Alexandria Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1515 N Alexandria Ave., Los Angeles, California 90027
- CMS Provider Number
- 056113
- Inspections on file
- 56
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Alexandria Care Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A resident with DM, moderate persistent asthma, and a history of venous thrombosis and embolism twice reported shortness of breath, muscle tightening, and not getting enough air while on BiPAP. An LVN and an RN responded at the bedside, adjusted BiPAP settings, obtained vital signs, and provided a breathing treatment, but the RN did not initiate a Change of Condition process or notify the physician, contrary to facility policy requiring immediate consultation with the physician or NP for significant physical changes.
A resident admitted with diabetes mellitus and a documented personal history of venous thrombosis and embolism did not have a person-centered care plan developed to address DVT-related needs. Although the admission records and history and physical showed intact cognition and clearly listed the DVT/embolism history, facility staff, including those responsible for MDS and care planning, did not initiate a care plan for this condition. The DON confirmed that the care plan should have identified the DVT diagnosis and risk, and that the facility’s policy requires comprehensive care plans with measurable objectives and timetables for all medical and psychosocial needs, which was not followed in this case.
A resident with cognitive impairment, limited decision-making capacity, and Spanish as a preferred language received a STAT bilateral hip x-ray order related to prior hip fractures and leg pain, but neither the resident nor the responsible party was properly informed. An RN acknowledged there was no documentation of notification, and the resident later reported that a man was taking a picture of her. An LVN stated they explained the x-ray in English while accompanying the technician but did not speak Spanish and also confirmed there was no documentation of the explanation. This resulted in the resident and responsible party not being fully informed of the x-ray, in violation of the facility’s resident rights policy requiring notification and participation in care and treatment decisions.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls and a change in condition, during which staff failed to maintain accurate and complete documentation. For one fall, the CIC recorded an incorrect physician notification time, and the RN who assessed the resident and called 911 did not document her interventions in the progress notes. For another fall, the CIC omitted where the resident was found and who found the resident first. In a separate change in condition, the date and time of family notification were left blank, contrary to facility policy requiring complete, objective, and accurate charting of events, assessments, and notifications.
A resident with severe cognitive impairment, traumatic subdural hemorrhage, COPD, and muscle weakness had physician orders and a care plan for use of a bed alarm in bed, with checks of placement and function each shift. A family member provided informed consent for the device. Surveyors observed a bed alarm hanging on the side of the bed and an LVN reported it was used to alert staff when the resident attempted to get up. The DON identified the bed alarm as the least form of physical restraint and stated that residents on bed alarms must be monitored and that monitoring documented on the MAR. Review of the MAR showed no documented monitoring of the bed alarm over an extended period, despite facility restraint policy requiring frequent observation and detailed documentation when a restraint is used.
A resident with severe cognitive impairment, poor safety awareness, and multiple medical conditions had a fall-risk care plan that required placement in a room within direct line of sight of the nurse’s station and use of a wander guard. After admission, the resident was initially placed near the nurse’s station with a wander guard, but was later moved to a room farther away and the wander guard was discontinued by physician order. The care plan was not updated to reflect the room change or the discontinuation of the wander guard, even though the resident continued to ambulate independently in the new room. Staff interviews confirmed reliance on the outdated care plan, and facility policy required ongoing assessment and revision of care plans as resident conditions and circumstances changed.
A resident with intact decision-making capacity and an immunodeficiency diagnosis reported receiving a breakfast tray with a dirty spoon containing dried food residue. The spoon was visually confirmed as dirty by the Dietary Supervisor and Social Service Director. Interviews revealed that Dishwasher Staff, a Dietary Aide, and CNAs were each expected to check utensil cleanliness but failed to identify and remove the soiled spoon before it reached the resident, contrary to the facility’s sanitation policy requiring all utensils to be properly cleaned and sanitized.
A resident with severe cognitive impairment received double doses of famotidine due to unclarified physician orders and was also given guaifenesin and dextromethorphan-guaifenesin less than the prescribed six-hour interval. Nursing staff did not clarify conflicting orders or follow the facility's medication administration policy, resulting in medication errors.
Staff failed to follow enhanced barrier precautions by not wearing required PPE, including masks, gloves, and gowns, while providing high-contact care to two residents with indwelling devices and wounds. Despite clear signage and available supplies, nurses entered rooms and performed care activities without proper protection, in violation of facility policy and local health orders.
A resident with severe cognitive impairment and a recent diagnosis of legionnaires disease and pneumonia did not have a care plan developed for their infection or for the use of azithromycin until after treatment had begun or was completed. Staff confirmed that care plans were delayed, and facility policy requires timely, individualized care planning for all residents.
A resident with severe cognitive impairment experienced low oxygen saturation and received emergency oxygen therapy. Nursing staff documented that 15 liters of oxygen were given via face mask, but interviews revealed that a non-rebreather mask was actually used. The nurse later confirmed the documentation was incorrect, resulting in an inaccurate medical record that did not reflect the actual intervention provided.
A resident with severe cognitive impairment and multiple health conditions was prescribed azithromycin for pneumonia, but staff failed to document monitoring for antibiotic use and side effects as required by facility policy. Both the IP and DON confirmed that monitoring should have occurred every shift, but no such documentation was found in the resident's records.
Three residents with severe cognitive impairment and high care needs were found with their call lights out of reach, despite care plans requiring accessibility. Staff interviews confirmed the devices were not returned to proper placement after care, and the DON acknowledged this was against facility policy.
A resident with cognitive impairment and risk for skin breakdown had a care plan specifying a low air loss mattress (LALM) setting of 100-150 pounds, but staff were observed using a setting of 200 pounds, inconsistent with the care plan and the resident's weight. Interviews with the DON, treatment nurse, and DSD confirmed the importance of following the care plan and that the incorrect setting could reduce the mattress's effectiveness in preventing pressure injuries.
A resident with severe cognitive impairment and incontinence was not provided with proper pressure ulcer prevention when staff failed to ensure the low air loss mattress was functioning as ordered. The mattress was set above the resident's weight, had multiple warning indicators active, and the alarm was muted, contrary to the care plan and manufacturer instructions. Staff were aware of the malfunction but did not resolve it, resulting in care inconsistent with professional standards.
A resident with dementia and hypertension received blood pressure medications from an LVN despite a physician order to hold the medications if the diastolic blood pressure was below 60. The LVN administered the medications when the resident's blood pressure was 104/53, contrary to the order. Facility staff confirmed the order was not followed, and policy review showed that vital signs should be checked and medications held as directed.
A resident receiving anticoagulant therapy had multiple entries on the MAR indicating the presence of bleeding, but no clinical evidence or progress notes supported these findings. Interviews with the DON and nursing staff revealed that no signs of bleeding were actually observed and that the documentation was inaccurate due to misinterpretation of physician orders. This failure to maintain accurate and complete medical records had the potential to cause confusion in the resident's care.
A resident with cognitive impairments was physically abused by another resident in a LTC facility. The aggressor, who has a history of psychosis and confusion, struck the victim on the head without provocation, resulting in pain and the need for medication. Staff interviews confirmed the incident as abuse, despite the aggressor's confusion.
The facility failed to develop and implement comprehensive care plans for residents, leading to potential risks. A resident using side rails lacked a care plan, another on Pradaxa was not monitored for side effects, a third refused physical therapy without a care plan update, and a fourth's low air loss mattress was improperly managed. These deficiencies were acknowledged by the facility's DON.
A facility failed to rotate insulin injection sites for three residents, leading to a deficiency. One resident with type 2 diabetes and other health issues received repeated injections in the same areas, confirmed by an LVN and the DON. Another resident with congestive heart failure and diabetes also had injections without proper site rotation, as shown in their MAR. A third resident experienced similar issues, with insulin administered multiple times in the same arm. The DON confirmed these practices were against facility policy and manufacturer guidelines, posing risks of skin complications.
A facility failed to maintain a safe environment for residents by placing overbed tables on floor mats, compromising their integrity and stability, and leaving a resident's bed in a high position unattended, despite fall risk precautions. Staff were unaware of guidelines, leading to potential injury risks.
The facility failed to properly dispose of medications in Medication Room Station 2, leaving them intact and retrievable, contrary to policy. Additionally, accountability logs for controlled substances lacked necessary verifying signatures from the DON or RN, increasing the risk of medication diversion and accidental exposure.
The facility failed to ensure proper medication management for two residents. One resident had duplicate orders for rivaroxaban, risking excessive dosing, while another resident on Pradaxa lacked documented monitoring for side effects. The facility's policies were not effectively implemented, leading to these deficiencies.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident was prescribed sertraline without specific behavior monitoring, while another was given quetiapine and sertraline based on vague terms like 'agitation' and 'unhappiness.' The facility's policy required specific behavioral manifestations for psychotropic use, which was not followed, risking adverse effects.
A facility failed to maintain a medication error rate below five percent, resulting in a 10.35% error rate. Two residents were affected: one did not receive the prescribed form of aspirin, and another received metformin and aspirin outside the prescribed timeframe. The errors were due to staff not adhering to physician orders and facility guidelines, potentially impacting residents' health.
A facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite guidelines and policies requiring site rotation to prevent complications like lipodystrophy, staff repeatedly used the same sites for insulin administration. This deficiency was confirmed through interviews and record reviews, highlighting a lapse in adherence to standard practices.
A facility failed to store and label medications properly, risking resident safety. An inhalation solution was stored outside its protective pouch, an insulin vial lacked a storage date, and an eye drop bottle was expired. Additionally, two Aplisol vials were not labeled with their opening date. These deficiencies could lead to ineffective treatments.
The facility failed to provide adequate nutrition by not leveling food portions for puree and soft mechanical diets, leading to reduced caloric intake. Additionally, mashed potatoes were substituted for rice without proper menu adherence, causing dissatisfaction among residents. The facility also did not post alternate menus, limiting residents' ability to choose meal options.
The facility failed to maintain appropriate food temperatures, with sliced pears served at 68°F and coleslaw left out at 75°F, contrary to policy requirements. A resident with diabetes and other conditions reported dissatisfaction with food temperatures, which could affect intake. The District Manager noted the trayline service was longer than usual, impacting food temperature maintenance.
The facility failed to prepare puree foods according to individual needs, with the puree tortilla being too sticky and the puree corn too watery, affecting the consistency required by IDDSI guidelines. This deficiency was observed during a test tray evaluation, potentially impacting 27 residents on a puree diet.
The facility failed to maintain sanitary food storage and preparation practices, with dirty refrigerator and freezer floors, dusty vents, and improper thawing of chicken. Uncovered light bulbs, dented cans, cracked trays, wet-stacked pans, and staff wearing jewelry during food prep were observed. Expired food and unmonitored freezer temperatures further compromised food safety, violating facility policies and the Food Code 2022.
The facility failed to properly dispose of garbage, with a trash bin in the handwashing area lacking a plastic liner and the dumpster area being unsanitary with spills and an uncovered dumpster. These conditions were acknowledged by the Dietary and Maintenance Supervisors as unsanitary and potentially attracting pests, posing a risk of infection spread.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating resident needs. One resident with mobility issues was found without access to a call light, and another resident's call light was on the floor. Staff confirmed that call lights should be accessible to prevent falls and ensure timely assistance, but facility policies were not followed.
A resident's electric stand fan was found with dust buildup, indicating a failure by the facility to maintain a clean and homelike environment. The resident, with COPD and other conditions, required assistance with daily activities. The housekeeping staff, responsible for daily cleaning, did not ensure the fan's cleanliness, as confirmed by both an LVN and the Housekeeping Supervisor. The DON acknowledged that this failure could affect the resident's quality of life.
A resident with Alzheimer's and high fall risk was improperly restrained using pillows tucked under the fitted sheet without a physician's order, assessment, informed consent, or care plan. Staff confirmed the use of pillows restricted the resident's movement, violating the facility's restraint policy.
A facility failed to conduct an accurate PASRR screening for a resident with mental health diagnoses, resulting in a negative Level 1 PASRR despite the resident's bipolar disorder and schizoaffective disorder. The resident was prescribed antipsychotic medication, which should have triggered a positive PASRR. Interviews with the ADON and DON confirmed the oversight, highlighting a lapse in following the facility's policy for PASRR completion.
A resident with a history of falls and requiring supervision while smoking had their care plan inadequately updated after a change in condition. Despite a smoking evaluation indicating the need for supervision, the care plan continued to state the resident could smoke independently. This oversight was acknowledged by the ADON and DON, who confirmed that facility policies were not followed, potentially leading to unsupervised smoking and increased risk of injury.
A resident with a fracture and rheumatoid arthritis refused physical therapy, and the facility failed to conduct an IDT meeting with the resident's responsible party or inform the physician. Despite the resident's ability to communicate, refusals were not documented or addressed in the care plan, contrary to facility policy.
A facility failed to ensure proper care for a resident at mild risk for pressure ulcers by not having a physician's order or care plan for a low air loss mattress (LALM). The LALM settings were improperly adjusted by a CNA to prevent alarms, a practice ongoing for three months. The LVN was unaware of the issue, and the DON confirmed that CNAs should not adjust LALM settings. This deficiency demonstrated a failure to adhere to facility policies and had the potential to worsen pressure injuries.
A resident with impaired cognition and total assistance needs was found with a loop in their urinary catheter tubing, which contained urine and posed a risk for UTIs. The LVN and DON confirmed the tubing should be free of loops to prevent urine backup. The facility's policy emphasized unobstructed urine flow, but the deficiency occurred due to improper catheter management.
A resident with type 2 diabetes, hypertension, and dementia experienced significant weight loss, which the facility failed to monitor adequately. Despite a nutritional assessment recommending monitoring, staff interviews revealed lapses in documentation and adherence to protocols. The DON confirmed that a 72-hour monitoring protocol was not followed, leading to the deficiency.
A facility failed to ensure the safe use of side rails for a resident with spinal stenosis and other conditions requiring substantial assistance. The facility did not attempt alternatives before using side rails, failed to assess entrapment risks, did not obtain informed consent, and lacked a Care Plan for side rail use. This oversight was acknowledged by staff, including the DON, who confirmed non-compliance with facility policies.
The facility failed to document medication administration for two residents, leading to missing records for hypoglycemic medications. One resident had missing documentation for Humulin, while another had missing records for insulin lispro. The DON acknowledged the importance of documentation for monitoring medication administration and blood sugar levels, as per the facility's policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two deficiencies. A resident's urinal was not labeled, risking cross-contamination, and another resident's nebulizer setup was improperly stored, risking contamination. Staff confirmed these actions were against facility policy, highlighting lapses in infection control practices.
The facility failed to provide written notifications to two residents or their responsible parties regarding the termination of Medicare Part A services and potential financial liabilities. The SNF ABN and NOMNC forms were not provided in writing, nor did they include estimated out-of-pocket costs, which are essential for informed decision-making. The BOA, who recently assumed responsibility, was unaware of the requirement for written notifications, leading to a failure in following the facility's policy.
A facility failed to accurately document a resident's diagnoses of schizophrenia and bipolar disorder in the MDS assessment, leading to inconsistencies with the resident's medical records and prescribed medications. The DON acknowledged the oversight, which could impact care planning and treatment.
The facility failed to manage enteral feeding for two residents, leading to potential inaccuracies in nutrition delivery and infection risk. Feeding supplies were not labeled with necessary information, and feeding machine settings were not cleared at shift changes, resulting in potential incorrect formula volumes. The DON confirmed these deficiencies, noting the facility's failure to monitor and follow physician orders.
A resident with partial intestinal obstruction, tendinitis, and osteoarthritis refused showers, and the facility failed to develop a timely care plan addressing this refusal. Despite the resident's cognitive ability to make decisions, staff were unsure about the existence of a care plan, and the DON confirmed that only bed baths were documented. The facility's policy requires timely documentation and modification of care plans, but the care plan for this resident was created late.
A resident with cognitive impairment and mobility assistance needs eloped from the facility unsupervised during a candlelight dinner event. The receptionist mistook the resident for a visitor, allowing him to exit without his front wheel walker. The resident was found three blocks away, highlighting a deficiency in supervision and adherence to safety protocols.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Failure to Notify Physician of Resident’s Significant Change in Respiratory Status
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one of three sampled residents. The resident was admitted with diagnoses including diabetes mellitus, moderate persistent asthma, and a history of venous thrombosis and embolism, and had intact cognitive function. On the evening in question, the resident experienced shortness of breath while on BiPAP at 7 p.m. An LVN reported that an RN came to the bedside, adjusted the BiPAP settings, and obtained vital signs, including an oxygen saturation of 97%. Later that evening at 10 p.m., the resident again reported difficulty breathing, muscle tightening, and not getting enough air, and the RN was again called to the bedside, where the resident received a breathing treatment. During subsequent interviews and record reviews, the RN acknowledged that he failed to initiate and implement a Change of Condition (COC) for the resident’s shortness of breath and did not report the resident’s symptoms to the medical doctor. The DON confirmed that staff failed to initiate a COC despite the resident’s complaints of not getting enough air and muscle tightening, and stated it was the RN’s responsibility to complete a COC and notify the physician. Review of the facility’s policy, “Change in Condition: Notification of,” indicated the facility must immediately consult with the resident’s physician or NP when there is a significant change in the resident’s physical condition and ensure all pertinent information is provided. This failure to follow policy and notify the physician constituted the cited deficiency.
Failure to Care Plan for Resident With History of DVT and Embolism
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented personal history of other venous thrombosis and embolism. The resident’s face sheet showed admission with diagnoses including diabetes mellitus and a personal history of venous thrombosis and embolism, and the history and physical documented that the resident’s cognitive functioning was intact. Despite this information being available in the admission records, there was no care plan initiated to address the resident’s diagnosis and history of deep vein thrombosis (DVT) and embolism. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator were responsible for initiating the care plan upon admission and that this had not been done for the resident’s DVT condition. The DON acknowledged that the care plan should have addressed the resident’s DVT diagnosis and risk for developing DVT, and that the care plan serves as a guide for necessary interventions. The facility’s own policy on comprehensive, person-centered care plans required development of a care plan with measurable objectives and timetables to meet each resident’s medical, physical, mental, and psychosocial needs, and to reflect recognized standards of practice for identified problem areas and conditions, which was not followed in this case.
Failure to Inform Resident and Responsible Party of STAT Hip X-Ray Order
Penalty
Summary
The facility failed to follow its resident rights policy requiring that residents and/or their responsible parties be notified of their medical condition, changes in condition, and treatments. A resident admitted with multiple diagnoses, including displaced intertrochanteric fracture of the right femur, displaced fracture of the epiphysis, anxiety disorder, and major depressive disorder, had documented limited decision-making capacity and moderate cognitive impairment. The resident required assistance with toileting, bathing, and lower body dressing, and the MDS indicated Spanish as the preferred language with a need for an interpreter to communicate with medical staff. A physician’s order was entered for a STAT bilateral hip x-ray due to the resident’s condition. During interviews and record review, the RN acknowledged that although the resident was alert to name and able to express basic needs, it would be better to inform the responsible party because the resident would not remember, and confirmed there was no documentation that either the resident or responsible party had been informed of the x-ray order. The RN stated the resident later alleged that a man was taking a picture of her and admitted the failure to notify and document notification of the procedure. An LVN reported being present with the x-ray technician and explaining to the resident, in English, that the x-rays were being taken due to leg pain, but the LVN did not speak Spanish and confirmed there was no documentation that the order and procedure were explained to the resident. This sequence of events resulted in the resident and responsible party not being fully informed or able to understand and participate in decisions regarding the x-ray, contrary to the facility’s written resident rights policy.
Incomplete and Inaccurate Documentation of Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and objective medical records for a cognitively impaired resident with multiple diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS showed severely impaired cognitive skills and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On one fall incident dated 1/10/2026, the eInteract Change in Condition Evaluation (CIC) documented that the physician was notified at 12 midnight, even though the fall occurred at 7:15 a.m. and the nurse later stated she actually notified the physician around 7:20–7:30 a.m. Both the LVN involved and the DON confirmed that the documented time of physician notification was inaccurate. The facility also failed to document the interventions of an RN who responded to the same 1/10/2026 fall. The LVN reported that she called an RN, who assessed the resident and called 911 and the physician, but a review of the resident’s progress notes for that date showed no documentation by the RN. The DON confirmed that the medical record did not show that the RN had been notified, had performed a head-to-toe assessment, or had called 911, leaving the record without evidence of the RN’s involvement or actions related to the fall. Additional documentation gaps were identified for prior incidents. For a fall on 11/13/2025, the CIC noted that the resident was found on the floor holding the left side of the head and face and complaining of left hip pain, but did not indicate where the resident was found or who found the resident first; the DON stated this CIC was incomplete. For a change in condition on 5/16/2023, the CIC left blank the date and time of responsible party (family) notification. The facility’s own charting and documentation policy required that all services, changes in condition, events, incidents, and notifications be documented in an objective, complete, and accurate manner, including date, time, person providing care, assessment data, and notifications, which was not followed in these instances.
Failure to Monitor and Document Bed Alarm Use as a Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint by not monitoring the use of a bed alarm device as ordered and care planned. The resident was initially admitted in 2022 and readmitted in 2026 with diagnoses including traumatic subdural hemorrhage, unspecified COPD, and muscle weakness. An MDS dated 10/31/2025 documented that the resident’s cognitive skills for daily decision-making were severely impaired and that the resident required staff supervision for hygiene, showering, dressing, transfers, and walking. A physician’s order dated 1/13/2026 authorized the use of a bed alarm device, and a device informed consent dated the same day showed that a family member gave permission for the alarm while the resident was in bed. The resident’s care plan, also dated 1/13/2026, identified fall risk and included an intervention to apply a bed alarm when the resident was in bed and to check its placement and function every shift. A subsequent physician order dated 1/14/2026 reiterated that the resident may use a bed alarm in bed and that staff should check placement and function every shift. The resident’s H&P dated 1/15/2026 documented that the resident did not have capacity to understand and make decisions. On 1/27/2026, during an observation and interview in the resident’s room, a bed alarm device was seen hanging on the left side of the bed, and an LVN stated the resident used the bed alarm in bed to alert staff when the resident got up. On 1/28/2026, during an interview and record review with the DON, the DON confirmed that the resident had been on a bed alarm since 1/13/2026 and described the bed alarm as the least form of physical restraint. The DON stated that residents on bed alarms should be monitored for placement and function of the alarm and that this monitoring should be documented on the MAR. Review of the MAR for January 2026 showed no documented monitoring from 1/16/2026 to 1/27/2026. The DON stated that monitoring and documentation were needed to ensure the bed alarm device was effective for the resident in preventing falls. The facility’s restraint policy, last reviewed on 1/14/2026, required that restraints be used only for safety and well-being after alternatives were tried, that the least restrictive alternative be used for the least amount of time, that ongoing re-evaluation be documented, and that a resident placed in a restraint be observed at least every 30 minutes with an account of the resident’s condition recorded in the medical record, along with detailed documentation of the restraint episode and monitoring. These policy requirements were not met for this resident’s bed alarm use.
Failure to Revise Fall-Risk Care Plan After Room Change and Wander Guard Discontinuation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS dated 10/31/2025 showed severely impaired cognitive skills for daily decisions and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On 1/10/2026, an eInteract Change in Condition Evaluation documented that an LVN heard a loud sound and found the resident lying on his right side on the hallway floor between his room and the shower room, moaning, with eyes closed and unable to talk, after which the physician ordered transfer to a general acute care hospital. The resident’s care plan for fall risk, dated 1/13/2026, included interventions that the resident be in a room with direct line of sight to the nurse’s station and have a wander guard due to poor safety awareness. Subsequently, the resident was moved from a room near the nurse’s station (room A) to a previous room farther away (room B) and the wander guard was discontinued by physician order on 1/16/2026, but the care plan was not revised to reflect these changes. Observation on 1/27/2026 showed the resident ambulating back and forth in his room without assistance, with the room located seven rooms away from the nurse’s station. Interviews with nursing staff confirmed that the written care plan still indicated the resident should be in direct line of sight of the nurse’s station and have a wander guard, despite the room change and discontinuation of the device. The DON stated that the care plan serves as the nurses’ guideline for resident care and interventions and acknowledged that it should have been updated when the room change occurred and the wander guard was discontinued. The facility’s care plan policy required that care plans incorporate identified problem areas, include measurable goals and timetables, and be reviewed and revised as resident information and condition change, which did not occur in this case.
Failure to Ensure Clean and Sanitized Eating Utensils
Penalty
Summary
The deficiency involves the facility’s failure to implement infection control measures by not ensuring clean and sanitary eating utensils for a resident. The resident, admitted with diagnoses including unspecified epilepsy, immunodeficiency, and essential hypertension, had intact cognitive skills and was independent with eating. The resident reported receiving a breakfast tray with a dirty spoon that had dried food residue on it and stated that the spoon appeared used and not properly washed. The resident expressed concern about the possibility of acquiring a bacterial infection from using the dirty spoon and reported the issue to the Social Service Director. Interviews and record review confirmed that the dirty spoon was observed by both the Dietary Supervisor and the Social Service Director, who each acknowledged seeing dried food residue on the utensil. The Dietary Supervisor stated that the Dishwasher Staff should have checked the utensils after washing, the Dietary Aide should have inspected the spoon before placing it on the tray, and the CNA distributing the tray should have checked the utensils before delivery. The DON stated that the CNA did not notice the spoon was dirty and reiterated that the Dietary Aide and CNAs were responsible for ensuring utensils were clean and for removing dirty utensils before providing them to residents. The facility’s sanitation policy required all utensils and food contact surfaces to be cleaned and sanitized, but this was not followed in this instance.
Failure to Clarify and Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure proper clarification and administration of physician orders for a resident with severe cognitive impairment and a history of neuropathy and falls. Specifically, licensed nurses did not clarify two separate physician orders for famotidine, resulting in the resident receiving double doses of the medication on multiple days. The orders included one for a daily dose and another for administration before breakfast, but both were administered without clarification, as confirmed by staff interviews and medication administration records. Additionally, the facility did not ensure that licensed nurses followed the physician's order for administering guaifenesin and dextromethorphan-guaifenesin. The orders specified that these medications should be given every six hours as needed, but the resident received doses of guaifenesin and dextromethorphan-guaifenesin only three hours apart. Staff interviews confirmed that these medications were considered the same and that the six-hour interval was not maintained. Review of facility policy indicated that medications are to be administered as prescribed and that any concerns about dosage or potential adverse consequences should be clarified with the prescriber. Despite this, the nurses did not clarify the orders or follow the prescribed administration intervals, leading to medication errors for the resident.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for residents on enhanced barrier precautions (EBP). Specifically, staff did not adhere to required personal protective equipment (PPE) protocols when providing care to residents with indwelling devices and open wounds. Observations revealed that a registered nurse and two licensed vocational nurses entered the rooms of residents on EBP and performed high-contact care activities, such as disconnecting and flushing an IV line, checking blood pressure, and providing gastrostomy tube care, without wearing the mandated mask, gloves, and gown. Resident 2, who was admitted with diagnoses including acute osteomyelitis, dysphagia, and a chronic ulcer, was on EBP due to wounds and a midline catheter. Despite clear signage and availability of PPE outside the resident's room, staff were observed entering and providing care without donning the required protective equipment. Interviews with the involved staff confirmed that they were aware of the EBP requirements but failed to comply, citing reasons such as forgetting to wear a mask or not noticing the available supplies. The Director of Nursing and Infection Preventionist both acknowledged that the staff should have worn the appropriate PPE during these care activities. Similarly, Resident 6, who had a gastrostomy tube and required maximum assistance for activities of daily living, was also on EBP. An LVN was observed providing gastrostomy tube care at the bedside without wearing a gown, despite the presence of EBP signage and PPE supplies. The LVN admitted awareness of the EBP requirement but did not comply. Facility policies and local health orders reviewed by surveyors confirmed the necessity of PPE use during high-contact care and during respiratory virus season, yet these protocols were not followed during the observed incidents.
Failure to Timely Develop and Implement Care Plan for Infection and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who returned to the facility with a presumptive positive test for legionnaires disease and an order for azithromycin to treat pneumonia. Upon review, it was found that the care plan addressing legionnaires disease was not created until several days after the resident's return, and the care plan for azithromycin was not developed until after the medication course had already been completed. The delay in care plan development was confirmed by both the registered nurse and the director of nursing, who acknowledged that the care plans should have been established at the time of the resident's return and initiation of treatment. The resident in question had a history of hereditary and idiopathic neuropathy, a history of falls, and was assessed as having severely impaired cognitive skills, requiring moderate assistance with daily activities. The resident was admitted with multifactorial pneumonia, including legionnaires disease, and was prescribed azithromycin for a three-day course. Despite these significant medical needs and the initiation of antibiotic therapy, the facility did not promptly create or update the resident's care plan to reflect these new diagnoses and treatments. Interviews with facility staff, including the infection preventionist, confirmed that the lack of timely care plan development could potentially delay necessary care and services. Review of facility policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and that these plans should be updated as the resident's condition changes. The failure to develop and implement appropriate care plans in a timely manner was a direct violation of these policies.
Failure to Accurately Document Oxygen Device Used During Resident Emergency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by incorrectly documenting the type of oxygen device used during a critical event. The resident, who had severe cognitive impairment and required moderate assistance with daily activities, experienced desaturation and chest congestion. Documentation in both the Change in Condition Evaluation and Progress Notes indicated that 15 liters of oxygen were administered via a face mask. However, interviews with nursing staff and the Director of Staff Development revealed that a face mask can only deliver up to six liters of oxygen, and that 15 liters should be administered using a non-rebreather mask. The registered nurse involved later confirmed that she had used a non-rebreather mask but documented it incorrectly as a face mask. This inaccurate documentation was acknowledged by both the nurse and the Director of Nursing, who emphasized the importance of precise record-keeping to reflect the actual interventions provided during episodes of low oxygen saturation. The facility's policy on nursing documentation requires that records be concise, clear, pertinent, and accurate, but this standard was not met in this instance, resulting in a medical record that did not accurately communicate the care provided to the resident.
Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control policies for one resident by not monitoring the use and adverse effects of azithromycin, an antibiotic prescribed for pneumonia. The resident, who had a history of hereditary and idiopathic neuropathy, a history of falls, and severely impaired cognitive skills, was admitted with significant care needs and lacked the capacity to make decisions. The resident received azithromycin over a three-day period, as documented in the Medication Administration Record. Despite facility policy requiring monitoring for antibiotic side effects every shift, there was no documentation in the resident's progress notes indicating that such monitoring occurred during the period the antibiotic was administered. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that nurses are expected to monitor and document for side effects and adverse reactions to antibiotics every shift, but acknowledged that this was not done for this resident. A review of the facility's policies showed that antibiotic usage and outcomes are to be documented using an approved surveillance tracking form, and that all clinical infections treated with antibiotics should be reviewed by the Infection Preventionist or designee. The lack of documentation and monitoring for this resident was inconsistent with these established policies and procedures.
Failure to Ensure Call Lights Within Reach for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that call light devices were within reach for three residents with severe cognitive impairment and significant care needs. For each resident, care plans specifically required that the call light be accessible while in bed or in close proximity. However, during observations, surveyors found that the call lights were either hanging on the wall, on the floor, or otherwise out of reach for these residents. Staff interviews confirmed that the call lights were not accessible and that this was due to oversight or failure to return the device to the proper location after care was provided. Resident 1, who had diagnoses including chronic kidney disease, dementia, and hypertension, was admitted with severely impaired cognitive skills and required maximum assistance for daily activities. The resident was observed with the call light hanging on the wall, out of reach, and was unable to identify or use the device. Certified Nursing Assistant staff acknowledged forgetting to check the call light's placement and noted that nurses sometimes failed to return it to the resident's reach. Similarly, Resident 2, with dementia and dysphagia, and Resident 3, with Alzheimer's disease and atrial fibrillation, were both found with their call lights on the floor and out of reach. Both residents had care plans requiring the call light to be accessible, and staff confirmed during interviews that the residents could not reach the devices. The Director of Nursing stated that facility policy requires call lights to be within reach and acknowledged that failure to do so could delay care.
Failure to Follow Care Plan for Low Air Loss Mattress Settings
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan for a resident by not ensuring the prescribed settings for a low air loss mattress (LALM) were followed. The resident, who had diagnoses including chronic kidney disease, dementia, and hypertension, was assessed as having severely impaired cognitive skills and required maximum assistance for daily activities. The care plan specified that the LALM should be set between 100-150 pounds to match the resident's weight and prevent skin breakdown. However, during multiple observations, the LALM was found set at 200 pounds, which was inconsistent with both the care plan and the resident's actual weight of 111.8 pounds. Staff interviews confirmed that the LALM setting should have matched the care plan and that exceeding the recommended setting could compromise the mattress's effectiveness in protecting the resident's skin. The DON, treatment nurse, and DSD all acknowledged the importance of adhering to the care plan and the potential impact of not doing so. Facility policy required care plans to be individualized, measurable, and followed as written, but in this instance, the care plan was not implemented as intended for the resident at risk for skin breakdown.
Failure to Ensure Proper Functioning of Pressure-Relief Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic kidney disease, dementia, and hypertension, was not provided with proper pressure ulcer prevention care as per professional standards. The resident was assessed as having severely impaired cognitive skills, required maximum assistance for daily activities, and was always incontinent. The care plan and physician orders specified the use of a low air loss mattress (LALM) with settings between 100-150 for skin maintenance and prevention of pressure ulcers. However, observations revealed that the LALM control unit at the resident's bedside had multiple cycle time indicators lit, the weight setting at 200 lbs (higher than the resident's actual weight of 111.8 lbs), the low pressure warning light on, and the mute button activated, which silenced the alarm for malfunctions. Staff interviews confirmed that the low pressure indicator had been on since the previous day and was reported to the treatment nurse, but the issue was not resolved. The LALM remained in a malfunctioning state, with incorrect settings and warning indicators active. The treatment nurse and other staff acknowledged that the LALM was not functioning as intended, and that the settings did not match the care plan or the resident's actual weight. The operator's manual for the LALM specified that the weight setting should correspond to the patient's weight and that the low pressure indicator signaled inadequate air pressure, which could compromise the mattress's effectiveness in preventing pressure ulcers. Despite staff awareness of the malfunction and the discrepancy in settings, the LALM was not promptly repaired or adjusted to meet the resident's needs as outlined in the care plan. The facility's policy did not specify procedures for timely repair of the LALM, and staff did not ensure the device was functioning according to manufacturer instructions. This failure to provide care consistent with professional standards placed the resident at risk for developing pressure ulcers.
Failure to Follow Physician Orders for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered carvedilol and losartan to a resident despite a physician order specifying to hold these medications if the resident's systolic blood pressure (SBP) was below 100 or diastolic blood pressure (DBP) was below 60. On the date in question, the resident's blood pressure was recorded as 104/53, but the LVN proceeded to give both medications. The resident had a history of dementia, essential hypertension, and dysphagia, and was assessed as having severely impaired cognitive skills and requiring moderate assistance with daily activities. Interviews with facility staff, including the LVN, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the physician's order was not followed and that the LVN should have held the medications and clarified the order with the physician. Review of the facility's medication administration policy indicated that medications are to be administered in accordance with prescriber orders and that vital signs should be checked and verified prior to administration when necessary. The failure to follow these procedures resulted in the identified deficiency.
Inaccurate Documentation of Anticoagulant Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of three sampled residents. The resident in question was admitted with diagnoses including unspecified dementia, essential hypertension, and dysphagia, and was receiving anticoagulant therapy. Physician orders required staff to monitor for specific signs of bleeding and to document findings on the Medication Administration Record (MAR) every shift, using 'Y' if no signs were observed and 'N' if any signs were present. A review of the MAR revealed that 'N' was documented on several dates and shifts, indicating the presence of bleeding. However, there was no corresponding documentation in the resident's progress notes to support that any signs of bleeding were observed or that the physician was notified, as required by facility policy and the physician's order. Interviews with the DON and nursing staff confirmed that no signs of bleeding had actually been observed, and that the documentation on the MAR was inaccurate due to misinterpretation of the order by nursing staff. The facility's policies on anticoagulant monitoring and nursing documentation require clear, accurate, and timely entries reflecting the resident's status and any interventions performed. The inaccurate documentation in the MAR, which was not supported by clinical findings or additional notes, had the potential to cause confusion regarding the resident's condition and care needs.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On February 17, 2025, a Certified Nursing Assistant (CNA) witnessed one resident hitting another resident on the right side of the head with a closed fist. The incident resulted in the victim experiencing a pain level of 3 out of 10, for which acetaminophen was administered. The victim, who has a history of schizoaffective disorder, major depressive disorder, and hypertension, was admitted to the facility in April 2022 and has moderately impaired cognition, requiring assistance with daily activities. The aggressor, admitted in February 2020, has diagnoses including unspecified psychosis, hypertension, and major depressive disorder, with severely impaired cognition. The aggressor has a history of wandering into other residents' rooms and exhibiting confusion and agitation. On the day of the incident, the aggressor was walking with a CNA when he suddenly turned and struck the victim without any prior interaction or argument. Interviews with staff indicated that the aggressor's actions were considered abuse, despite his confusion, as the act of hitting was intentional and caused harm. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury or punishment resulting in harm or mental anguish. Despite the aggressor's cognitive impairments, the incident was classified as abuse due to the physical harm inflicted. The facility's administrator acknowledged the incident as an altercation but was uncertain if it was intentional, given the suddenness and lack of prior interaction between the residents.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and inadequate care. For Resident 145, the facility did not create a care plan for the use of side rails, which were ordered as an enabler for turning and repositioning in bed. Despite the resident's dependency on staff for various activities and the presence of side rails, there was no care plan to ensure the resident's safety and to monitor for potential injuries related to side rail use. This oversight was acknowledged by the Director of Nursing, who confirmed that the facility's policy was not followed. Resident 141 was prescribed Pradaxa, an anticoagulant, for atrial fibrillation, but the facility failed to implement the care plan intervention to monitor for side effects of the medication. The Medication Administration Record for January 2025 lacked documentation of monitoring for bleeding, a critical aspect of managing anticoagulation therapy. The Director of Nursing admitted that the facility did not implement the care plan to reflect the resident's needs accurately, which could have led to unnoticed bleeding and potential harm. For Resident 147, the facility did not develop a care plan addressing the resident's repeated refusals of physical therapy treatments. Despite the resident's rehabilitation plan and good potential for recovery, multiple therapy sessions were missed due to refusals, which were not adequately documented or addressed in the care plan. Additionally, Resident 86's use of a low air loss mattress was not included in a care plan, and the mattress settings were improperly adjusted by a CNA without proper orders or documentation. This lack of a care plan and monitoring could have resulted in pressure ulcers, as the mattress settings were not correctly managed.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for three residents, leading to a deficiency. Resident 51, who was admitted with type 2 diabetes mellitus, chronic obstructive pulmonary disease, and generalized muscle weakness, received insulin injections repeatedly in the same areas, specifically the left upper quadrant of the abdomen and the left arm. This practice was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the insulin administration sites were not rotated as per the manufacturer's guidelines and standards of practice. Similarly, Resident 137, who had diagnoses including congestive heart failure and type 2 diabetes mellitus, also received insulin injections without proper site rotation. The resident's Medication Administration Record (MAR) showed repeated use of the same injection sites, such as the right arm and left upper quadrant of the abdomen. The LVN and DON confirmed the failure to rotate injection sites, which is contrary to the facility's policy and the manufacturer's guidelines, increasing the risk of complications like lipodystrophy and cutaneous amyloidosis. Resident 129, diagnosed with type 2 diabetes mellitus, also experienced the same issue with insulin administration. The MAR indicated that insulin was administered multiple times in the left arm without rotation. The DON reviewed the records and confirmed that the licensed nurses did not rotate the injection sites as required by the facility's policy and the manufacturer's guidelines. This oversight was identified as a significant medication error, potentially leading to skin abnormalities at the injection sites.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to potential risks of injury. For Residents 94, 21, and 27, the facility did not maintain a clutter-free environment as required by their care plans. Observations revealed that overbed tables were placed on top of floor mats, which compromised the integrity of the mats and posed a risk of the tables becoming unstable and potentially falling on the residents. Staff members, including LVNs and CNAs, were unaware of the guidelines prohibiting the placement of furniture on floor mats, which could lead to indentations and instability. Resident 129's environment was also not adequately supervised, as the resident's bed was left in a high position while unattended by staff. This oversight occurred despite the resident being identified as a fall risk, with care plans and orders indicating the need for fall precautions, including keeping the bed in a low position. A CNA admitted to leaving the bed elevated after assisting the resident with breakfast, unaware of the resident's fall risk status. The Director of Staff Development confirmed that leaving beds in a high position unattended increases the risk of falls and injuries. The facility's policies and procedures regarding fall management and maintaining a safe environment were not followed, as evidenced by the placement of furniture on floor mats and the unattended elevated bed. The Director of Nursing acknowledged these deficiencies, noting that the facility's guidelines were not adhered to, which could lead to potential injuries for the residents involved.
Medication Disposal and Accountability Deficiencies
Penalty
Summary
The facility failed to properly dispose of medications in one of the two inspected medication rooms, specifically Medication Room Station 2. During an observation, it was found that the pharmaceutical waste bin contained intact loose medication tablets and capsules, as well as medications in orange bottles, which were not disposed of according to facility policy. The policy required medications to be disintegrated by pouring a liquid over them to prevent retrieval, but the bin did not contain any liquid, leaving the medications in their original form. Additionally, the facility did not include the necessary verifying signatures on the Controlled or Antibiotic Drug Record accountability logs for three of the six sampled records awaiting disposal in the Controlled Substances locked cabinet. The logs lacked signatures from either the Director of Nursing (DON) or a Registered Nurse (RN), alongside the Licensed Vocational Nurse (LVN). This oversight occurred despite the DON and Assistant Director of Nursing (ADON) acknowledging the importance of verifying and signing these logs to ensure accountability and prevent medication diversion. The facility's policies and procedures, last reviewed on January 22, 2025, outlined the requirements for handling, storage, disposal, and documentation of controlled medications. These policies emphasized the need for proper disposal in the presence of a nurse and a witness, with signatures on the disposition sheet. The failure to adhere to these policies increased the risk of medication diversion and accidental exposure to harmful substances, compromising the safety of residents and staff.
Medication Management Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary medications. Resident 10 had duplicate medication orders for rivaroxaban, a blood thinner, which were both active on the Medication Administration Record (MAR) starting from January 19, 2025. The MAR indicated that both doses were signed off as administered by various nurses over several days, although the Director of Nursing (DON) later stated that this was a documentation error and only one supply of the medication was available from the pharmacy. The failure to discontinue the previous order when a new one was prescribed led to the potential risk of the resident receiving both doses, which could cause excessive bleeding. Resident 141 was prescribed Pradaxa, another anticoagulant, for atrial fibrillation, but there was no documentation of monitoring for side effects, such as bleeding, on the MAR between January 1, 2025, and January 30, 2025. The DON confirmed that the care plan for Resident 141 indicated a risk for complications from Pradaxa and required monitoring for active bleeding, which was not documented. This lack of monitoring could result in unnoticed bleeding, potentially harming the resident. The facility's policies and procedures, last reviewed on January 22, 2025, required the Medical Records Department to verify that physician orders are complete and accurate. Additionally, the consultant pharmacist was expected to identify potentially problematic medications through drug regimen reviews. However, these procedures were not effectively implemented, leading to the deficiencies observed in the medication management for Residents 10 and 141.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents, Resident 21 and Resident 358, were free from unnecessary psychotropic medications. For Resident 21, the facility did not establish a specific, measurable target behavior related to the use of sertraline, an antidepressant medication prescribed for depression. The Minimum Data Set (MDS) for Resident 21 indicated no symptoms of depression, yet the medication was prescribed and administered without clear monitoring for specific behaviors, leading to potential unnecessary medication use. Resident 358 was prescribed quetiapine fumarate, an antipsychotic, and sertraline HCl, an antidepressant, without specific measurable behavioral manifestations to monitor. The orders for these medications were based on general terms like 'agitation' and 'unhappiness,' which were not specific enough to justify the use of psychotropic medications. The facility's policy required specific behavioral manifestations to be monitored, which was not followed, leading to the potential for unnecessary medication administration. The Director of Nursing (DON) and the Minimum Data Set Coordinator (MDSC) acknowledged the lack of specific behavioral monitoring and the potential risks associated with the use of psychotropic medications in the elderly. The facility's policy and procedures emphasized the need for specific indications and monitoring for psychotropic medication use, which were not adhered to in these cases. This oversight placed the residents at risk for significant adverse effects from unnecessary medications.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.35% due to three medication errors out of 29 opportunities. These errors affected two residents, Resident 257 and Resident 109, during medication administration. Resident 257, who was diagnosed with atrial fibrillation, did not receive the prescribed form of aspirin, which was intended for DVT prophylaxis. Instead of the enteric-coated aspirin, a chewable form was administered, which could lead to stomach irritation. Resident 109, diagnosed with Diabetes Mellitus 2, received both metformin and aspirin at times different from those prescribed by the physician. The facility's policy allows a 60-minute window for medication administration, but the medications were given outside this timeframe. The metformin was supposed to be administered at 7:00 a.m. and 5:00 p.m., and the aspirin at 8:00 a.m., but both were given at 9:40 a.m. This deviation from the prescribed schedule was acknowledged as a medication error by the LVN involved. The Director of Nursing confirmed the errors and emphasized the importance of following physician orders and facility guidelines for medication administration. The facility's policy on administering medications specifies that medications should be given in a safe and timely manner, adhering to prescriber orders and within the designated time frame. The errors were attributed to the failure of the nursing staff to adhere to these guidelines, resulting in the potential for adverse effects on the residents' health.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of insulin. Specifically, the facility did not adhere to the standard practice of rotating subcutaneous insulin injection sites for three residents, which is necessary to prevent adverse effects such as lipodystrophy and cutaneous amyloidosis. This deficiency was identified during a survey that included interviews and record reviews. Resident 51, who was admitted with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease, received insulin injections without proper site rotation. The resident's Medication Administration Record (MAR) showed repeated use of the same injection sites, contrary to the manufacturer's guidelines and facility policy. Licensed Vocational Nurse (LVN) 2 confirmed that the insulin administration sites were not rotated as required, which was acknowledged as a medication error by both the LVN and the Director of Nursing (DON). Similarly, Resident 137 and Resident 129 also experienced improper insulin administration practices. Resident 137, with diagnoses including congestive heart failure and diabetes, had insulin administered without site rotation, as verified by LVN 2 and the DON. Resident 129's records indicated repeated use of the same injection site by multiple LVNs, which was also recognized as a significant medication error by the DON. The facility's policy and the manufacturer's guidelines both emphasize the importance of rotating injection sites to prevent complications, yet these were not followed, leading to the identified deficiencies.
Improper Medication Storage and Labeling in LTC Facility
Penalty
Summary
The facility failed to properly store and label medications according to manufacturer guidelines and facility policies, leading to potential risks for residents. During an inspection, it was observed that seven ipratropium with albuterol inhalation solutions for a resident were stored outside their protective foil pouch, contrary to the manufacturer's instructions. These inhalation solutions were labeled with a date indicating they were removed from the foil pouch on a specific date, and they were not discarded within the required two-week period, rendering them expired. This improper storage could result in the medication being ineffective in treating the resident's shortness of breath. Additionally, an unopened insulin Humulin R vial for another resident was found stored at room temperature without a date indicating when this storage began. The manufacturer's guidelines require that unopened vials be stored in a refrigerator and discarded after 31 days if stored at room temperature. The lack of proper labeling made it impossible to determine the expiration date, risking the administration of expired insulin, which could be ineffective in regulating the resident's blood sugar levels. Furthermore, an expired dorzolamide eye drop bottle for a third resident was found in a medication cart, labeled with a date indicating it should have been discarded after 28 days of use. The facility also failed to label two open Aplisol vials with the date of first use, which should be discarded after 30 days according to the manufacturer's instructions. These deficiencies in medication storage and labeling practices could lead to the administration of expired medications, potentially resulting in ineffective treatment and health complications for the residents.
Inadequate Nutritional Provision and Menu Management
Penalty
Summary
The facility failed to adhere to its menu guidelines, resulting in inadequate nutritional provision for residents on puree and soft mechanical diets. Observations revealed that staff did not level off the #8 scoop when serving pureed rice and corn, leading to smaller portions than specified in the facility's Diet Guide Sheet. This discrepancy was confirmed by the Dietary Supervisor and Registered Dietitian, who both acknowledged that not leveling the scoop resulted in reduced caloric intake, potentially causing long-term weight loss and delayed wound healing for the residents. Additionally, the facility substituted mashed potatoes for rice in meals for residents on both puree and regular texture diets due to a shortage of rice. This substitution was not in line with the menu, which specified rice as part of the meal. The District Manager admitted that the substitution was not ideal and could lead to resident dissatisfaction and complaints. The Registered Dietitian also noted that while mashed potatoes and rice have similar carbohydrate content, the combination with tacos was not appropriate, potentially leading to residents refusing to eat the meal. Furthermore, the facility failed to post alternate menus in designated areas, as evidenced by the experience of a resident who was unable to find the alternate menu and expressed dissatisfaction with the food options. Interviews with staff confirmed that the menus were not posted in a readable manner, and the alternate menu was not available in the resident's room or on the menu board. This lack of menu visibility prevented residents from being informed of their meal options and requesting alternatives if desired.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures, which could potentially affect the residents' food intake and satisfaction. During observations, it was noted that sliced pears were served at 68 degrees Fahrenheit, and coleslaw was left out on the trayline without ice, reaching a temperature of 75 degrees Fahrenheit. These temperatures are not within the safe and appetizing range as per the facility's policy. The District Manager acknowledged that the trayline lunch service took longer than usual, resulting in food temperatures not being at the desired levels. The facility's policy requires hot foods to be held at temperatures greater than 135 degrees Fahrenheit and cold foods at less than 41 degrees Fahrenheit. Resident 91, who has a medical history of type 2 diabetes mellitus, chronic kidney disease stage 3, and essential hypertension, reported that the hot food was cold and the cold food was hot when served. The resident's dietary orders included a consistent carbohydrate diet with no salt on the tray. The facility's failure to maintain proper food temperatures could potentially lead to dissatisfaction and poor food intake among residents, including Resident 91, who requires assistance with eating. The facility's policy emphasizes that food should be prepared to conserve nutrient value, flavor, and appearance, and served at a safe and appetizing temperature.
Deficiency in Puree Food Preparation for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree diet, as observed during a survey. Specifically, the puree tortilla was found to be too sticky and did not pass the spoon tilt test, indicating it was not prepared with the appropriate consistency. Additionally, the puree corn was watery and did not hold its shape when plated, which could affect the visual presentation and appeal of the food to residents. These issues were identified during a test tray evaluation with the District Manager and Dietary Supervisor, who acknowledged the deficiencies in food preparation. The facility's policies and procedures, as well as standardized recipes, were reviewed and indicated that menus should be planned to meet the nutritional needs of residents according to established guidelines. However, the puree foods did not meet the required consistency as per the International Dysphagia Diet Initiative (IDDSI) guidelines, which state that Level 4 Pureed foods should fall off a spoon in a single spoonful and hold their shape on the plate. The failure to adhere to these guidelines had the potential to result in difficulty swallowing, decreased food intake, and unintended weight loss for the 27 residents on a puree diet.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as evidenced by several observations during a survey. The walk-in refrigerator and freezer floors had dirt and dust buildup, and the kitchen vents were also dusty. The District Manager acknowledged the dirt buildup and emphasized the importance of cleanliness to prevent cross-contamination. Additionally, the facility's policy required regular cleaning of these areas, which was not adhered to. During food preparation, a staff member washed a towel in a sink adjacent to where raw chicken was thawing, causing water splatters onto the chicken, which could lead to cross-contamination. The Dietary Supervisor and District Manager confirmed this practice was inappropriate and against the facility's policy, which aims to prevent contamination during food preparation. Furthermore, light bulbs in the dry storeroom were uncovered, posing a risk of physical contamination, and dented cans were improperly stored with non-dented cans, which could lead to chemical contamination. Additional deficiencies included cracked and chipped resident trays, wet-stacked pots and pans, and staff wearing jewelry during food preparation, all of which could contribute to contamination. Expired food items were found in the residents' refrigerator, and the freezer temperature was not monitored due to the absence of a thermometer, leading to improperly stored ice cream. These practices violated the facility's policies and the Food Code 2022, potentially endangering the health of the residents.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in two specific areas. In the handwashing area, a trash bin was not lined with plastic, which was acknowledged by the Dietary Supervisor as unsanitary and a breach of infection control protocols. This oversight was noted during an observation and interview on January 29, 2025. The lack of a plastic liner in the trash bin could potentially lead to cross-contamination and infection spread among the facility's residents. Additionally, the area surrounding the facility's dumpster was found to be unsanitary, with liquid spills, food juices, and trash on the ground. The dumpster itself was not fully covered, leaving a gap that could attract pests. Both the Dietary Supervisor and the Maintenance Supervisor acknowledged the unsanitary conditions, noting that the sticky dirt and debris could attract rodents and insects, posing a risk of infection spread. The facility's policies and procedures, as well as the Food Code 2022, require that trash be contained in leak-proof containers and that the surrounding areas be kept clean to prevent contamination and pest attraction.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident 33, who was admitted with conditions such as heart failure, a fractured femur, and reduced mobility, was found without access to a call light. During an observation, the call light was discovered dangling behind the bed, out of the resident's reach, which was confirmed by a Restorative Nurse Aide. The Director of Staff Development acknowledged that the lack of access to the call light could result in falls, and the Director of Nursing confirmed that facility policy was not followed. Similarly, Resident 94, who had diagnoses including diabetes and hypertension, was also found without access to a call light. The resident's call light was observed on the floor, and a Licensed Vocational Nurse confirmed it should have been within reach. The Director of Nursing reiterated that staff should ensure call lights are accessible to prevent residents from attempting to get out of bed unassisted, which could lead to falls. The facility's policies on answering call lights and resident rights emphasize the importance of ensuring call lights are accessible to residents to facilitate timely responses to their needs. However, in both cases, the facility failed to adhere to these policies, resulting in a deficiency that could delay care and services for the residents.
Failure to Maintain Cleanliness of Resident's Electric Fan
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, identified as Resident 10, by not ensuring the cleanliness of the resident's electric stand fan. The resident, who was admitted with chronic obstructive pulmonary disease, major depressive disorder, and generalized weakness, had an intact cognition and required assistance with activities of daily living. During an observation, it was noted that the fan in the resident's room had strips of gray powder-like material, identified as dust, on its frame. This was confirmed by both a Licensed Vocational Nurse and the Housekeeping Supervisor, who acknowledged that the housekeeping staff was responsible for cleaning such equipment daily. The Housekeeping Supervisor and the Director of Nursing both stated that the housekeeping department is responsible for maintaining the cleanliness of furniture, including electric fans, and that these items are scheduled for deep cleaning monthly. However, the staff is expected to check and clean the fans daily to prevent dust buildup. The Director of Nursing noted that failure to maintain cleanliness could lead to allergens and does not provide a homelike environment, thus affecting the resident's quality of life. The facility's policy on providing a homelike environment emphasizes the importance of a clean, sanitary, and orderly setting for residents.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by regulations. The deficiency was identified during a review of the care provided to a resident diagnosed with Alzheimer's disease, hypertension, and atrial fibrillation. The resident was admitted to the facility with a high risk for falls and severely impaired cognition, requiring substantial assistance with daily activities. Despite these needs, the facility did not obtain a physician's order, perform an assessment, obtain informed consent, or develop a care plan for the use of pillows tucked under the fitted sheet, which were used as a restraint. During an observation, the resident was found lying in bed with pillows tucked under the fitted sheet on both sides, restricting their movement. A Certified Nursing Assistant confirmed that the pillows were used to prevent the resident from falling when attempting to get out of bed unassisted. The Director of Staff Development and the Director of Nursing both acknowledged that the use of pillows in this manner was a form of restraint and not acceptable without proper authorization and documentation. The facility's policy on the use of restraints clearly states that restraints should only be used for the safety and well-being of residents after other alternatives have been tried. It requires a physician's order, informed consent, and a care plan that addresses the medical symptoms and underlying problems. The facility failed to adhere to these policies, resulting in the improper use of restraints on the resident.
Failure to Conduct Accurate PASRR Screening
Penalty
Summary
The facility failed to ensure that a resident was properly screened using the Preadmission Screening and Resident Review (PASRR) process for mental disorders or intellectual disabilities prior to admission. Specifically, the facility did not submit a new Level 1 PASRR for a resident who had a discrepancy in the previous PASRR Level I screening. The resident, who was admitted with diagnoses including bipolar disorder and schizoaffective disorder, was prescribed antipsychotic medication, which should have triggered a positive Level 1 PASRR. However, the PASRR was incorrectly marked as negative. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the PASRR should have been coded as positive due to the resident's mental health diagnoses and medication regimen. The DON acknowledged that any mental changes in a resident would necessitate a new PASRR screening to ensure accuracy. The facility's policy indicated that designated staff are responsible for ensuring the completion of appropriate PASRRs for all admissions, but this was not adhered to in this case.
Failure to Update Care Plan for Smoking Safety
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident, identified as Resident 62, after a change in condition, specifically regarding smoking safety. Resident 62 was admitted to the facility with diagnoses including seizures, difficulty walking, and muscle weakness. The resident was assessed to require supervision while smoking due to being a fall risk, following a fall incident on the patio. However, the care plan continued to indicate that the resident could smoke independently, which was not updated to reflect the need for supervision. The Assistant Director of Nursing (ADON) acknowledged that the care plans are essential tools for all departments to understand a resident's care needs. The ADON confirmed that the care plan for Resident 62 was not updated after the fall, despite the smoking evaluation indicating the need for supervision. This oversight could have led to the resident smoking unsupervised, increasing the risk of injury from falls or burns. The Director of Nursing (DON) also reviewed the facility's policies and procedures, which require care plans to be updated with any significant change in a resident's condition. The DON confirmed that the facility's policies were not followed, as the care plan was not revised to include the necessary supervision for smoking. This failure to update the care plan could have resulted in the resident not receiving the appropriate supervision, potentially leading to an incident.
Failure to Address Resident's Refusal of Physical Therapy
Penalty
Summary
The facility failed to provide quality care in accordance with professional standards for Resident 147, who was admitted with a nondisplaced intertrochanteric fracture of the right femur, orthopedic aftercare, and rheumatoid arthritis. The resident had a plan for rehabilitation due to good rehab potential, which included physical therapy (PT) for therapeutic exercises, neuromuscular reeducation, therapeutic activities, and gait training. However, the resident repeatedly refused to participate in PT sessions, and the facility did not conduct an interdisciplinary team (IDT) meeting with the resident's responsible party to address these refusals. The facility also failed to inform Resident 147's physician about the resident's refusals to participate in PT treatments. Despite the resident's ability to make herself understood and understand others, she consistently refused therapy, even with maximum encouragement from the PT staff. The missed PT sessions were reported to the Director of Rehabilitation, but there was no documentation of IDT meetings or updates to the care plan to address the resident's refusals. Interviews with staff revealed that the IDT meetings did occur but were not documented, and the resident's care plan was not revised to reflect the updated goals. The facility's policy required that refusals be documented and communicated to the healthcare practitioner, which was not done. The Director of Nursing acknowledged the oversight and the need for documentation and communication with the resident's family and physician.
Failure to Ensure Proper Use and Documentation of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure injuries. Specifically, the facility did not have a physician's order or a care plan for the use of a low air loss mattress (LALM) for a resident who was at mild risk for pressure ulcers. The resident, who was admitted with chronic kidney disease, major depressive disorder, and dementia, was observed using an LALM without the necessary documentation and care planning. During observations, it was noted that the LALM settings were adjusted beyond the resident's weight to prevent alarms, a practice that had been ongoing for about three months. A Certified Nursing Assistant (CNA) admitted to adjusting the settings and stated that the issue had been reported to a previous charge nurse but not to the current Licensed Vocational Nurse (LVN). The LVN was unaware of the malfunctioning LALM, and the Director of Nursing (DON) confirmed that CNAs should not adjust LALM settings and that a physician's order and care plan were required for its use. The facility's policies and procedures indicated that physician orders should be complete and accurate, and care plans should be comprehensive and individualized. However, the lack of a physician's order and care plan for the LALM, along with improper handling of the mattress settings, demonstrated a failure to adhere to these standards. This deficiency had the potential to contribute to the development and worsening of pressure injuries for the resident.
Improper Urinary Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, which led to a deficiency in preventing urinary tract infections (UTIs). The resident, who had impaired cognition and required total assistance with activities of daily living, was observed with a loop in the urinary catheter tubing. This loop contained urine, which could impede the free flow of urine and potentially lead to a UTI. The Licensed Vocational Nurse (LVN) confirmed the presence of the loop and acknowledged that it should not have been there, as it posed a risk for urine backup into the bladder. The Director of Nursing (DON) also confirmed that the urinary catheter tubing should be positioned properly to prevent loops or kinks, which could cause urine to back up into the bladder. The facility's policy on preventing catheter-associated UTIs emphasized maintaining unobstructed urine flow by keeping the catheter and tubing free of kinks. Despite these guidelines, the facility did not ensure that the resident's catheter tubing was properly managed, leading to the identified deficiency.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident's significant weight loss, which was identified as a deficiency. Resident 69, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and dementia, experienced a notable weight loss over several months. The resident's weight decreased from 170.3 pounds in July 2024 to 152.8 pounds by January 2025. A nutritional assessment conducted on January 2, 2025, highlighted the significant weight change and recommended monitoring the weight trend, meal intake, and lab results. Despite these recommendations, the facility did not implement sufficient monitoring or documentation to address the resident's weight loss. Interviews with facility staff revealed lapses in following the facility's policies and procedures for weight management and change in condition notifications. Registered Nurse 2 acknowledged the lack of monitoring for the resident's weight loss, and Licensed Vocational Nurse 4 admitted to incomplete documentation of the change in condition evaluation. The Director of Nursing confirmed that a 72-hour monitoring protocol should have been followed to prevent further weight loss. The facility's policies required notifying the attending physician, family, and dietetics professional, but these steps were not adequately documented or executed, leading to the deficiency.
Failure to Ensure Safe Use of Side Rails for a Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate use of side rails for Resident 145, who was admitted with conditions including spinal stenosis, radiculopathy, lack of coordination, and muscle weakness. The resident required substantial assistance for various activities, including transferring and moving in bed. Despite these needs, the facility did not attempt to use appropriate alternatives before installing bilateral upper side rails, which were intended as enablers for turning and repositioning in bed. The facility did not conduct a comprehensive assessment for the risk of entrapment associated with the use of bilateral upper side rails. The Bed Rail Evaluation for Resident 145 indicated that side rails were not recommended, yet they were still used without a proper assessment of potential entrapment risks. Additionally, the facility failed to review the risks and benefits of using side rails with the resident or their representative and did not obtain informed consent for their use. Furthermore, the facility did not develop and implement a Care Plan for the use of side rails for Resident 145. The absence of a Care Plan meant there were no resident-specific interventions and goals documented to ensure the resident's safety and to monitor the effectiveness of the side rails. This oversight was acknowledged by the facility's staff, including the Director of Nursing, who confirmed that the facility's policy and procedures for side rail use were not followed, potentially leading to the risk of entrapment.
Failure to Document Medication Administration for Two Residents
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for two residents, leading to missing documentation of medication administration. Resident 116, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and dementia, had missing documentation for Humulin administration on two occasions in January 2025. The Director of Nursing (DON) acknowledged that documentation is crucial for monitoring medication administration and blood sugar levels, and stated that when licensed nurses do not document, it implies the medication was not administered. Similarly, Resident 120, admitted with type 2 diabetes mellitus, seizures, and hypertension, had missing documentation for insulin lispro administration on multiple occasions in January 2025. The DON reiterated the importance of documentation for monitoring medication administration and blood sugar levels. The facility's policy and procedure on charting and documentation emphasized the need for documenting services provided, progress toward care plan goals, and any changes in the resident's condition, including medication administration details.
Infection Control Deficiencies in Urinal Labeling and Nebulizer Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific deficiencies. Firstly, a urinal used by Resident 357 was not labeled with a resident identifier, which is a breach of the facility's policy. This oversight was observed during a visit, where the urinal was found on the resident's bedside table without any labeling. Licensed Vocational Nurse 4 confirmed that urinals should be labeled to prevent cross-contamination between residents, especially since there were two residents in the room. The Director of Staff Development and the Director of Nursing both acknowledged that the facility's policy requires urinals to be labeled to prevent the spread of infection, and this policy was not followed in this instance. Secondly, the facility did not ensure that Resident 21's hand-held nebulizer (HHN) tubing was stored properly after use. During an observation, the HHN setup, including the mask, medicine cup, and tubing, was found lying on the resident's bedside table instead of being placed inside a plastic storage bag. Registered Nurse 2 confirmed that the setup should have been stored in a plastic bag to prevent contamination. The Assistant Director of Nursing reiterated that the HHN setup should be stored properly to avoid contamination, which was not done in this case. These deficiencies highlight lapses in the facility's infection prevention and control practices, as outlined in their policies. The failure to label urinals and properly store medical equipment like nebulizers poses a risk of infection transmission among residents, which the facility's policies are designed to prevent.
Failure to Provide Written Medicare Coverage Notices
Penalty
Summary
The facility failed to provide written notifications to residents or their responsible parties regarding the termination of Medicare Part A services and potential financial liabilities. This deficiency was identified during a review of the facility's handling of the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) for two residents. The facility did not provide these notices in writing, nor did they include the estimated out-of-pocket costs, which are essential for residents or their representatives to make informed decisions about their care and financial responsibilities. For Resident 118, the facility initiated the discharge from Medicare Part A services without exhausting benefit days. The Business Office Assistant (BOA) notified the resident's responsible party via telephone but failed to provide the SNF ABN and NOMNC forms in writing. The forms were incomplete, lacking the estimated share of costs, and there was no documented evidence that the responsible party was informed of these costs. The BOA, who had recently taken over these responsibilities, was unaware of the requirement to provide written notifications, leading to a failure in following the facility's policy. Similarly, for Resident 13, the facility's previous Business Office Manager (BOM) notified the responsible party via telephone about the termination of services but did not provide the necessary forms in writing. The SNF ABN form was incomplete, missing the estimated share of costs, and there was no evidence that the responsible party received written notification. The facility's policy, which mandates providing these forms in writing and including cost estimates, was not adhered to, resulting in a lack of informed decision-making for the residents or their representatives.
Inaccurate Resident Assessment and Diagnosis Documentation
Penalty
Summary
The facility failed to accurately complete the admission diagnosis and the Minimum Data Set (MDS) assessment for a resident, identified as Resident 21, by omitting a diagnosis of schizophrenia and bipolar disorder. This oversight was discovered during a review of the resident's records, which showed inconsistencies between the Admission Record, General Acute Care Hospital (GACH) records, and the MDS assessment. The Admission Record included a diagnosis of bipolar disorder but omitted schizophrenia, while the MDS assessment included bipolar disorder but omitted schizophrenia and depression. The resident was prescribed medications for schizophrenia and depression, indicating the presence of these conditions, yet they were not accurately reflected in the MDS assessment. The Director of Nursing (DON) acknowledged the discrepancies during an interview and record review, stating that the accurate diagnoses were missed and overlooked. The facility's policy and procedures require that the Resident Assessment Coordinator ensures timely and appropriate resident assessments, and that information in the MDS assessments consistently reflects information in the progress notes and plans of care. The failure to accurately document the resident's diagnoses in the MDS assessment could lead to inadequate care planning and treatment, potentially affecting the resident's overall health and well-being.
Deficiencies in Enteral Feeding Management for Two Residents
Penalty
Summary
The facility failed to properly manage enteral feeding for two residents, leading to potential inaccuracies in the amount of nutrition delivered and increased risk of infection. For Resident 1, the enteral feeding supplies were not labeled with the licensed nurse's signature, date, and time. The feeding machine was turned on earlier than the physician's order specified, and the machine settings were not cleared at the end of each shift, which could result in the resident receiving an incorrect volume of formula. The Director of Nursing (DON) confirmed these practices and acknowledged the potential for Resident 1 to experience abdominal discomfort and bloating due to inaccurate feeding volumes. Resident 2 also experienced similar issues with their enteral feeding management. The feeding supplies were not labeled with the necessary information, and the feeding machine settings were not cleared at the end of shifts. This oversight could lead to Resident 2 receiving an incorrect amount of formula, potentially causing discomfort and bloating. The DON confirmed these deficiencies and noted the facility's failure to monitor and follow the physician's orders for Resident 2's enteral feeding. The facility's policy and procedure for closed enteral feeding, last reviewed in January 2024, required that enteral feeding be administered as ordered by the attending physician, with the formula labeled with the date and time. The procedure also required setting a dose limit on the machine and documenting the administration in the resident's medical records. The facility's failure to adhere to these procedures contributed to the deficiencies observed in the management of enteral feeding for both residents.
Failure to Develop Comprehensive Care Plan for Shower Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to shower. The resident, admitted on December 7, 2022, had diagnoses including partial intestinal obstruction, left shoulder bicipital tendinitis, and primary osteoarthritis. Despite having intact cognitive skills and the capacity to make decisions, the resident was dependent on staff for showering and bathing. Interviews with staff revealed that the resident had refused showers, and there was uncertainty among the staff about whether a care plan for shower refusal existed. The Director of Nursing (DON) confirmed that there was no documented shower provided to the resident in December 2024, only bed baths, and acknowledged that a care plan for the resident's shower refusal should have been initiated earlier in the month. The facility's policy on care plans, which was last reviewed in January 2024, requires that care plan goals and objectives be documented and modified when not achieved. However, the care plan for the resident's refusal to shower was created late, indicating a lapse in following the facility's established procedures.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident 4, who left the facility unsupervised. On the evening of 12/17/2024, Resident 4, who had a history of cognitive impairment and required assistance for mobility, walked out of the facility without his front wheel walker. The resident was later found three blocks away from the facility, indicating a lapse in supervision and monitoring. Resident 4 had been admitted to the facility with diagnoses including unspecified anemia, alcohol abuse, and a history of transient ischemic attack and cerebral infarction. Despite having the capacity to understand and make decisions as per a medical examination conducted in November 2023, the resident's cognitive skills for daily decisions were noted to be moderately impaired in a Minimum Data Set assessment dated November 2024. The resident's care plan included interventions for safety awareness, yet these measures were insufficient to prevent the elopement. The incident occurred during a candlelight dinner event at the facility, where the receptionist mistook Resident 4 for a visitor and allowed him to exit through the main entrance. The facility's policy on elopement required staff to evaluate residents for elopement risk and implement appropriate interventions, but the policy did not adequately prevent this incident. The facility's response included a search for the resident and notification of relevant parties, but the initial failure to recognize and prevent the elopement highlights a deficiency in supervision and adherence to safety protocols.
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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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