up was done, and a vision exam on 8/25/23 was not followed up until 2/27/24, which was a significant delay. The facility's Director of Nursing confirmed that social services were inconsistent in the previous three months and that the responsibility had been delegated to the desk nurse and MDS nurse, who were also training a new social services person since December 2023. The facility's job description for the Social Worker, dated October 2020, states that the Social Worker is responsible for assisting in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident and coordinating social services activities with other members of the interdisciplinary team. However, the facility did not adhere to these responsibilities, resulting in Resident 416's dental and vision needs being neglected. The Director of Nursing acknowledged that social services should have followed up on the dental and vision services as per their policy and procedure, but this was not done, leading to the deficiency identified in the report.
Medication Labeling Deficiencies
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two residents. For Resident 44, who was admitted with essential primary hypertension and a history of myocardial infarction, the label for clonidine was incomplete. During a medication pass observation, the Licensed Vocational Nurse (LVN) noted a blood pressure reading of 138/78 and a heart rate of 52 for Resident 44 and decided to hold the clonidine because the heart rate was less than 60. However, the medication label only instructed to hold the medication for a systolic blood pressure under 100, with no instruction regarding the heart rate. This discrepancy between the medication label and the medication administration record (MAR) could lead to inappropriate administration of the medication, potentially causing a dangerously low heart rate. The Director of Nurses (DON) confirmed that the MAR should always match the medication label exactly to prevent such errors. For Resident 38, who was admitted with diagnoses including diabetes mellitus and heart failure, an opened container of Visine dry eye drops was found labeled with only the resident's first and last initials. The eye drops were taken from general stock and not properly labeled with the resident's full name. This labeling practice could lead to confusion about the intended recipient and potential cross-contamination. The DON acknowledged that using only initials on medications could result in the medications being given to the wrong residents with similar initials.
Failure to Ensure Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for Resident 416, who had been experiencing tooth pain. Resident 416, admitted with diagnoses including Chronic Pain, COPD, Diabetes, and Dysphagia, had a BIMS score indicating no cognitive impairment. Despite his complaints of tooth pain and the need for dental treatment, no appointment had been made for him. Hygiene notes from 6/9/23 indicated that Resident 416 could benefit from oral appliances due to multiple broken or rotting teeth, and he was prescribed a Chlorhexidine dental rinse. However, during interviews in April 2024, Resident 416 reported daily tooth pain and expressed frustration over the lack of dental care, stating that he felt like giving up on getting his teeth treated. The Minimum Data Set/Social Services Nurse (MDS/SS B) confirmed that the dental service process could take 6-8 weeks, but it had been 16 weeks since Resident 416's last dental exam on 11/30/23. The Director of Nursing (DON) confirmed that Social Services was responsible for coordinating dental care and should have followed up on Resident 416's dental consultation. The DON also mentioned that the Administrator had delegated social services work to the desk nurse and MDS nurse three months prior, due to inconsistencies in Social Services. Despite these changes, no further dental records were available after 11/30/23, and Resident 416 continued to experience unresolved dental pain.
Failure to Ensure Competency in Dietary Services
Penalty
Summary
The facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). The review of records indicated that the facility did not have consistent full-time RD coverage for 20 out of 26 weeks, with hours ranging from 16 to 36 hours per week. Additionally, the facility's Sanitation and Food Safety Checklist revealed that the Dietary Manager was not consistently present, and there were no RD approval signatures on menu substitutions records for over a month. Observations during a kitchen audit found issues with labeling, maintenance, and the absence of a written policy to honor resident preferences safely. Further inspection revealed that the facility lacked a Quality Assurance (QA) process to ensure residents were consuming physician-ordered nutritional supplements and did not have a Dining Committee that met quarterly. The menu was not followed as posted, and the cool-down log was not used accurately. Skill checks for food service workers were not up to date, and there was an inadequate supply of food based on licensed bed capacity. During an interview, the Administrator confirmed the facility did not have a qualified DSS and a full-time RD, and observations in the kitchen showed improper food storage practices.
Failure to Incorporate Resident Dietary Preferences
Penalty
Summary
The facility failed to consistently incorporate resident preferences in personal dietary choices for 8 of 68 sampled residents. The dietitian or nursing staff were supposed to identify a resident's food preferences within 24 hours after admission and offer a variety of foods at scheduled meals and snacks. However, observations and interviews revealed that residents were receiving food items they disliked, such as pre-made Jell-O that was described as rubbery, and lukewarm hot chocolate. Additionally, residents reported a lack of fresh fruit and snacks, with only canned or prepackaged options available. The facility also did not have a Dining Committee and had an inadequate supply of food based on licensed bed capacity. During interviews, residents expressed dissatisfaction with the food quality and availability. One resident mentioned that snacks were not always available on weekends, and another noted that the facility often ran out of snacks. The nourishment refrigerator was observed to have limited options, and prepackaged dried snacks were not readily available. Additionally, a resident's dietary ticket indicated butter packets, but the tray contained margarine instead. The facility only ordered margarine for resident food trays, although large blocks of butter were available for cooking. The Resident Council Minutes indicated that some residents were receiving dislikes on their meal trays and had not received butter for three weeks. The facility conducted a staff in-service training on meal preferences and the difference between margarine and butter. However, the issues persisted, and the facility's Quality Assessment and Performance Improvement (QAPI) Committee was supposed to review food preferences and meals periodically. Despite these measures, the facility failed to meet the residents' dietary needs and preferences consistently.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several observations and interviews. In the medication room, medical supplies were found in a dirty condition on the floor, and the sink, soap dispenser, and towel dispenser were also dirty. The Director of Nurses confirmed that the equipment and products were dirty and could cause cross-contamination. This indicates a lapse in maintaining a clean and sanitary environment in critical areas of the facility. Resident 316 was allowed to store and wash her soiled laundry in a shared bathroom, which had the potential to spread infection to Resident 44. Observations revealed that Resident 316 kept her soiled laundry in an open basin on the floor under the sink and washed her clothes in the shared bathroom sink. Interviews with the Environmental Services staff and the Infection Preventionist confirmed that this practice posed a risk of cross-contamination and was against the facility's infection control policies. Certified Nursing Assistant (CNA) E failed to perform hand hygiene between assisting two residents, Resident 15 and Resident 50. CNA E was observed assisting Resident 15 with toileting, including removing soiled briefs and wiping the resident, without performing hand hygiene before moving on to assist Resident 50. The CNA confirmed the lapse in hand hygiene, and the Infection Preventionist acknowledged that proper hand hygiene was not followed, increasing the risk of cross-contamination between residents.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure the safe administration of medications for four residents. Licensed Vocational Nurse (LVN) C did not check the expiration dates on medications administered to Resident 44, who had a history of essential primary hypertension and myocardial infarction. During a medication pass, LVN C administered several medications without verifying their expiration dates, which was confirmed by the Director of Nurses (DON) as a necessary step to prevent ineffective or harmful medication administration. LVN D failed to confirm the identities of Residents 39 and 60 before administering medications. Resident 39, diagnosed with paraplegia, adult failure to thrive, and GERD, received three medications without identity verification. Similarly, Resident 60, diagnosed with diabetes mellitus and fractures of the lumbosacral spine and pelvis, received gabapentin without identity confirmation. The DON acknowledged that proper identification is crucial to ensure medications are given to the correct residents. Additionally, Resident 38, who had diabetes mellitus and heart failure, was given the wrong eye drop medication. A bottle of Visine dry eye drops, pulled from over-the-counter stock, was found labeled with Resident 38's initials, despite the resident having an order for Refresh Tears Ophthalmic solution. The DON confirmed that the incorrect eye drops were administered to Resident 38, highlighting a failure to follow the prescribed medication orders.
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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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