Alhambra Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 415 South Garfield, Alhambra, California 91801
- CMS Provider Number
- 055760
- Inspections on file
- 27
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Alhambra Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Two residents were not treated with dignity: one was left with food particles on her clothing and bed after a meal, and another was addressed by staff with a term she did not prefer, rather than her chosen name. Staff acknowledged these actions did not align with facility policy requiring respect for resident preferences and cleanliness.
Two residents with feeding tubes did not receive care according to physician orders and facility policy: one resident's head of bed was not elevated to the required angle during enteral feeding, and another resident's feeding tube was not properly connected, resulting in nutritional supplement leaking onto the bed and floor. The DON and staff confirmed these practices did not meet established procedures for safe and effective enteral feeding.
Two residents did not receive respiratory care in accordance with facility policy: one resident's suction equipment was not discarded and replaced after use as required, and another resident received oxygen therapy without a physician's order. These deficiencies were confirmed through observation, record review, and staff interviews.
Expired vegetables, including lettuce, cilantro, parsley, and cucumbers, were discovered in the kitchen refrigerator during an observation. A dietary aide confirmed the items were past their expiration dates and acknowledged the risk of illness from consuming expired food. The registered dietitian reviewed facility policy and confirmed the vegetables had not been checked or discarded as required.
Surveyors observed improper disposal of garbage, including overflowing trash bins, uncovered containers, trash bags on the floor, and the use of a hamper as a trash can. Dietary staff confirmed that these practices did not follow facility policy, which requires waste to be placed in closable, covered containers.
Staff and a visitor failed to follow infection control protocols, including improper glove removal and hand hygiene after providing peri-care to a resident with severe cognitive impairment and multiple diagnoses, and incorrect use of PPE such as not wearing a face shield and improper N-95 mask placement in isolation rooms, contrary to facility policy during a COVID-19 outbreak.
The facility did not complete required surveillance data collection forms before administering antibiotics to three residents with various infections and impairments. The IPN and DON confirmed that these forms, which are necessary to assess the need for antibiotics and are mandated by facility policy, were not filled out prior to starting antibiotic therapy.
A resident with significant physical and cognitive impairments was not provided with a Low Air Loss (LAL) mattress set to their comfort level as ordered by the physician. Despite ongoing complaints from the resident and their responsible party about the mattress being too hard and lacking air, staff did not adjust the mattress settings for several months. Staff interviews confirmed awareness of the issue, and facility policy required mattresses to promote comfort, but this was not implemented.
A resident dependent on staff for daily care and receiving tube feeding was left in an unclean and unsafe environment after Glucerna formula spilled onto their bedding, bedrail padding, and the floor. Staff did not promptly clean the spill or replace soiled items, resulting in unsanitary conditions and an accident hazard, in violation of facility policy.
A resident with significant physical and cognitive impairments, fully dependent on staff for hygiene and incontinence care, was found with dried stool on the skin and soiled incontinent brief, indicating staff did not provide required cleaning. Staff and DON interviews confirmed this was not in accordance with facility protocols for maintaining resident cleanliness and dignity.
A resident with end stage renal disease and generalized edema, who required dialysis, was given more fluids than prescribed by the physician on multiple occasions. Despite a care plan and physician order limiting fluid intake to 1000cc per day, records showed the resident received up to 1420cc on several days. Staff interviews and record reviews confirmed that the fluid restriction was not followed as required by facility policy.
A resident with paraplegia and dizziness did not receive a scheduled dose of Meclizine at the prescribed time, as it was administered over an hour late by an LVN. Facility policy requires medications to be given within one hour of the scheduled time, and both the LVN and DON confirmed the importance of timely administration for effective treatment.
A resident with malnutrition and dysphagia was repeatedly served a pureed diet instead of the physician-ordered mechanical soft diet, despite documented complaints and clear dietary orders. Staff interviews and observations confirmed the mismatch between the prescribed and provided diets.
A resident with dysphagia and a mechanically altered diet order was fed regular food brought by family, which was not checked by an LVN as required by facility policy. The DON confirmed that the food should have been reviewed for compliance with the resident's diet, and the family was not educated on safe food handling or dietary restrictions.
A room was found to house more than four residents, exceeding regulatory limits. The room was divided by a wall with two beds on one side and three on the other, but only had a single entry/exit door, making it a single room with five residents. Interviews and observations confirmed that residents and staff had sufficient space and no concerns about care or privacy, but the room did not meet occupancy requirements.
The facility failed to implement a scheduled toileting program for three residents who were assessed as candidates for the bowel and bladder program. Despite being identified as good candidates, there were no orders or care plans for scheduled toileting, which could aid in improving continence status. Interviews with staff confirmed the absence of necessary orders and care plans, contrary to the facility's policy and procedure.
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. A resident's oxygen was not administered as ordered, and nasal cannulas for two residents were not stored properly, risking contamination. Another resident's oxygen equipment was not labeled with the date of use, and a fourth resident lacked necessary suction equipment at the bedside. These actions violated the facility's policy on safe and sanitary oxygen therapy.
The facility failed to follow proper food handling practices, as observed during a survey. A container of rice and a container of brown sugar were not sealed properly, and a can opener was found dirty with dried food residue, gunk, and rust. The Dietary Supervisor confirmed these deficiencies, which were against the facility's policies requiring tight-fitting lids for food storage and sanitation of the can opener between uses.
The facility failed to follow infection control practices during incontinence care for a resident, as a CNA did not change gloves before touching the resident's personal items, increasing infection risk. Additionally, the facility did not conduct water testing for legionella or other pathogens, contrary to guidelines, as they believed it unnecessary without reported cases of legionnaires' disease. This lack of testing contradicts both the facility's policy and national guidelines, which recommend regular water quality assessments.
A facility failed to provide an appropriate call light system for a resident with severe cognitive and physical impairments, resulting in the call light being inaccessible. The resident's care plan required the call light to be within reach, but it was found on the floor, and the DON acknowledged the need for a padded alarm instead of a button due to the resident's condition.
A facility failed to maintain a current copy of a resident's advance directive in their medical record. The resident, admitted with cancer and immunodeficiency, had the capacity to make decisions but was moderately impaired in cognitive skills. Despite facility policy requiring the inclusion of advance directives in medical records upon admission, the document was missing, as confirmed by the DON and Social Services.
A facility failed to initiate a comprehensive care plan for a resident's pressure injury, resulting in delayed care. The resident, at risk for pressure injuries, developed a stage 2 pressure injury, but no treatment orders or care plan were in place. Interviews with staff confirmed the absence of a care plan, despite facility policies requiring timely development and updates of care plans.
A resident with muscle weakness and osteoarthritis experienced a decline in mobility, but the care plan was not updated to reflect these changes. Despite therapy evaluations indicating impairments in both upper and lower extremities, the care plan remained unchanged, leading to inadequate care. Facility staff acknowledged the need for revision, and the facility's policy requires updates for new problems or changes in condition.
Two residents in an LTC facility did not receive the required one-to-one feeding assistance as ordered, leading to untouched meal trays and inadequate supervision during meals. Resident 643, with severe cognitive impairment and dysphagia, was not included in the feeding assistance list, while Resident 10, with cognitive impairment and other health issues, was left to feed herself unsupervised. These actions were contrary to the facility's policies on resident care and dignity.
A resident with a history of muscle weakness and osteoporosis developed a Stage 2 pressure injury due to the facility's failure to notify the physician and update care plans. The resident's initial MASD progressed without proper treatment orders or a wound consult, contrary to the facility's policies.
A resident with diabetic neuropathy missed a dose of gabapentin due to the facility's failure to maintain an adequate supply. The medication was not reordered in time, despite the facility's policy requiring refills to be ordered three to four days in advance. This oversight was identified during a medication pass observation and confirmed through staff interviews.
The facility failed to refrigerate unused insulin pens for two residents, as required by its Medication Storage policy. During an observation, a Novolin R Flex Pen and a Basaglar Kwik Pen were found in a medication cart instead of being refrigerated. LVN 4 and the ADON confirmed the need for refrigeration to maintain medication potency, as per the facility's policy.
The facility was found to have a room exceeding the maximum allowed number of residents, with five beds in a room divided by a wall but sharing a single entry door. Despite this, residents could move freely, and staff had enough space to provide care. A waiver request was submitted and recommended for approval, with no resident concerns reported.
A resident assessed as high risk for falls was not provided necessary assistance when getting up from bed to go to the bathroom, resulting in an unwitnessed fall and head injury. The facility failed to initiate a fall care plan as required by their policy, despite the resident's need for substantial assistance with daily activities. The lack of communication between physical therapy and nursing staff contributed to the incident.
A resident with a history of dysphagia and generalized muscle weakness was found unresponsive and without a pulse. Instead of immediately initiating CPR, an LVN checked the resident's code status at the nurses' station, causing a delay. The resident was also moved to his bed before CPR was started. The resident had been given a regular-texture sandwich, posing a choking risk. The delay in CPR and inappropriate diet contributed to the resident's death, as paramedics pronounced the resident dead 35 minutes after becoming unresponsive.
A resident with dysphagia was given a regular texture sandwich instead of a mechanical soft texture diet as ordered by the physician. The CNA did not verify the resident's diet order, and the UAP provided the inappropriate sandwich. The DSS confirmed the resident's diet required a mechanical soft texture with nectar thick consistency. The facility's Snack Spreadsheet also indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids. This led to the resident choking, losing consciousness, and subsequently passing away.
A resident with a history of respiratory issues experienced a significant drop in oxygen saturation, which was not promptly reported to the doctor by the facility staff. Despite the facility's policy requiring immediate notification, the doctor was only informed after the resident became unresponsive and expired.
A resident with multiple respiratory and cardiac conditions was given oxygen therapy without an active physician's order. Staff assumed there was an order and did not follow protocol to inform the doctor, placing the resident at risk for inadequate oxygen therapy.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Two residents were not treated with respect and dignity according to facility policy. One resident, who had severe cognitive impairment and required assistance with most activities of daily living, was observed with food particles on her gown and bed linen after a meal. Staff interviews confirmed that the resident was not cleaned up after eating, and that it is the responsibility of staff to ensure residents are clean from food particles to maintain their dignity. Facility policy requires provision of a clean, comfortable bed and environment to support resident dignity and well-being. Another resident, who was moderately impaired cognitively and required some assistance with personal care, was addressed by a staff member as "grandma" rather than by her preferred name. The resident expressed that she did not like being called "grandma" and preferred to be addressed as "Miss." Staff and the Director of Nursing acknowledged that addressing the resident by a name other than her preference was inappropriate and not in accordance with the facility's policy, which requires staff to speak respectfully and use residents' names of choice.
Failure to Ensure Proper Gastrostomy Tube Practices and Procedures
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) practices and procedures for two residents. For one resident with a history of hemiplegia, hemiparesis, acute respiratory failure, and dementia, the head of bed was observed to be elevated at only 20 degrees during enteral feeding, despite physician orders and care plan interventions requiring elevation to at least 30-45 degrees. The Director of Nursing confirmed that the observed bed elevation was below the required angle, and facility policy also specified a minimum of 30 degrees during enteral feedings. For another resident with diagnoses including gastrostomy, dementia, and dysphagia, the GT feeding was not properly connected, resulting in Glucerna leaking into the resident's bed and onto the floor. The resident was dependent on staff for most activities and received more than half of their nutrition through the feeding tube. The nurse present acknowledged that the feeding should not be leaking and that staff are responsible for ensuring all tubing is properly connected so the resident receives the prescribed nutrition. Facility policy required that enteral feedings be administered as ordered by the attending physician, with procedures to check tube placement and ensure proper connection of feeding containers and tubing. The Director of Nursing confirmed that improper connection of the GT feeding could result in the resident not receiving the full prescribed amount of nutrition.
Failure to Follow Respiratory Care Protocols and Physician Orders
Penalty
Summary
Two deficiencies were identified during the review of respiratory care provided to residents. For one resident with hemiplegia, hemiparesis, dementia, gastrostomy, and dysphagia, there was an order to swab/suction every shift as appropriate, and a separate order to suction as needed for excessive secretions. However, observation revealed that suction equipment, including a yankauer, suction tubing, and a collection canister, remained at the bedside well beyond the facility's policy for single-use items. The equipment was dated several days prior and had not been discarded or replaced after use, contrary to the facility's protocol and infection control policy. Staff interviews confirmed that the equipment should have been changed after each use to prevent contamination and infection, but this was not done. A second deficiency involved another resident with diagnoses including type 2 diabetes, cerebral infarction, and dependence on oxygen. This resident was observed receiving oxygen therapy at two liters per minute, but a review of the medical record revealed there was no physician's order for the administration of oxygen. Staff confirmed that the resident was receiving oxygen without a doctor's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen therapy. The DON also confirmed that the policy mandates administration of oxygen only per physician orders. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The facility failed to follow its own policies regarding the safe administration of respiratory care, specifically in the areas of equipment management and ensuring proper physician authorization for oxygen therapy.
Expired Vegetables Found in Kitchen Refrigerator
Penalty
Summary
During a kitchen observation, expired vegetables including lettuce, cilantro, parsley, and cucumbers were found stored in the facility's refrigerator, with expiration dates ranging from 6/19/2025 to 6/22/2025. The dietary aide present confirmed that the vegetables were expired and acknowledged that consuming expired food could make residents sick. Review of the facility's Food Storage and Handling policy indicated that fresh vegetables should be checked, sorted, labeled, and dated, but the registered dietitian confirmed that the expired vegetables had not been checked or discarded as required. The dietitian also stated that the labels clearly indicated the vegetables were expired and should have been thrown away.
Improper Disposal of Garbage in Facility's Disposal Area
Penalty
Summary
During a kitchen observation, surveyors found that the facility failed to properly dispose of garbage in the designated disposal area. Specifically, trash bins were seen overflowing, some bins had lids that were not fully closed, trash bags were left on the floor, a hamper was being used as a trash can, and some trash cans were uncovered. A dietary aide confirmed that trash bags should not be on the floor, trash should be covered, and hampers are not appropriate for use as trash cans, noting that uncovered trash can attract animals and spread disease. Review of the facility's waste management policy indicated that waste containers must be closable, waste must be disposed of in appropriate non-combustible containers, and waste bags must be placed in covered bins. The dietary supervisor also confirmed that trash should be disposed of in closable containers and not left on the floor or in hampers.
Deficient Infection Control Practices and Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as outlined in its own policies and procedures. Certified Nurse Assistant 1 (CNA 1) was observed exiting a resident's room after providing peri-care while still wearing contaminated gloves and used those gloves to close the resident's door. CNA 1 acknowledged during an interview that gloves should have been removed and hand hygiene performed before leaving the room. The Infection Preventionist Nurse (IPN) and Director of Nursing (DON) both confirmed that this action was not in accordance with facility policy and could contribute to the spread of infection, especially during an ongoing COVID-19 outbreak in the facility. The facility's policies require gloves to be discarded in the room where care is provided and for staff to perform hand hygiene before and after glove removal and upon exiting a resident's room. Additionally, there were failures related to the use of personal protective equipment (PPE) in rooms under novel respiratory precautions. CNA 1 was observed entering an isolation room without wearing a required face shield, despite signage and facility policy indicating that a face shield, N-95 mask, gown, and gloves must be worn before entry. CNA 1 admitted knowledge of the requirement but did not comply. In another instance, a family member (FM 2) was observed entering a resident's room with an N-95 mask worn incorrectly, with the metallic strip under the chin instead of over the nose, which was confirmed by a Licensed Vocational Nurse (LVN 2) to be improper and not in line with the facility's instructions for proper fit and use. The facility's policies on management of COVID-19 and transmission-based precautions require strict adherence to PPE protocols, including correct donning and doffing procedures and proper use of equipment to prevent the spread of communicable diseases. Observations and interviews confirmed that staff and visitors did not consistently follow these protocols, resulting in deficiencies in infection control practices.
Failure to Complete Antibiotic Surveillance Forms Prior to Administration
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program protocol by not completing the required surveillance data collection forms prior to administering antibiotic therapy to three residents. For each of these residents, antibiotics were prescribed and administered without the documented assessment to determine if the criteria for antibiotic use were met, as required by facility policy. The Infection Preventionist Nurse (IPN) confirmed in interviews that the surveillance data collection forms were not completed for any of the three residents before antibiotics were given. One resident was readmitted with diagnoses including sepsis and contact dermatitis and was prescribed Cephalexin for a urinary tract infection. Another resident, admitted with immune system disorder and malnutrition, received Sulfamethoxazole-Trimethoprim for a left buttock ulcer secondary to a ruptured abscess. The third resident, admitted with MRSA and malnutrition, was prescribed Ciprofloxacin for a urinary tract infection. In each case, the Minimum Data Set (MDS) assessments indicated varying levels of cognitive and physical impairment, and the physician orders for antibiotics were documented in the residents' records. Interviews with the IPN and the Director of Nursing (DON) confirmed that the surveillance data collection forms, which are intended to evaluate the necessity of antibiotic use and prevent antibiotic resistance, were not completed as required by the facility's policies. The facility's policies specify that the IPN is responsible for collecting and analyzing infection surveillance data and ensuring adherence to antibiotic stewardship processes, including the completion of surveillance forms prior to antibiotic administration.
Failure to Adjust LAL Mattress to Resident Comfort Level
Penalty
Summary
A deficiency occurred when the facility failed to accommodate the needs and preferences of a resident by not ensuring that the resident's Low Air Loss (LAL) mattress was set to the comfort level as ordered by the physician. The resident, who was admitted with diagnoses including scoliosis, chest and rib deformity, and muscle weakness, was dependent on staff for most activities of daily living and was moderately impaired in cognitive skills. Physician orders specified that the LAL mattress should be adjusted for the resident's comfort, yet observations revealed that the mattress had very little air, and the metal part of the bed could be felt with minor pressure. The resident repeatedly complained about the mattress being uncomfortable and lacking sufficient air. Interviews with staff and the resident's responsible party confirmed that complaints about the mattress had persisted for two to three months, with both the resident and their responsible party noting the mattress was hard and uncomfortable. Staff acknowledged that the mattress should be set to the resident's comfort level in accordance with physician orders and resident rights. Facility policies also required providing a comfortable mattress to promote comfort and prevent complications of immobility, but these were not followed in this instance.
Failure to Maintain Clean and Safe Resident Environment After Enteral Feeding Spill
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for a resident who was dependent on staff for most activities of daily living and received the majority of nutrition through a gastrostomy tube. The resident, who had diagnoses including dementia and dysphagia, was found with spilled Glucerna formula on their fitted bed sheet, bed sheet, bedrail padding, and the floor. Staff present at the time acknowledged that the enteral feeding formula had leaked and that the environment was not clean or sanitary. Housekeeping had not been called to clean the floor, and the bedrail padding had not been replaced or cleaned at the time of observation. The facility's policy and procedure required staff to provide a safe, clean, and comfortable environment and to pay close attention to cleanliness and order. Despite this, staff did not promptly address the spill or ensure the resident's environment was sanitary. The Director of Nursing confirmed that the situation was unacceptable and that any staff member could have assisted in cleaning the environment and bedside padding. This failure resulted in an unclean environment and accident hazard for the resident, other residents, and facility staff.
Failure to Provide Adequate Incontinence and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including perineal hygiene and incontinence care, was found in bed with brown residue on the right inner thigh and a brown smear on the outside and top of the incontinent brief. The resident had a history of hemiplegia, hemiparesis, dementia, and Parkinson's disease, and was documented as always incontinent and requiring total assistance for toileting and hygiene. Staff interviews confirmed that the presence of stool on the resident's skin and brief indicated that the resident had not been fully cleaned or checked as required. Facility policy required that residents who are incontinent be kept clean, dry, and comfortable, and that perineal care be provided to maintain cleanliness and prevent skin breakdown. Both the CNA and LVN present at the time of observation acknowledged that the resident should have been cleaned properly, and the DON confirmed that facility protocol mandates residents be left clean, presentable, and odor free. The failure to provide adequate assistance with hygiene and incontinence care was directly observed and confirmed through staff interviews and record review.
Failure to Follow Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident receiving dialysis, resulting in the resident being given more fluids than prescribed on multiple occasions. The physician's order and care plan specified a strict fluid restriction of 1000cc per 24 hours, divided among the three nursing shifts. However, medication administration records showed that the resident received a total of 1420cc of fluid on several days, exceeding the prescribed limit. This discrepancy was confirmed during interviews with both a licensed vocational nurse and the director of nursing, who acknowledged that the physician's order was not being followed. The resident involved had diagnoses of end stage renal disease and generalized edema, and required dialysis as well as assistance with daily activities. The facility's policies on fluid restriction and dialysis management required strict adherence to physician orders, but these were not followed in practice. The failure to comply with the fluid restriction was documented through record reviews, staff interviews, and review of facility policies.
Failure to Administer Scheduled Medication on Time
Penalty
Summary
A scheduled medication was not administered on time to a resident with paraplegia and dizziness. The resident was admitted with these diagnoses and was assessed to have intact cognitive skills, requiring varying levels of assistance for daily activities. The resident had a physician's order for Meclizine to be given three times daily for dizziness. On the day in question, the medication was scheduled for 8:00 AM but was not administered until 9:40 AM, as observed by surveyors and confirmed by the LVN responsible for medication administration. The facility's Medication Administration policy requires medications to be given within one hour before or after the scheduled time, and emphasizes the importance of administering medications at the right time. The LVN acknowledged the medication was given late and stated that late administration could result in symptoms not being relieved on time. The Director of Nursing confirmed the policy and the importance of timely medication administration to ensure proper treatment of residents' medical conditions.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident with diagnoses of protein-calorie malnutrition and hyperlipidemia, who was moderately cognitively impaired and dependent on staff for several activities of daily living, was not provided with the therapeutic diet as ordered by the physician. The resident's Minimum Data Set and speech therapy evaluation indicated a need for a carbohydrate-controlled, mechanical soft diet with regular/thin liquid consistency, and the physician's order specified a dysphagia mechanical soft texture. However, multiple observations revealed that the resident was consistently served a pureed diet instead of the ordered mechanical soft diet. Interviews with the resident, a CNA, and the Director of Dietary Services confirmed that the resident had been complaining about the food texture for at least a week, and possibly as long as six months. The Director of Dietary Services acknowledged that the resident's tray did not match the physician's order, and the DON confirmed that the diet should have followed the speech therapy evaluation and physician's order. The facility's policy required meals to be consistent with physician orders and resident preferences, but this was not followed in the resident's case.
Failure to Review Family-Brought Food for Resident with Dysphagia
Penalty
Summary
The facility failed to implement its policy regarding the review and storage of food brought in by family members for a resident with significant swallowing difficulties. Specifically, a resident with diagnoses including dysphagia, hyperlipidemia, and adult failure to thrive, and who was on a mechanically altered, fortified diet as ordered by the physician, was observed being fed a regular diet of wonton soup and kiwi by a family member. The resident's care plan and physician orders required adherence to a mechanically altered diet due to the risk of choking and aspiration. Despite this, the food brought in by the family was not checked by the Licensed Vocational Nurse (LVN) as required by facility policy. Interviews with the LVN and the Director of Nursing (DON) confirmed that the food was not reviewed for compliance with the resident's prescribed diet, and that the family was not educated on the facility's policy or the resident's dietary needs. The facility's policy required staff to review the diet order with the resident's representative and assist families in understanding safe food handling practices, but this was not followed in this instance.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that one of its rooms did not exceed the maximum occupancy of four residents per room, as required by regulations. Specifically, the room in question was separated by a wall into two sections, with two beds on one side and three beds on the other, but only had a single door for entry and exit, effectively making it a single room with five residents. This arrangement was confirmed through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the configuration and the number of residents in the room. Interviews with the administrator, residents, and nursing staff confirmed the presence of more than four residents in the combined room. Despite the room's size and the ability for residents and staff to move freely and provide care, the room did not meet the regulatory requirement for maximum occupancy. The residents and staff did not express concerns about space, privacy, or the ability to provide care, and observations indicated that the room's configuration did not adversely affect health or safety at the time of the survey.
Failure to Implement Scheduled Toileting Program
Penalty
Summary
The facility failed to implement a toileting schedule for three residents who were assessed as candidates for the bowel and bladder (B&B) program. Resident 40, who was occasionally incontinent with urinary continence and always continent with bowel continence, was identified as a good candidate for retraining on multiple occasions. Despite this, there was no order for a scheduled toileting program, as confirmed by interviews with the Certified Nursing Assistant and Licensed Vocational Nurse. The Assistant Director of Nursing acknowledged that without a scheduled toileting order, Resident 40's incontinence may not improve. Resident 16, who was always incontinent for bowel continence, was also identified as a good candidate for scheduled toileting. However, the Director of Nursing confirmed that there was no physician's order for scheduled toileting, which could aid in restoring bowel and bladder continence. The lack of a scheduled toileting program for Resident 16 was a missed opportunity to improve their continence status. Resident 82, who was frequently incontinent and had a Foley catheter, was assessed as a candidate for scheduled toileting. Despite this, there was no care plan implemented for a scheduled toileting program. The Assistant Director of Nursing stated that a scheduled toileting program could help improve incontinence status and promote dignity, but it was not in place for Resident 82. The facility's policy and procedure emphasized the importance of providing appropriate treatment and services to restore bowel and bladder function, which was not adhered to in these cases.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. For Resident 2, the facility did not administer oxygen via nasal cannula according to the physician's order, as the nasal cannula was found hanging at the back of the wheelchair and not in use. This oversight was confirmed by both a CNA and an LVN, who acknowledged that the nasal cannula should have been placed in a plastic bag to prevent contamination. Additionally, the Assistant Director of Nursing (ADON) noted that the resident could develop shortness of breath and hypoxia if the oxygen was not provided as ordered. For Residents 2 and 49, the facility failed to ensure that the nasal cannula was stored in a clean plastic bag when not in use, which could lead to respiratory infections. Resident 49's nasal cannula was observed wrapped around the bedside rail, exposed to potential contamination. Both an LVN and the ADON confirmed that the nasal cannula should be stored in a plastic bag to avoid exposure to germs. The facility's policy on oxygen therapy, which requires oxygen to be administered under safe and sanitary conditions, was not followed. Resident 641's oxygen nasal cannula and water container for humidified oxygen were not labeled with the date of first use or change, as observed by a physical therapist and a CNA. This lack of labeling is against the facility's policy, which requires such equipment to be changed and dated every seven days. Additionally, Resident 63, who required suctioning as needed, did not have a suction canister or yaunker readily available at the bedside, and the nebulizer tubing was found on the floor. The Infection Preventionist and the Director of Nursing acknowledged the absence of a policy for suctioning and proper storage of oxygen and nebulizer tubing, which are crucial for infection control and resident safety.
Improper Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Specifically, a container of rice and a container of brown sugar were not sealed properly, which was confirmed by the Dietary Supervisor (DS) during an interview. Additionally, a can opener was found to be dirty, with dried food residue, gunk, and rust present. These observations were made during a kitchen inspection, and the DS acknowledged the improper sealing of the containers and the unclean state of the can opener. The facility's policies and procedures, as reviewed, require that opened food products be stored in containers with tight-fitting lids and that all storage products be labeled and dated. The policy also mandates routine monitoring for pest activity. Furthermore, the can opener is supposed to be sanitized between uses according to the manufacturer's guidelines. The DS confirmed that all food containers should be tightly closed to prevent pest infestation and that the can opener should be cleaned after each use.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident. The resident, who was admitted with diagnoses of muscle weakness and hypertension, was observed to be severely impaired in cognitive skills and required assistance with daily activities, including toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to the resident without changing gloves before touching the resident's personal items, such as the call light, blanket, bed rail, and bed remote. This action was acknowledged by the CNA and the Infection Preventionist Nurse as a breach of infection control protocol, as it increased the risk of spreading infection. Additionally, the facility did not implement water sample testing to validate its water management program's control measures. Interviews with the Infection Preventionist and Maintenance Supervisor revealed that the facility did not conduct testing for legionella or other waterborne pathogens, as they believed there was no need due to the absence of reported cases of legionnaires' disease among residents. The facility's policy and procedure on water management, as well as guidelines from the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention, emphasize the importance of environmental testing to validate the effectiveness of control measures in preventing waterborne pathogens. The facility's failure to conduct initial or ongoing water testing for legionella and other pathogens was further confirmed by the Administrator, who stated that testing was not deemed necessary unless there were issues with water temperature. This lack of testing contradicts the facility's own policy and national guidelines, which recommend regular water quality assessments to prevent conditions conducive to legionella growth, especially in healthcare settings serving at-risk populations.
Inadequate Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to provide an appropriate call light system for a resident, identified as Resident 5, who was admitted with diagnoses of muscle weakness and osteoarthritis. The resident's care plan, revised on two occasions, indicated the need for the call light to be within reach due to the resident's risk for injury and falls. However, during an observation, it was noted that the call light was on the floor and not accessible to the resident, who had both arms and legs contracted. The Director of Nursing (DON) acknowledged that the call light should have been a padded alarm instead of a button due to the resident's condition and inability to use the standard call light. The resident's medical records, including an Occupational Therapy Evaluation and Minimum Data Set, highlighted severe impairments in cognitive skills and physical abilities, indicating dependency on assistance for daily activities. Despite these documented needs, the facility's policy on call systems, which required call cords to be within the resident's reach, was not adhered to. This oversight had the potential to delay necessary care and services for the resident, as the call light was not appropriately adapted to the resident's physical limitations.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a current copy of a resident's advance directive in the medical record, which is a legal document that provides instructions for medical care if the resident cannot communicate their wishes. This deficiency was identified for one resident who was admitted with diagnoses of malignant neoplasm of the left lower limb and immunodeficiency. The resident had the capacity to understand and make decisions as per the History and Physical dated January 8, 2024, but was noted to be moderately impaired in cognitive skills for daily decision-making according to the Minimum Data Set dated May 17, 2024. During a record review on June 25, 2024, it was found that there was no advance directive in the resident's chart. Interviews with the Director of Nursing (DON) and Social Services (SS) confirmed that the facility did not have the resident's advance directive and acknowledged that it should have been followed up shortly after admission. The facility's policy, revised in July 2018, requires that a copy of the advance directive be obtained upon admission and included in the resident's medical record, which was not adhered to in this case.
Failure to Initiate Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was initiated for a resident, resulting in delayed care and services for the resident's pressure injury. The resident was admitted with diagnoses of muscle weakness and osteoporosis and was at risk of developing pressure injuries, as indicated by the Braden Scale. Despite these risks, the facility did not develop a care plan to address the resident's pressure injury, which was observed by a CNA and later classified as a stage 2 pressure injury by a treatment nurse. Interviews with facility staff, including a CNA, a treatment nurse, the DON, and the ADON, revealed that there were no orders for treatment of the resident's pressure injury, and the facility did not have a care plan in place for the injury. The facility's policies required the development of a comprehensive care plan within seven days of the MDS assessment and updates to the care plan with the onset of new problems or changes in condition. However, these procedures were not followed, leading to the deficiency.
Failure to Revise Care Plan for Resident with Declining Mobility
Penalty
Summary
The facility failed to revise the care plan for one of the sampled residents, identified as Resident 5, which led to inadequate care for the resident's needs. Resident 5 was admitted with diagnoses of muscle weakness and osteoarthritis and was noted to have impaired cognitive skills, requiring extensive assistance with daily activities. Despite the resident's declining mobility, as evidenced by occupational and physical therapy evaluations indicating impairments in both upper and lower extremities, the care plan was not updated to reflect these changes. Observations showed the resident with contracted arms and legs, and interviews with facility staff confirmed that the care plan should have been revised to address the resident's declining condition. The Assistant Director of Nursing acknowledged that the care plan needed revision since the resident was no longer in the Restorative Nursing Assistant program and had experienced a decline in mobility. The Director of Rehabilitation also noted the resident's declining mobility and recommended splinting to prevent contractures. The facility's policy on comprehensive person-centered care planning requires care plans to be revised at the onset of new problems or changes in condition, which was not adhered to in this case.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide one-to-one feeding assistance for two residents, Resident 643 and Resident 10, as ordered. Resident 643, who was admitted with a displaced intertrochanteric fracture and dysphagia, was observed multiple times with untouched meal trays and no staff assistance, despite having an order for 1:1 feeding assistance. The Assistant Director of Nursing (ADON) confirmed that Resident 643 was not included in the list of residents requiring feeding assistance, which was an oversight. The Speech Therapist and Director of Rehab noted that Resident 643 needed 1:1 support for feeding to ensure safety and adequate food intake. Resident 10, admitted with anemia, malnutrition, and end-stage heart failure, also required assistance with feeding. Observations revealed that Resident 10 was feeding herself with food all over her mouth and clothes, contrary to the care plan that required staff supervision during meals. The ADON confirmed that Resident 10's care plan indicated a need for assistance with eating and personal hygiene due to cognitive impairment and other health issues. CNA 7 admitted to leaving Resident 10 to feed herself, which was not in line with the required supervision for safety and dignity. The facility's policies on resident rights and quality of life emphasize the need for individualized care to maintain residents' dignity and well-being. However, the failure to provide the necessary feeding assistance for Residents 643 and 10, as per their care plans, put them at risk for weight loss, aspiration, and compromised dignity. The oversight in including Resident 643 in the feeding assistance list and the lack of supervision for Resident 10 highlight deficiencies in the facility's adherence to its policies.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate treatment for a Stage 2 pressure injury for one of the sampled residents, Resident 26. Initially, Resident 26 had Moisture-Associated Skin Damage (MASD) on the sacrum area, which progressed to a Stage 2 pressure injury. Despite this progression, the facility did not notify the physician, resulting in no wound treatment orders being issued. Additionally, there was no Change of Condition form completed to document the progression of the wound. Interviews and record reviews revealed that Resident 26's physician orders did not reflect the presence of a pressure injury, and there was no order for a wound consult. Consequently, Resident 26 had not been seen by a wound doctor after the wound progressed. Furthermore, Resident 26's care plan did not indicate any pressure injuries, contrary to the facility's policies and procedures, which require care plans to be reviewed and revised upon the onset of new problems or changes in condition. The facility's policies also mandate daily observation and reporting of any signs of active pressure injuries, which was not adhered to in this case.
Failure to Maintain Adequate Medication Supply
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with type 2 diabetes mellitus and diabetic neuropathy, had a sufficient supply of gabapentin, a nerve pain medication, as per the physician's order and facility policy. The physician's order required the administration of gabapentin 100 mg twice daily for neuropathy. However, during a medication pass observation, it was noted that the resident did not have any gabapentin available in the medication cart, resulting in a missed morning dose. Interviews with the Licensed Vocational Nurses (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse responsible for the resident's medication should have ordered a refill when the stock was low. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply. The failure to reorder the medication in a timely manner led to the resident missing a dose, which could potentially result in unrelieved nerve pain.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not refrigerating unused insulin pens for two residents, which is a requirement for maintaining the medication's effectiveness. During an observation of Medication Cart 3, it was found that a Novolin R Flex Pen belonging to one resident and a Basaglar Kwik Pen belonging to another resident were not stored in the refrigerator as required. Both insulin pens had green stickers indicating the need for refrigeration, yet they were found in the medication cart instead. Licensed Vocational Nurse (LVN 4) confirmed that the insulin pens should have been refrigerated, and the Assistant Director of Nursing (ADON) reiterated the importance of proper storage to maintain the potency of the medications. The facility's policy, dated August 2019, specifies that medications should be stored according to the manufacturer's recommendations, which include refrigeration for these insulin pens. The failure to store these medications properly could compromise their effectiveness, posing a risk to the residents' health.
Room Capacity Exceeded in Shared Resident Room
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents in a shared room to no more than four. During an observation, it was noted that one room, identified by specific room numbers, was divided by a wall and contained a total of five beds, with two beds on one side and three on the other, accessible through a single door. This setup did not meet the requirement of having no more than four residents per room. Despite the room's configuration, residents were able to move freely, and nursing staff had adequate space to provide care with dignity and privacy. The facility had submitted a room waiver request, indicating sufficient space and safety for residents, and the Department recommended approval of this waiver. Interviews with residents revealed no concerns about room size.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to prevent a fall for a resident who was assessed as high risk for falls. The resident, admitted with diagnoses including muscle weakness, history of falling, and abnormality of gait and stability, had a high fall risk score of 11. Despite requiring substantial assistance with daily activities such as toileting and transfers, the resident was not provided assistance when getting up from the bed to go to the bathroom. This lack of assistance led to an unwitnessed fall in the resident's room, resulting in a head injury and transfer to a general acute care hospital. The facility did not initiate a fall care plan for the resident, as required by their policy and procedure. The Director of Nursing acknowledged that the resident was assessed as high risk for falls and should have had a fall care plan in place. Additionally, the Physical Therapy Director noted the need for communication with nursing staff regarding the resident's assistance needs. The facility's policy on fall management emphasizes the importance of documenting interventions on the resident's care plan when a fall risk factor is identified, which was not done in this case.
Delayed CPR Initiation and Inappropriate Diet Lead to Resident Fatality
Penalty
Summary
The facility failed to ensure immediate initiation of CPR for Resident 1, who was found unresponsive and without a pulse. Instead of starting CPR right away, LVN 1 walked to the nurses' station to check on Resident 1's code status before beginning CPR. Additionally, Resident 1 was moved from outside his room to his bed before CPR was initiated, causing a delay in life-saving measures. Despite Resident 1's need for immediate CPR due to cardiac and respiratory arrest, the staff did not act promptly, resulting in the resident being pronounced dead by paramedics 35 minutes after becoming unresponsive. Resident 1 had a history of dysphagia and generalized muscle weakness, requiring a specific diet and supervision with eating. Despite these known conditions, Resident 1 was given a sandwich of regular texture, which posed a choking risk. The staff's delay in recognizing the severity of the situation and the failure to provide appropriate care, such as immediate CPR and addressing the choking incident effectively, contributed to the tragic outcome. The facility's policy on cardiopulmonary resuscitation was not followed, as staff did not initiate CPR promptly upon finding Resident 1 unresponsive.
Failure to Adhere to Dysphagia Diet Order Results in Resident's Death
Penalty
Summary
The facility failed to follow the physician's order to provide a mechanical soft texture diet for a resident with dysphagia, resulting in a tragic incident. Despite the resident's documented need for a specific diet due to difficulty swallowing, the Certified Nursing Assistant (CNA) did not verify the resident's diet order before allowing them to consume a sandwich of regular texture and unknown content. This failure led to the resident choking and subsequently losing consciousness, ultimately resulting in their death. The deficiency was exacerbated by the actions of the Uncertified Assistive Personnel (UAP), who handed the inappropriate sandwich to the resident despite being instructed by the CNA to obtain it from the facility's refrigerator. The Dietary Service Supervisor (DSS) confirmed that the resident should not have been given a sandwich due to being on a dysphagia mechanical soft diet with nectar thick consistency. Additionally, the facility's Snack Spreadsheet indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids, highlighting a breakdown in communication and adherence to established protocols.
Failure to Notify Doctor of Resident's Low Oxygen Saturation
Penalty
Summary
The facility failed to notify the doctor of a resident's change in condition, specifically a decreased oxygen saturation level of 78%. The resident, who had a history of pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was found by an LVN to be short of breath with uneven breathing. Despite the facility's policy requiring immediate notification of significant changes in condition, the LVN did not inform the doctor of the resident's low oxygen saturation level. The Director of Nursing (DON) was informed of the situation but also did not notify the doctor until after the resident became unresponsive and expired. Interviews and record reviews revealed that the resident's vital signs, including the low oxygen saturation level, were documented but not communicated to the doctor in a timely manner. The medical doctor confirmed that he was only informed of the resident's condition after the resident had already passed away. The facility's policy and procedure clearly stated that physicians should be informed immediately of any significant changes in a resident's condition, which was not followed in this case, leading to a failure in providing timely medical intervention for the resident.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident had an active doctor's order for oxygen therapy before and during its administration. The resident, who had diagnoses including pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was given oxygen at 2 liters per minute on multiple occasions without a physician's order. This was confirmed through a review of the resident's Medication Administration Records and Order Summary, which did not indicate an active physician's order for the oxygen therapy during the specified period. Interviews with the CNA, LVN, and DON revealed that the staff assumed there was an active order and did not follow the facility's protocol to inform the doctor and obtain a proper order for the oxygen therapy. The resident's primary doctor confirmed that he did not order oxygen administration and was unaware that the resident was receiving oxygen therapy. The facility's policy and procedure for oxygen therapy, which requires licensed nursing staff to administer oxygen as prescribed by the doctor, was not followed. This failure placed the resident at risk for inadequate oxygen therapy, which could negatively impact their health and well-being. The DON acknowledged that administering oxygen without a physician's order is a significant problem that could lead to respiratory distress and potentially fatal outcomes for the resident.
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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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