Adventist Health Delano
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 1401 Garces Hwy, Delano, California 93215
- CMS Provider Number
- 056426
- Inspections on file
- 28
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Adventist Health Delano during CMS and state inspections, most recent first.
A resident with ALS, ventilator dependence, incontinence, and a stage 3 sacral pressure ulcer, assessed as totally dependent for care and requiring a Q2H turning/repositioning program, was repeatedly observed lying on the same side for several hours despite orders and facility policy requiring repositioning at least every two hours. Documentation showed the last recorded turn occurred several hours before the observation, and wound records indicated the sacral wound had deteriorated over time. Multiple CNAs and nursing staff reported there was no organized system to signal when residents needed to be turned, acknowledged that residents often waited longer than two hours—sometimes up to three hours—for repositioning, and the risk manager confirmed the absence of a set process for ensuring timely turning, contrary to the facility’s pressure injury prevention policy.
A resident who was fully dependent on staff for daily care due to severe medical conditions was observed with dry, flaky lips and significant debris on the teeth and tongue, indicating inadequate oral hygiene. Staff interviews confirmed that oral care was not being performed to the required standard, and there was no documentation of any difficulties in providing this care, despite facility policy requiring thorough oral hygiene.
A resident with a tracheostomy and cerebral infarction, who was cognitively intact, alleged abuse by a CNA using a communication board. After the allegation, the CNA was not removed from the facility or supervised, but was only told to avoid the resident's room and continued working her shift. Facility policy required separation or supervision of staff accused of abuse during investigations, but this was not followed.
The facility did not have a governing body responsible for establishing and implementing management policies, nor did it appoint a properly licensed administrator to manage operations, resulting in a deficiency in organizational leadership.
Surveyors found that a portable fire extinguisher located near the generator had not received its required annual inspection, as indicated by an outdated inspection tag. The Maintenance Director confirmed the missed inspection, which affected one smoke compartment and 23 residents.
Surveyors found that corridor doors were obstructed by a trash can and a bag of clothes, preventing proper closure. The Maintenance Director confirmed staff had placed these items, affecting one smoke compartment and 22 residents.
Surveyors found that the facility did not have documented agreements with other facilities or providers to receive residents during emergencies, as required in the Emergency Operations Plan. The Safety Director acknowledged an agreement with the county but could not provide supporting documentation.
The facility did not have a qualified Director of Activities overseeing the resident activities program, as the previous director had been on medical leave and no interim was appointed. CNAs, trained by a unit clerk, were conducting and assessing activities without the required supervision, and the facility could not provide a job description for the Director of Activities. This resulted in the activities program not being managed according to facility policy.
Two dented cans of garbanzo beans were found stored with other canned foods in the dry storage area, contrary to facility policy requiring dented cans to be separated for return or credit. This failure was identified during an inspection and confirmed by staff, indicating noncompliance with established food safety procedures.
Nursing staff used non-bleach wipes to disinfect a glucometer after use on three residents, contrary to manufacturer guidelines requiring bleach-based products. Infection control precaution signage was inconsistently posted and did not match current orders for several residents, and some staff lacked knowledge of the different types of precautions. Additionally, an EMTT failed to remove PPE and perform hand hygiene after caring for a resident on enhanced barrier precautions.
The facility did not ensure that informed consent for psychotropic medications was properly obtained according to policy for two residents. In both cases, nursing staff obtained signatures for consent, and the physician signed at a later date, rather than directly reviewing medication information and obtaining consent prior to administration as required.
A resident with a diagnosis of Bipolar Disorder and prescribed Risperidone was admitted with a PASRR that did not reflect their mental health condition or medication use. Facility staff did not review or update the PASRR after admission to accurately document the resident's diagnoses and treatments, and there was no policy in place for ongoing PASRR review.
A nurse did not follow facility policy for medication administration via a GTube when she failed to flush the tube with water between giving multiple medications to a resident who was NPO and receiving continuous tube feeding.
The QAA committee did not meet at least quarterly as required, with only three meetings held over a twelve-month period. The RNM confirmed the lack of quarterly meetings, and the facility's QAPI policy did not specify meeting frequency.
The facility failed to provide adequate nail care for four residents, leading to potential health risks. A resident with immobility was observed with long fingernails containing debris, posing an infection risk. Another resident required assistance for nail trimming, which was not provided. Two more residents were found with long fingernails, one of whom had contracted hands, increasing the risk of skin breakdown. The facility's policy on resident care management was not followed.
A facility failed to follow its restraint management policy for a resident using a right-hand mitten restraint. The resident's restraint was not monitored every two hours as required, with missing documentation on several occasions. Additionally, the order for the restraint was not renewed every three days as mandated by the facility's policy.
The facility failed to monitor and document medication room temperatures consistently, with missing entries in the logs from August 2024 to January 2025. This affected all residents with medications stored in the room, potentially altering medication effectiveness. The Facility Manager confirmed the importance of maintaining appropriate room temperatures to prevent medications from going bad.
The facility failed to secure hazardous materials in resident areas, posing a risk to 25 residents, including those using oxygen. Items like dust/lint remover, germicidal cleaner, and liquid glycol were accessible in the activities room, contrary to the facility's policy on hazardous materials management.
The facility failed to implement its food storage policy, resulting in numerous unlabeled and undated food items in resident areas. This included perishable and non-perishable goods, which were not properly identified or stored according to the facility's guidelines. The oversight was acknowledged by the Facility Manager, highlighting a systemic failure to adhere to food safety practices.
A facility failed to provide a resident with their home medications upon discharge. During an observation, two boxes of Albuterol Sulfate, a medication for breathing difficulties, were found in the medication room labeled with the resident's name. The Facility Manager confirmed the resident was discharged a month ago and the medication should have been sent home, as it was purchased by the resident's insurance. The facility could not provide a policy for discharge medications.
A facility failed to report an abuse allegation involving a resident's call light to CDPH within 24 hours and did not complete the investigation within five days. The resident, who had intact cognition but was unable to speak or move, relied on a communication board. Two CNAs implicated in the allegation continued working without being removed or monitored, contrary to facility policy.
A facility failed to provide timely podiatry care and administer IV antibiotics as ordered, leading to surgical intervention and delayed treatment for a resident's foot infections. Another resident also experienced a lack of podiatry care, with overgrown and discolored toenails. The facility lacked documentation and a podiatry policy.
A facility failed to notify a family member about a resident's change in condition, specifically a black discoloration on the resident's right heel. The family member discovered the issue during a podiatry appointment and was informed by staff that the condition had been present for some time. A nurse confirmed the presence of a dry callus and a wound consultant had seen it, but there was no record of family notification. The facility also failed to provide a change of condition policy when requested.
A resident with quadriplegia and other health issues had grievances regarding care that were not addressed by the facility. Despite being cognitively intact and dependent on staff, the resident's family reported issues such as the need for podiatry services and poor hygiene care. The facility's grievance policy was not followed, leaving the complaints unresolved.
A resident in a persistent vegetative state with a history of cardiac arrest and anoxic brain injury was found with maggots in their mouth due to inadequate oral care. Despite an MD's order to increase oral care frequency, the facility failed to update the care plan, resulting in continued twice-daily care instead of every six hours.
The facility failed to provide adequate staffing, affecting 12 out of 13 sampled residents who were dependent on staff for all aspects of care. Staff interviews and observations confirmed that essential tasks like turning residents every two hours and checking for incontinence were not being performed. This led to new skin wounds for two residents, highlighting the facility's inability to meet resident needs due to insufficient staffing.
The facility failed to follow their abuse policy when an LVN accused of hitting and pushing a resident was not removed from the schedule or monitored during the investigation. The resident had severe cognitive impairments and a history of chronic respiratory failure. Despite the policy requiring monitoring, the LVN continued to work without supervision.
A facility failed to complete an investigation for an abuse allegation within five working days. A resident's sister reported that an LVN had hit and aggressively pushed the resident's head. The investigation was delayed due to the DON being at a conference and the PCE being unaware of the allegation. The facility's policy did not specify a timeframe for completing abuse investigations, leading to a significant lapse in response.
The facility failed to provide adequate staffing, resulting in residents not being turned every two hours, delays in answering call lights, and incomplete RNA exercises. Interviews and record reviews confirmed that the workload was too high for CNAs to meet the residents' needs.
The facility failed to ensure that 41 licensed nurses were competent in managing nephrostomy and G-tube care. One resident's nephrostomy bag was placed on the floor, leading to potential contamination and infection. Additionally, two residents with G-tubes were administered medications improperly, with an LVN not following proper procedures. The facility's policies and procedures were found to be inadequate in ensuring proper training and competency for the nurses.
The facility failed to implement an effective QAPI program. Meeting minutes showed blank action columns for survey findings, and the QM admitted to a lack of data and collaboration. The DON confirmed the QAPI's ineffectiveness without data. The QAPI plan was not effectively implemented due to the absence of data and departmental assessment.
The facility failed to conduct proper infection control surveillance, store and label oxygen tubing correctly, maintain a clean environment for a nephrostomy, and ensure proper hand hygiene practices among staff. These deficiencies had the potential to cause serious infections among residents, staff, and visitors.
The facility failed to complete Minimum Data Set (MDS) quarterly assessments for multiple residents within the required timeframe. The MDS Coordinator admitted to being behind on assessments and cited a lack of trained staff and recent training as contributing factors. This failure had the potential to delay the development and implementation of individualized care plans.
The facility failed to maintain professional standards of quality, including improper care of a nephrostomy tube, incorrect administration of medications through a G-tube, a CNA performing tasks outside their scope of practice, and a missed physician order for a psychiatric consult, leading to delays in care.
The facility failed to follow its policy for pressure ulcer care by not turning and repositioning a completely immobile resident every two hours, as required. Despite being at very high risk for skin breakdown, the resident was left in the same position for extended periods, compromising the healing process of a stage 4 pressure injury.
The facility failed to provide the Restorative Nursing Assistant (RNA) program to maintain or improve mobility for five residents. Observations and interviews revealed that residents were not receiving the prescribed range of motion (ROM) exercises. Staffing records indicated inconsistent assignment of RNA duties, and several dates showed no RNA staff assigned at all. Interviews with CNAs revealed they were overwhelmed with other duties and lacked proper training and access to residents' RNA orders. The Director of Nursing acknowledged awareness of the issue but admitted there was no plan to replace the RNA staff who had left.
The facility failed to maintain safe and sanitary food handling practices in one freezer and one refrigerator. Open food items in Freezer #6 and Refrigerator #5 were found without open dates, contrary to the facility's policy. The Certified Dietary Manager confirmed that all food items should be labeled with a use-by date and opened date.
The facility failed to create a policy and procedure for safe food handling and storage of food brought to residents by family and visitors. Staff members, including the Activities Director, Regulatory Specialist, and Registered Nurses, were unaware of any existing guidelines, and the Director of Nursing confirmed the absence of such a policy.
The facility failed to perform the antibiotic stewardship program for three residents when critical information was missing from the Infection Surveillance Log. The Infection Preventionist acknowledged the mistake, and the Director of Infection Prevention admitted to not reviewing the log, contrary to the facility's policy on optimizing clinical outcomes and appropriate antimicrobial use.
The facility failed to follow their P&P for a resident who did not have a spare tracheostomy tube at the bedside. Observations revealed the absence of an ambu bag, emergency blow by, and spare tracheostomy supplies. Staff confirmed that these items should have been present, and the facility's P&P required a second tracheostomy tube to be kept at the bedside.
A facility failed to consistently monitor a resident's behavior who was on Sertraline for depression. The resident showed signs of frustration and sadness, but staff did not regularly document these behaviors. The Pharmacist Supervisor found no evidence of behavior review, and the DON confirmed missing and incomplete monitoring sheets for several months.
The facility failed to ensure a gradual dose reduction (GDR) for an anti-depressant medication prescribed to a resident. The Pharmacist Supervisor confirmed that the review for GDR should have started in November 2023, but no documentation was found. The facility's policy required at least two GDR attempts within the first year of residency or after medication initiation, with at least one month between attempts. The lack of GDR documentation could potentially indicate the unnecessary continuation of the medication.
The facility failed to label and date an IV solution and tubing for a resident, and also failed to date the glucose QC testing strips vial upon opening on one of the medication carts. The RN admitted the IV bag was not labeled, and the DON confirmed this was against policy. The LVN and CN acknowledged the QC strips should be dated upon opening.
Failure to Consistently Reposition High-Risk Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered turning and repositioning interventions every two hours for a resident with significant risk factors and an existing pressure ulcer. The resident was admitted with severe sepsis with septic shock, ALS, and ventilator dependence, and was assessed on the MDS as having a BIMS score of 0, being totally dependent on staff for all care, and always incontinent of bowel and bladder. The MDS documented that the resident was at risk for developing pressure ulcers and required a turning/repositioning program. Subsequent wound documentation showed the development of a sacral shearing injury that progressed to a stage 3 pressure ulcer not present on admission, with measurements indicating deterioration over time and the need for strict repositioning every two hours. On the day of survey observation, the resident was repeatedly observed lying on the left side with pillows to the back at multiple time points over several hours. Nursing staff interviews confirmed that the resident was supposed to be turned and repositioned every two hours due to the stage 3 pressure ulcer. However, the electronic medical chart for that day showed the last documented turn to the left side at 10:05 a.m., and by 1:47 p.m. the wound nurse acknowledged the resident should have been turned around noon but remained on the left side. Multiple CNAs and nursing staff reported there was no organized or set process in the facility to know when residents needed to be turned and repositioned. CNAs stated they tried to remember when to turn residents, that residents often waited more than two hours, sometimes up to three hours, and that turning could be delayed more than 30 minutes past the intended time, especially when staffing was short or staff were busy. The risk manager confirmed the facility did not have a set process for determining when it was time to turn and reposition residents, despite a written policy requiring repositioning at least every two hours for residents unable to reposition themselves and applying this standard to residents with stage 3 pressure injuries.
Failure to Provide Adequate Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral hygiene for one of three sampled residents who was completely dependent on staff for all activities of daily living due to severe medical conditions, including ALS, ventilator dependence, and chronic respiratory failure. During observation, the resident was found in bed, unable to verbally respond, with dry, flaky lips and significant white to yellowish debris covering the teeth and tongue. The tongue had a visible film elevated approximately 1/16 of an inch, indicating a lack of proper and consistent oral care. Interviews with facility staff revealed that oral care was not being performed to the required standard. The Director of Staff Development acknowledged that the resident's mouth and tongue needed cleaning and that staff should be providing oral hygiene every shift, but admitted it was not being done adequately. A respiratory technician stated oral care had been attempted earlier but described the resident as difficult to clean, without having reported these difficulties to nursing or supervisory staff. Review of the resident's care plan confirmed the need for staff-assisted oral care, but there was no documentation of any challenges in providing this care. Facility policy required thorough oral hygiene, including cleaning the cheeks, palate, and tongue, and applying lubricant to dry lips, but these procedures were not followed as observed.
Failure to Separate Accused Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure for one resident who alleged abuse by a Certified Nursing Assistant (CNA). The resident, who had a tracheostomy and cerebral infarction and was assessed as cognitively intact, communicated an allegation of bullying by a CNA using a letter board. The allegation was reported to the facility's Nursing Facility Supervisor (NFS) and Quality Assurance Nurse (QAN), who confirmed that the accused CNA was neither removed from the facility nor placed under supervision after the allegation was made. The CNA continued to work her shift and was only instructed not to enter the resident's room, but no further action was taken to separate her from other residents or to monitor her interactions. Review of the facility's policy indicated that in cases of alleged abuse, the involved staff member should be assigned to non-patient care activities or, if not possible, should be supervised at all times during the investigation. The policy emphasizes the need to protect residents from potential abuse during investigations. However, the facility did not follow these procedures, as the CNA remained in her regular duties without supervision or reassignment, potentially exposing other residents to risk.
Failure to Establish Governing Body and Appoint Licensed Administrator
Penalty
Summary
The facility failed to establish a governing body that is legally responsible for setting and implementing policies for the management and operation of the facility. Additionally, the facility did not appoint a properly licensed administrator to oversee the management of the facility. These actions resulted in a deficiency related to the facility's organizational structure and leadership responsibilities.
Missed Annual Inspection of Portable Fire Extinguisher
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by a missed annual inspection. During a facility tour, surveyors observed that the exterior portable fire extinguisher located adjacent to the generator had an inspection tag dated over a year prior. The Maintenance Director confirmed that the annual inspection had not yet been completed at the time of the survey. This deficiency affected one of two smoke compartments and impacted 23 of 45 residents.
Plan Of Correction
K 355 Immediate Correction: The fire extinguisher was replaced with one that had completed the annual inspection timely. This finding had the potential to affect all residents. No harm was identified. Sustainment: The Facilities Staff was educated by the Facilities Manager on the importance of ensuring all fire extinguishers have their required inspection and maintenance. See attached education signature sheet. Monitoring: The specified fire extinguisher location will be included in ongoing EOC rounds to ensure it doesn't get missed again in the future due to its remote location. Data will be collected and reported out to the EOC Committee and the SCU Quality Assurance committee as part of the facility QAPI program. Person Responsible: Facilities Manager
Corridor Doors Obstructed by Staff Items
Penalty
Summary
During a facility tour, surveyors observed that corridor doors intended to protect openings were obstructed, preventing them from closing as required by NFPA 101 Life Safety Code. Specifically, the corridor door of Room 226 was blocked by a trash can, and the corridor door of Room 221 was obstructed by a plastic bag full of clothes. These obstructions resulted in both doors being unable to close properly. The Maintenance Director confirmed during interviews that staff had placed these items in front of the doors, with the intention of moving them later. These findings affected one of two smoke compartments in the facility and impacted 22 of 45 residents. The report does not provide additional details about the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Immediate Correction: The items blocking the doors were removed. All residents have the potential to be impacted by the finding, but no harm was identified and no other doors were found blocked upon inspection. Sustainment: Education was provided to the SCU staff by the Director of Staff Development on the requirement that all fire doors remain clear and able to close properly in order to protect life and property in case of fire. See attached sign-in sheets. Monitoring: Rounding will occur three times a week by the Manager of the Special Care Department to verify that no doors are blocked or obstructed in any way. Data will be collected and reported out to the SCU Quality Assurance Committee as part of the facility's QAPI program. Person Responsible: SCU Nurse Manager
Missing Documentation of Emergency Transfer Arrangements
Penalty
Summary
The facility failed to maintain an Emergency Operations Plan (EOP) that included required documentation of arrangements with other facilities or providers to receive residents in the event of limitations or cessation of operations. During a record review and interview with the Safety Director, surveyors found that the facility could not provide evidence of such agreements or arrangements as mandated by federal regulations. The Safety Director stated that there was an agreement with the county, but was unable to produce any documentation to support this claim. This lack of documented arrangements was identified during the review of the EOP and confirmed in the interview, resulting in a deficiency related to emergency preparedness and continuity of care for residents.
Plan Of Correction
Immediate Corrections: The Emergency Management binder and missing documentation were located and returned to the AHDL site. See attached Kern County Emergency Operation Manual, ADHL KCHCC Partner Participation Agreement, and the AH Delano Grant Letter. All residents had the potential to be affected by this issue, but no harm was identified for any residents. Sustainment: The Accreditation Manager educated the Facilities Manager on the requirement to maintain the Emergency Operations Manual on site at all times, and to not allow the binder to be removed for any reason, even short term use. Likewise, the Emergency Management Manager was also educated to complete any updates or changes to the manual on site, and not to take it to another location to work on it. Monitoring: The Manager of Facilities will verify the binder is in the unit at least monthly to ensure that the Manual is still on site and has not been removed. This will continue for 6 months to ensure sustainment. Data will be reported out to the SCU Quality Assurance Committee as part of the QAPI program. Person Responsible: Facilities Manager E 025
Lack of Qualified Activities Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified full-time Director of Activities for all 45 residents. According to interviews with staff, the Director of Activities had been out on medical leave since February 2025, and no interim Director of Activities had been appointed. Certified Nursing Assistants (CNAs) were trained by a unit clerk to complete the Activities Evaluation in the electronic health record system and on paper, but there was no qualified individual overseeing the activities program. The Registered Nurse Manager confirmed that CNAs were responsible for assessing and conducting activities in the absence of a Director of Activities. The facility was unable to provide a job description for the Activities Director when requested. Review of the facility's policy indicated that the activities program should be under the direct supervision of an Activities Coordinator, who is responsible for planning, coordinating, and directing activities, as well as participating in resident assessments and care planning. The lack of a qualified Director of Activities meant that the program was not being supervised or managed according to facility policy, potentially impacting the quality and appropriateness of activities provided to residents.
Failure to Remove Dented Canned Food from Storage
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the storage of foods and physical environment when two out of six 12-ounce cans of garbanzo beans with significant dents were not removed from the dry storage room. During an observation in the dry food storage area, the lead staff member identified and removed the dented cans, noting that they should not have been stored with other canned foods intended for resident use. The facility's policy required that any dented cans be placed in a designated section for return or credit, which was not followed in this instance. This lapse was confirmed during interviews and a review of the facility's written procedures.
Infection Control Failures in Disinfection, Precaution Signage, and PPE Use
Penalty
Summary
Nursing staff failed to properly disinfect a glucometer after use on three residents. The staff used Super Sani-Cloth Germicidal Disposable Wipes, which contain isopropyl alcohol and quaternary ammonium compounds, instead of the manufacturer-recommended hospital-approved germicidal bleach products. The infection preventionist confirmed that the facility used these wipes, which do not contain bleach, for glucometer disinfection. Manufacturer guidelines specifically require the use of EPA-registered bleach products for cleaning the glucometer, but this protocol was not followed. The facility did not implement its own infection control policies regarding the posting and accuracy of infection control precaution (ICP) signage for residents. In several cases, the signage on residents' doors did not match the current physician orders or the residents' actual precaution status. For example, one resident had a contact precautions sign posted despite not having an active order for contact precautions, while another resident had enhanced barrier precautions (EBP) signage posted when the order was for contact precautions due to a multidrug-resistant organism. Staff interviews revealed a lack of knowledge about the different types of ICPs and the reasons for their use, and attendance records showed that not all staff had received required training on these precautions. Additionally, an Emergency Medical Technician Transport (EMTT) staff member failed to remove personal protective equipment (PPE) and perform hand hygiene after providing care to a resident under enhanced barrier precautions. The EMTT exited the resident's room still wearing gown and gloves and did not clean his hands, contrary to facility policy and posted instructions. Both the EMTT and a licensed nurse acknowledged that PPE should have been removed and hand hygiene performed before leaving the room. The facility's policies and CDC guidelines require proper disposal of PPE and hand hygiene to prevent the spread of infection.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and complete informed consent for psychotropic medications for two of four sampled residents. For one resident, the consent for Seroquel 25 mg at bedtime was signed by nursing staff on one date and by the physician on a later date, with the process described as nurses obtaining consent from the family or resident and the physician signing during their visit. For another resident, the consent for Risperidone 1 mg at bedtime was similarly signed by nurses and then by the physician at a later date, with the nurse stating that consents are obtained from the family and resident in the facility. A review of the facility's policy indicated that it is the physician's responsibility to review medication information and obtain informed consent from the patient or legal guardian prior to the initial administration of the medication. The policy also allows for consent to be obtained in person or by telephone, with a licensed nurse witnessing the conversation if consent is given verbally. The documented process in these cases did not align with the facility's policy, as the physician did not directly obtain informed consent prior to medication administration.
Failure to Accurately Complete and Review PASRR for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to accurately review and complete the annual Pre-Admission Screening Assessment and Resident Review (PASRR) for a resident. The PASRR Level 1 Screening, completed prior to admission, indicated that the resident did not have a serious diagnosed mental disorder and was not prescribed psychotropic medications for mental illness. However, upon review of the resident's diagnosis list and physician orders, it was found that the resident had a diagnosis of Bipolar Disorder and was prescribed Risperidone, a medication used to treat this condition. These diagnoses and medications were not reflected in the PASRR documentation. Interviews with facility staff revealed that while the hospital completed the initial PASRR upon admission, the facility did not review or update the PASRR to reflect the resident's current diagnoses and medication orders. The Registered Nurse confirmed that the resident's mental health diagnosis was present in the medical record but not on the PASRR. Additionally, the facility did not have a policy in place for reviewing or updating PASRRs after admission.
Failure to Flush GTube Between Medications During Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 2 failed to follow the facility's policy and procedure for medication administration through a feeding tube for one resident with a gastrostomy tube (GTube). During a medication pass, LVN 2 administered Docusate Sodium via the GTube and proceeded to administer the next medication without flushing the tube with water in between, as required by the facility's policy. The policy specifically states that when giving multiple medications, the tube should be flushed with 5-10 mL of water between medications. LVN 2 acknowledged during an interview that she did not flush the tube as required. The resident involved had orders for continuous tube feeding and was NPO (nothing by mouth) at the time of the incident.
QAA Committee Failed to Meet Quarterly as Required
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. Record review and interview with the Registered Nurse Manager (RNM) revealed that the QAA committee only met three times over a twelve-month period, with meeting dates documented as 1/20/25, 9/12/24, and 5/23/24. The RNM confirmed these were the only meetings held during the past year and acknowledged that the committee did not meet quarterly. Additionally, review of the facility's Quality Assurance and Performance Improvement Plan policy did not specify the required frequency for QAA committee meetings.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for four residents, leading to potential health risks. Resident 1, who was totally dependent on assistance for personal hygiene due to immobility, was observed with long fingernails containing dark gray debris. The Infection Preventionist noted that Resident 1 was at risk for infection due to behaviors such as digging or putting hands in briefs. Licensed Vocational Nurse 1 acknowledged that trimming should have been done. Similarly, Resident 2, who also required total assistance, was found with long fingernails and debris, and LVN 2 admitted the need for trimming. Residents 3 and 4 were also observed with long fingernails and debris. Resident 3 required total assistance for personal hygiene, and the Infection Preventionist confirmed the need for nail trimming. Resident 4, with contracted hands, was at risk for skin breakdown due to long fingernails touching the palms. The facility's policy on resident care management, which mandates a comprehensive approach to meet residents' needs, was not followed, as confirmed by the Risk and Regulatory Analyst during a review of the facility's procedures.
Failure to Monitor and Renew Restraint Orders
Penalty
Summary
The facility failed to adhere to its policy and procedure on restraint management for a resident who was using a right-hand mitten restraint to prevent the pulling of medical devices. The resident's restraint was not monitored every two hours as required, with missing documentation on several occasions, including specific times on multiple days. This lack of monitoring was confirmed through interviews with staff and a review of the resident's restraint flowsheet, which showed gaps in the required documentation. Additionally, the facility did not renew the order for the resident's restraint every three days as mandated by their policy. The order for the restraint, initially placed by a physician, had not been renewed since its original date. This oversight was acknowledged by the staff during interviews and was further supported by a review of the facility's restraint management policy, which clearly stated the need for renewal every three days if restraints were to be continued.
Failure to Monitor Medication Room Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the temperatures in the medication room, which is crucial for maintaining the effectiveness of medications stored there. This deficiency was identified through observation, interviews, and record reviews, revealing missing entries in the medication room temperature logs (MRTL) for several months. The Facility Manager acknowledged that there should be no missing entries, as the purpose of the MRTL is to ensure the room temperature is appropriate to prevent medications from going bad. The missing entries spanned from August 2024 to January 2025, affecting all 34 residents who had medications stored in the room. The facility's policy and procedure on air exchange rate, filtration, air pressure relationship, temperature, and humidity, dated July 27, 2022, requires daily documentation of room temperature in the Air Pressure Relationship, Temperature and Humidity - Mitigation form. This documentation is necessary to demonstrate compliance with adopted codes and to record any mitigation and corrective actions for failures. However, the facility did not adhere to this policy, as evidenced by the numerous missing entries in the MRTL, which could potentially alter the effectiveness of the medications for all residents in the facility.
Failure to Secure Hazardous Materials in Resident Areas
Penalty
Summary
The facility failed to implement its policy on hazardous materials for 25 out of 34 sampled residents. During an observation and interview in the activities room, it was noted that several hazardous items were not secured and were accessible to residents. These items included a can of dust/lint remover, a bottle of foaming germicidal cleaner, and eight cans of liquid glycol with wick. The Quality Assurance (QA) staff confirmed that these items should not be in resident care areas as they pose a risk to residents, especially since some residents use oxygen, which is flammable. The facility's policy on hazardous materials, waste management handling, storage, transport, and disposal was reviewed. It indicated that hazardous chemicals should be properly identified, segregated, contained, stored, transported, treated, and disposed of to minimize health risks. The policy defines hazardous substances as those that are toxic, corrosive, irritants, flammable, or combustible. The presence of these unsecured hazardous materials in the activities room, where residents requiring oxygen frequently gather, represents a failure to adhere to the facility's policy, potentially endangering the residents' safety.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy on the storage and labeling of food items brought in by family and visitors for 11 of 34 sampled residents. During observations, numerous food items in the resident refrigerator and cabinets were found unlabeled, undated, and without identification of ownership. These items included perishable goods such as chocolate cake, lemon pie, and various condiments, as well as non-perishable items like coffee grounds and cookies. The lack of proper labeling and dating of these items was confirmed by the Facility Manager (FM), who acknowledged the oversight and the potential risk of foodborne illness. The facility's policy, titled "Use and Storage of Foods Brought to Residents by Family and Visitors," mandates that all food items brought into the facility must be labeled with the resident's name, content, preparation date, and a discard/use-by date. Additionally, the policy requires that perishable foods be stored in designated refrigeration units separate from the main kitchen, and non-perishable foods be stored in airtight containers to prevent staleness and pest infestation. However, during the survey, it was evident that these procedures were not followed, as multiple food items were found without the necessary labeling and dating. The deficiency was observed over two consecutive days, with the FM admitting that the food items should have been labeled and dated according to the facility's policy. Despite the findings from the first day, similar issues were noted the following day, indicating a systemic failure to adhere to the established food safety and sanitation practices. This oversight had the potential to compromise the health and safety of the residents by increasing the risk of foodborne illnesses due to improper food storage and handling.
Failure to Provide Discharge Medications
Penalty
Summary
The facility failed to provide home medications for one of the sampled residents, identified as Resident 12, upon discharge. During an observation in the facility medication room, two boxes labeled with Resident 12's name were found containing Albuterol Sulfate, a medication used to treat breathing difficulties. The boxes, dated 12/22/24, contained 120 vials of the medication and had a note indicating that Resident 12 was discharged, although no specific discharge date was provided. During an interview, the Facility Manager confirmed that Resident 12 was discharged approximately a month prior and acknowledged that the Albuterol should have been sent home with the resident, as it was purchased by the resident's insurance. A review of Resident 12's order summary confirmed the discharge, but the facility was unable to provide a policy or procedure for discharge medications when requested.
Failure to Report and Investigate Abuse Allegation Timely
Penalty
Summary
The facility failed to implement its policy and procedure for abuse prevention and reporting for a resident who made an allegation of abuse. The resident, who had intact cognition but was unable to speak or move, relied on a communication board and a call light to indicate needs. During a care conference, the resident's family member reported an allegation of abuse involving staff taking away the resident's call light. However, the facility did not report this allegation to the California Department of Public Health (CDPH) within the required 24-hour timeframe, as the report was not made until several days later. Additionally, the facility did not complete the investigation into the abuse allegation within the mandated five-day period. The investigation, which should have been completed by a specific date, was delayed and only concluded ten days after the allegation was made. The department manager was unsure of who was responsible for handling abuse allegations, indicating a lack of clarity and adherence to the facility's procedures. Furthermore, two Certified Nursing Assistants (CNAs) who were implicated in the abuse allegation continued to work in the facility without being removed or monitored, contrary to the facility's policy. The CNAs were not taken off the schedule or observed while working with residents, which was a requirement during the investigation period. This oversight allowed the CNAs to continue their duties without the necessary precautions being taken to protect the residents, as outlined in the facility's policy and procedure for handling suspected abuse cases.
Deficiencies in Podiatry Care and Antibiotic Administration
Penalty
Summary
The facility failed to ensure timely podiatry care and treatment for a resident, resulting in the need for surgical intervention and intravenous antibiotics due to infections in the resident's feet. The resident, who had a history of quadriplegia, COPD, tracheostomy, and diabetes mellitus, was dependent on staff for lower body dressing and footwear. Despite a physician's order for a podiatry consult dated over a year prior, the resident was not seen by a podiatrist until much later, leading to the diagnosis of infected ingrown toenails requiring surgical and antibiotic treatment. Additionally, the facility did not administer IV antibiotics as ordered by the physician for the resident's foot infections. The antibiotics were prescribed to start immediately after a podiatry procedure, but there was a delay of three days before the treatment began. This delay was due to a missed physician order, as confirmed by a registered nurse, and was not documented in the resident's medication administration record. Another resident also experienced a lack of timely podiatry care. Despite having a physician's order for podiatry consults every two months, the resident had not been seen by a podiatrist for several months. The resident's toenails were overgrown, discolored, and thick, indicating a need for podiatry care. The facility lacked documentation of assessments or monitoring of the resident's feet, and no podiatry policy and procedure were provided when requested.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a family member regarding a change in condition for a resident, specifically concerning the resident's right heel. The family member noticed the resident's right heel was black with a possible skin injury during a podiatry appointment and was informed by unspecified facility staff that the heel had been in that condition for a while. However, the family member had not been informed about this change in condition. A registered nurse confirmed the presence of a dry callus with a black color on the resident's heel and mentioned that a wound consultant had seen it, with podiatry scheduled to follow up. The nurse was unsure if the family member had been contacted about this change. A review of the resident's electronic medical record by the Quality Assurance team revealed that the issue with the resident's right heel was first noted on August 28, 2024. However, there was no documentation indicating that the family member was notified of this change in condition. Additionally, when a request was made for the facility's change of condition policy and procedure, no such policy or procedure was provided by the facility.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure for a resident diagnosed with quadriplegia, COPD, acute on chronic respiratory failure with hypoxia, and a tracheostomy. The resident was cognitively intact and completely dependent on staff for personal care. Despite these needs, grievances regarding the resident's care were not addressed by the facility. The resident's family member reported issues such as the need for podiatry services, foul odor in the resident's hair and beard, pain and discharge in the resident's eye, and lack of communication when the resident refused care. During an interview, the family member stated that grievances had been verbally communicated to the facility staff for almost a year without resolution. A meeting was held with various staff members, including a registered nurse, social services director, and a respiratory therapist, where these issues were discussed. However, the family member did not receive any response from the facility regarding these grievances, some of which had been outstanding for months. The facility's policy required grievances to be documented in writing and investigated by an impartial team. However, the social services director admitted that the complaints raised during the interdisciplinary team meeting were not processed as grievances. The facility's failure to follow its grievance procedure resulted in the resident's care issues remaining unaddressed, as confirmed by the social services director who was unsure if any follow-up actions were taken.
Failure to Implement MD Orders for Oral Care
Penalty
Summary
The facility failed to implement the Medical Doctor's orders for a resident who was in a persistent vegetative state and completely dependent on staff for all aspects of care. The resident had a history of cardiac arrest, anoxic brain injury, and acute on chronic respiratory failure. During oral care, maggots were discovered in the resident's mouth, and it was noted that the resident was NPO and unable to close his mouth completely due to his medical condition. Following this discovery, the MD ordered an increase in oral care frequency from twice a day to every six hours. However, the facility did not input the new order into the resident's care plan, and the resident continued to receive oral care only twice a day. Interviews with staff revealed that the MD's order to increase oral care frequency was not executed. The facility's policy required all orders to be recorded and double-checked by the night nurse every 24 hours, but this process was not followed, leading to the deficiency in care for the resident.
Inadequate Staffing Leads to Deficient Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Observations, interviews, and record reviews revealed that 12 out of 13 sampled residents were affected by this staffing shortage. Residents who were completely dependent on staff for all aspects of care, such as those with functional quadriplegia, chronic respiratory failure, and persistent vegetative states, were not receiving the necessary assistance. For instance, Resident 1, who is incontinent and requires complete assistance, reported waiting 20 to 30 minutes for help due to insufficient staffing. Similarly, Resident 2, who cannot turn herself in bed, was only turned twice a day instead of every two hours as required. Interviews with staff members, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), confirmed the staffing issues. They reported being overwhelmed and unable to perform essential tasks like turning residents every two hours and checking for incontinence. One CNA mentioned being assigned 21 total care residents with another CNA, which is far beyond the manageable workload. The Director of Nursing (DON) acknowledged that approximately 98% of the residents were total care and that the current staffing levels were inadequate to meet their needs. The inadequate staffing led to new skin wounds for two residents, Resident 10 and Resident 12. Resident 10 developed a sore on her buttocks due to not being turned or changed every two hours, while Resident 12 acquired a blister on the left foot and an abrasion on the coccyx. The Wound Nurse confirmed that these wounds were preventable and attributed them to the lack of staffing. Observations also showed that multiple residents were left in the same position for extended periods, further highlighting the facility's failure to provide adequate care due to insufficient staffing.
Failure to Follow Abuse Policy and Procedure
Penalty
Summary
The facility failed to follow their policy and procedure on abuse for one of 13 sampled residents when the alleged abuser, an LVN, was not removed from the working schedule and/or monitored until cleared from the abuse allegation. Resident 13, who had a history of chronic respiratory failure, dependence on a respirator, a tracheostomy, and a myoneural disorder, was allegedly hit and aggressively pushed by the LVN. Despite the allegation, the LVN continued to work on subsequent days without being directly monitored, contrary to the facility's policy that requires staff accused of abuse to be monitored by their immediate supervisor during the investigation period. Interviews with the facility staff, including an RN, the Social Services Director, and the Risk and Regulation Analyst, confirmed that the LVN was not removed from the schedule and was not directly monitored while the investigation was ongoing. The facility's policy clearly states that staff members accused of abuse should not be assigned to the involved patient and must be monitored by their immediate supervisor. However, the LVN worked on two separate days after the allegation without such monitoring, and the investigation into the abuse allegation was still incomplete at the time of the surveyor's review.
Failure to Timely Investigate Abuse Allegation
Penalty
Summary
The facility failed to complete an investigation for an allegation of abuse within five working days. On 4/24/24, Resident 13's sister reported that a Licensed Vocational Nurse (LVN) had hit and aggressively pushed Resident 13's head. Despite this serious allegation, the investigation was not completed until 5/7/24, which is beyond the five-day timeframe typically expected for such investigations. Interviews with staff revealed that the Director of Nursing (DON) was unavailable due to attending a conference, and the Patient Care Executive (PCE) covering for the DON was unaware of the abuse allegation. Additionally, the Risk and Regulation Analyst (RRA) admitted that the facility's policy and procedure did not specify a timeframe for completing abuse investigations, highlighting a gap in their protocol. The delay in completing the investigation had the potential to compromise the thoroughness of the investigation and could have resulted in further abuse. The Social Services Director (SSD) confirmed that the investigation had not been completed as of 5/1/24, and the facility's Investigative Report Summary indicated that the investigation was only completed on 5/7/24. This failure to promptly investigate the abuse allegation demonstrates a significant lapse in the facility's response to serious incidents, potentially putting residents at risk.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate direct care staff to meet the daily needs of residents, resulting in several deficiencies. Residents 21, 18, 34, and 31 were not turned every two hours as required, increasing the risk of pressure injuries. Interviews with CNAs revealed that the workload was too high, with each CNA responsible for up to 16 residents, making it difficult to adhere to the turning schedule. Record reviews confirmed that the turning policy was not consistently followed, as documented in the Hourly Rounding Reports (HRR) for the residents involved. Resident 21 experienced delays in having her call light answered, sometimes waiting up to 30 minutes. This delay was attributed to the insufficient number of CNAs available to respond promptly. Additionally, Resident 21 reported that her face and hands were not cleaned before meals unless she specifically requested it, further indicating a lack of adequate care due to staffing shortages. The facility also failed to perform the Restorative Nursing Assistant (RNA) program as ordered for Residents 21, 34, and 19. CNAs were given the additional responsibility of RNA exercises, but they reported not having enough time to complete these tasks. Interviews with staff and residents confirmed that the RNA exercises were not being performed regularly, and the facility's Patient Oriented Council (POC) minutes indicated ongoing concerns about staffing levels and the quality of care provided.
Deficiency in Nephrostomy and G-Tube Care Competency
Penalty
Summary
The facility failed to ensure that 41 licensed nurses were competent in managing nephrostomy and gastrostomy (G-tube) care for residents. Specifically, one resident with a nephrostomy tube had their nephrostomy bag placed on the floor, which could lead to contamination and infection. The nurses involved admitted to not being trained in nephrostomy care, and there were no competencies in place for this procedure. The Infection Preventionist and Director of Nursing confirmed the lack of training and communication regarding nephrostomy care, which may have contributed to the resident's repeated urinary tract infections (UTIs). Additionally, two residents with G-tubes were administered medications improperly. An LVN was observed crushing and mixing multiple medications together and administering them through the G-tube without flushing it with water before or after the medication administration. The LVN acknowledged the mistake and admitted to not following proper procedures. The Clinical Nurse Educator confirmed that the competency checklist did not cover G-tube medication administration, and the Director of Nursing acknowledged the lack of competencies for this procedure. The facility's policies and procedures for medication administration through a feeding tube and employee competency were reviewed and found to be inadequate in ensuring proper training and competency for the nurses. The deficiencies in training and competency for both nephrostomy and G-tube care led to potential risks for the residents involved, including infections and improper medication administration.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance Performance Improvement Program (QAPI). During a review of the facility's Special Care Unit (SCU) Quality Assurance Meeting Minutes, it was found that the action column for the survey findings was left blank. The Quality Manager (QM) admitted that the QAPI was not collaborative and that no data was provided to present in QAPI meetings because she was unable to pull reports. The Director of Nursing (DON) confirmed that the QAPI would not be effective without data to support it. The facility's Quality Assurance and Performance Improvement Plan (QAPI) for the Special Care Unit (SCU) outlined a performance improvement model that included identifying opportunities for improvement, developing a plan for improvement, and collecting data. However, the plan was not effectively implemented as there was no data gathered or assessed at the department level. The Quality/Risk Coordinator was responsible for managing and coordinating performance improvement activities, but the lack of data and collaboration hindered the effectiveness of the QAPI program.
Infection Control Deficiencies
Penalty
Summary
The facility failed to conduct proper infection control surveillance, which included the collection of data, analysis, tracking, and trending of infections for all 46 residents. The Infection Preventionist (IP) and Director of Infection Prevention (DIP) did not perform their duties to complete infection control surveillance. The Infection Surveillance Log (ISL) was incomplete, with missing information for several residents. The IP admitted to not completing the ISL and not updating the facility floor map regularly. The DIP also did not review the ISL, contrary to their job description requirements. This lack of surveillance and data analysis hindered the facility's ability to trace infection sources and evaluate control measures effectively. The facility also failed to store and label oxygen tubing properly to prevent contamination. In one instance, a resident's oxygen tubing was found undated and hanging on a metal hook without a plastic bag. The Licensed Vocational Nurse (LVN) and Respiratory Therapist (RT) confirmed that the tubing should be changed every seven days or when it becomes dirty, but no policy was provided for proper storage and labeling. Additionally, the facility did not ensure that a resident's nephrostomy was secured and maintained in a clean environment. The nephrostomy bag was observed on the floor, and the site was not covered with a dressing. LVNs admitted to not receiving proper training for nephrostomy care, and the IP acknowledged that the site should be kept sterile to prevent infections. Furthermore, the facility failed to ensure proper hand hygiene practices among staff. In two separate instances, LVNs did not change gloves or perform hand hygiene after administering medications through a gastrostomy (G-tube) before providing oral care or suctioning a tracheostomy. The IP confirmed that nurses should change gloves and perform hand hygiene between different tasks to prevent cross-contamination. These failures in infection control practices had the potential to cause serious infections among residents, staff, and visitors in the facility.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) quarterly assessments were completed for five of nine sampled residents. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) admitted to being behind on assessments and acknowledged that quarterly MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD). Specific residents, including Resident 1, Resident 19, Resident 21, Resident 34, and Resident 13, had overdue MDS assessments, with some not being completed since December of the previous year. The MDSC also mentioned a lack of trained staff to assist with the assessments and noted that she had not received recent training herself, contributing to the delay in completing the assessments on time. The Resident Assessment Instrument Manual, dated October 2023, specifies that the MDS completion date must be no later than 14 days after the ARD and that quarterly assessments must be completed at least every 92 days following the previous OBRA assessment. The failure to complete these assessments in a timely manner had the potential to delay the development and implementation of individualized care plans for the affected residents. The MDSC's statements and the review of the residents' records confirmed that the facility was out of compliance with these requirements.
Multiple Deficiencies in Professional Standards of Quality
Penalty
Summary
The facility failed to ensure professional standards of quality in several instances. One resident's nephrostomy tube was not secured and maintained in a clean environment, with the nephrostomy bag found on the floor and the site not covered with a dressing. Multiple staff members, including LVNs, admitted to not being trained in sterile procedures for nephrostomy care, leading to repeated urinary tract infections for the resident. There was a lack of communication and training regarding nephrostomy procedures and infections among the staff. In another instance, multiple medications were crushed and administered together through a G-tube for two residents. The LVN did not flush the G-tube with water before or after medication administration, which is against the facility's policy. The LVN acknowledged the mistake, and the Charge Nurse confirmed that medications should be given separately in the G-tube. The facility's policy clearly states that medications should not be mixed and that the G-tube should be flushed with water before and after administration. Additionally, a CNA performed work outside of their scope of practice by reconnecting a resident to Blow By oxygen therapy via a tracheostomy. The CNA believed this was part of their job description, but the Respiratory Therapist Manager and the Director of Nursing confirmed that only RNs, LVNs, and Respiratory Therapists should perform this task. The facility's policy also indicated that unlicensed personnel should not perform invasive procedures or tracheostomy care. Furthermore, a physician order for a psychiatric consult was not followed for another resident, resulting in a delay of care. The Director of Nursing admitted that the order was missed and not completed timely, which was against the facility's policy for double-checking orders every 24 hours.
Failure to Reposition Resident Every Two Hours
Penalty
Summary
The facility failed to implement their policy and procedure for pressure ulcer care and prevention when staff did not turn and reposition Resident 15 every two hours. Resident 15 was completely immobile and had a very high risk for skin breakdown, as indicated by a Braden Scale Score of 9. Despite physician orders and wound care consultant recommendations to reposition the resident every two hours, the hourly rounding report showed multiple instances where Resident 15 was not turned for extended periods, sometimes up to six hours. This failure was confirmed through interviews with the wound care consultant and a registered nurse, who both acknowledged that the resident should have been turned every two hours to promote healing and prevent further skin breakdown. The facility's policy and procedure titled 'Pressure Injury or Skin/Wound Conditions- Assessment, Prevention and Management' clearly stated that patients at risk should be repositioned at least every two hours if they are unable to reposition themselves. However, the documentation in the electronic health record showed that this was not consistently done for Resident 15. The registered nurse admitted that the lack of regular repositioning could compromise the healing process of the resident's wound. This deficiency had the potential to result in impaired healing or worsening of the pressure injury to Resident 15's coccyx.
Failure to Provide Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to provide the Restorative Nursing Assistant (RNA) program to maintain or improve mobility for five residents. Observations and interviews revealed that residents were not receiving the prescribed range of motion (ROM) exercises. For instance, Resident 31's family member and the resident themselves confirmed that RNA care was not being provided as ordered. Staffing records indicated inconsistent assignment of RNA duties, and several dates showed no RNA staff assigned at all. Additionally, Resident 31's ROM order sheet specified daily passive ROM exercises, which were not being carried out according to the resident and family member's statements. Resident 354 also reported not receiving prescribed exercises, and their flow sheet showed multiple dates with no documented ROM exercises. Similarly, Resident 19 stated that ROM exercises were now infrequent, and their flow sheet indicated several dates with no documented exercises or application of ankle-foot orthoses (AFO). Resident 1 had limited ROM in both hands, and their flow sheet showed missing documentation for several dates. Interviews with CNAs revealed that they were overwhelmed with other duties and lacked proper training and access to residents' RNA orders, making it difficult to perform and document the required exercises. The Director of Nursing (DON) acknowledged awareness of the residents' concerns regarding the RNA program but admitted there was no plan to replace the RNA staff who had left. The facility's policy and procedure documents and job summaries indicated responsibilities for ensuring the quality and effectiveness of patient care, which were not being met. The lack of a structured RNA program and inadequate staffing and training led to the failure to provide necessary ROM exercises, potentially impacting the residents' mobility and range of motion.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food handling practices in one of three sampled freezers (Freezer #6) and one of three sampled refrigerators (Refrigerator #5). During an observation and interview with a Dietary Aide (DA), it was found that Freezer #6 contained an open four-pound bag of frozen mixed peas and carrots, an open four-pound bag of sliced carrots, and an open large half-empty bag of tater tots, all without open dates. Similarly, Refrigerator #5 contained a half-empty one-gallon jar of mayonnaise and a half-empty one-gallon jar of dill pickle relish, both without open dates. The Certified Dietary Manager (CDM) confirmed that all food items should be labeled with a use-by date and opened date as per the facility's policy. The facility's policy on food storage mandates that all stored food must be properly labeled and dated with the product name, date opened or prepared, and use-by date.
Lack of Policy for Safe Food Handling and Storage
Penalty
Summary
The facility failed to create a policy and procedure (P&P) to ensure safe food handling and storage guidelines for food brought to residents by family and visitors. During an observation and interview, the Activities Director (AD) mentioned that the refrigerator in the activities room was for resident use and contained items like ice cream and orange juice labeled with patient labels. The AD was responsible for cleaning the refrigerator and checking its temperature daily but was unsure if there was a P&P for safe food handling and storage. Interviews with the Regulatory Specialist (RS), Registered Nurse (RN) 2, and RN 1 revealed that they were also unaware of any existing P&P for this purpose. The Director of Nursing (DON) confirmed that the facility did not have a P&P for the safe handling and storage of food brought by family and visitors, although the AD was responsible for monitoring the resident refrigerator in the activities room. The deficiency was identified through multiple interviews and observations, highlighting a lack of awareness and formal guidelines among staff members regarding the safe handling and storage of food brought in by family and visitors. The absence of a P&P for this process was confirmed by the DON, who acknowledged that the facility should have had such a policy in place. This failure had the potential to result in foodborne illness for residents, as there were no established procedures to ensure the safety of the food being stored and consumed by residents.
Failure to Perform Antibiotic Stewardship Program
Penalty
Summary
The facility failed to perform the antibiotic stewardship program for three sampled residents (Resident 19, Resident 20, and Resident 27) when the surveillance data collection form and infection surveillance log were not completed. During a review of the Infection Surveillance Log (ISL) dated March 2024, it was found that critical information was missing for these residents, including dates of onset of symptoms, criteria for antibiotic use, organism details, re-cultured dates, and resolution dates. The Infection Preventionist acknowledged the mistake, and the Director of Infection Prevention admitted to not reviewing the ISL. The facility's policy and procedure on antibiotic stewardship, dated December 2022, emphasized the importance of optimizing clinical outcomes and appropriate antimicrobial use, which was not adhered to in this instance.
Failure to Maintain Emergency Tracheostomy Supplies at Bedside
Penalty
Summary
The facility failed to follow their Policy and Procedure (P&P) titled Tracheostomy Tube and inner Cannula Changing for Resident 24, who did not have a spare tracheostomy tube at the bedside. During an observation on 4/7/24 at 10:24 a.m., it was noted that Resident 24's room lacked an ambu bag, emergency blow by, and a spare tracheostomy tube or supplies. This was confirmed again on 4/9/24 at 8:37 a.m. during a concurrent observation and interview with LVN 6, who acknowledged that the supplies should have been at the bedside or on the hook in the closet area. RT 2 later confirmed that the emergency tracheostomy supplies were not moved when Resident 24 was relocated. The facility's P&P, dated 2/22/23, clearly indicated that a second tracheostomy tube should always be kept at the bedside.
Failure to Monitor Resident's Behavior on Psychotropic Medication
Penalty
Summary
The facility failed to ensure consistent monitoring of a resident's behavior who was on a psychotropic medication, Sertraline, for depression. The resident, identified as Resident 48, exhibited signs of frustration and sadness, as noted by an LVN and a CNA. However, the CNA admitted to not regularly documenting the resident's behavior or mood. A review of the Drug Regimen Review (DRR) by the Pharmacist Supervisor revealed that the resident's behaviors were not reviewed, and there was no documentation to confirm that the pharmacist had reviewed the behaviors. The Director of Nursing (DON) confirmed that there were missing monitoring sheets for February and March 2024 and incomplete documentation for January 2024. The facility's policy and procedure for Monthly Drug Regimen Review required the monitoring of behavioral expressions, indications of distress, and the onset or worsening of signs and symptoms. The DON acknowledged that the expected documentation was not maintained, and the behaviors were not monitored daily as required. This lack of consistent monitoring and documentation could prevent staff from identifying changes in the resident's mood or behavior, which is crucial for managing the resident's condition and medication regimen effectively.
Failure to Implement Gradual Dose Reduction for Anti-Depressant Medication
Penalty
Summary
The facility failed to ensure that a gradual dose reduction (GDR) was provided for an anti-depressant medication prescribed to Resident 45. During an interview and record review with the Pharmacist Supervisor (PS), it was revealed that Resident 45, who was admitted on an unspecified date, was prescribed Sertraline on 10/25/23. The PS noted that the review for GDR should have started in November 2023, but there was no documentation of any GDR attempts. The facility's policy indicated that within the first year of residency or after the initiation of medication, at least two GDR attempts should be made in separate quarters with at least one month between attempts. The PS confirmed that the pharmacy review was supposed to occur every three months, and the lack of GDR documentation could potentially indicate the unnecessary continuation of the medication.
Failure to Label and Date IV Solution and Glucose QC Testing Strips
Penalty
Summary
The facility failed to properly label and date an intravenous (IV) solution and tubing for one of the residents. During an observation, it was noted that the IV solution being administered to the resident did not have a patient identifier label or date, and the IV tubing was also missing a label with the date of first use. The Registered Nurse (RN) admitted that the IV bag was changed that morning but had not been labeled or dated. The Director of Nursing (DON) confirmed that without a label, the RN would be unable to complete the triple check procedure, and the facility's policy and procedure required the IV bag and tubing to be labeled with a patient identification sticker and the date and time it was hung on the patient. Additionally, the facility failed to date the glucose Quality Control (QC) testing strips vial upon opening on one of the medication carts. During an observation and interview, it was found that the vial containing the QC test strips was not dated. The Licensed Vocational Nurse (LVN) acknowledged that the test strips should be dated when opened. The Charge Nurse (CN) confirmed that QC strips should be dated upon opening and are only good for six months after opening. The manufacturer's guidelines indicated that test strips are stable for up to six months or until the expiration date, whichever comes first.
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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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