Angels Nursing Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 415 S Union Avenue, Los Angeles, California 90017
- CMS Provider Number
- 055704
- Inspections on file
- 29
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Angels Nursing Health Center during CMS and state inspections, most recent first.
A facility failed to account for 17 Percocet tablets prescribed to a resident with muscle weakness and spina bifida after the medication was discontinued. Lapses included inconsistent narcotic counts at shift changes, improper handling of discontinued medication, and leaving the medication cart key unattended, all contrary to facility policy. These actions resulted in the unaccounted loss of a Schedule II controlled substance.
During a meal service, staff failed to follow standardized menus and diet orders, resulting in several residents on fortified diets not receiving calorie-enriched foods, and others on regular and renal diets receiving incorrect menu items. The dietary aide did not communicate special diet orders, and the cook did not review the menu or spreadsheet, leading to multiple residents receiving incomplete or inappropriate meals.
Surveyors observed that dietary staff did not follow proper hand hygiene after handling soiled dishes and before touching clean ones, and the kitchen environment was not kept clean. The coffee machine's glass gauge pipe was stained and not properly cleaned, the dry storage area had food debris and an open bag of pasta, and several serving plates were found dirty with dried food stains. These deficiencies were confirmed by staff and were not in accordance with facility policy or FDA Food Code.
Three residents with cognitive impairments and complex medical conditions were admitted or readmitted without properly completed advance directive documentation. In each case, required forms were incomplete or missing signatures from the resident or their representative, and staff confirmed that facility policy was not followed. As a result, the facility did not have documentation of these residents' wishes regarding medical treatment.
Two residents with significant risk factors for pressure ulcers had their Low Air Loss Mattresses (LALM) set incorrectly, with settings not matching their body weights as required by physician orders and manufacturer guidelines. Staff interviews revealed confusion about responsibility for adjusting the LALM and a lack of knowledge regarding facility policy, resulting in improper pressure ulcer care and prevention.
Two residents were not informed of the names or purposes of their medications during medication administration by an LPN, despite facility policy and recent staff education requiring such explanations. One resident had severely impaired cognition and multiple chronic conditions, while the other was alert and able to make decisions. The LPN stated she only explained new medications or blood pressure medications, but the DON confirmed that all residents should be informed about their medications during administration.
Surveyors found that a dumpster outside the kitchen was overfilled with uncovered trash bags, while another empty dumpster was inaccessible to staff. Both the Dietary Supervisor and Maintenance Supervisor confirmed that trash should be covered to prevent pests, and facility policy requires daily inspection and closed lids. The facility did not maintain the dumpster area in a sanitary manner as required by policy and FDA Food Code.
A resident with cognitive impairment and a history of wandering was found unattended in the facility parking lot. Despite being at risk for elopement, staff did not document or investigate how the resident left her room, and no explanation was provided by security, nursing, or administration.
A resident with a history of aggressive behavior and psychiatric conditions was not properly managed, leading to an incident where they physically assaulted another resident. The facility failed to document the aggressive behaviors and update the care plan as required, resulting in a deficiency in protecting residents from abuse.
A resident with quadriplegia and diabetes was denied readmission to the facility after hospitalization, despite having discharge orders and available beds. The facility cited insufficient staffing for IV antibiotic administration and bed availability issues, leading to the resident remaining in the hospital and at risk for psychosocial harm.
A facility failed to revise the care plan for a resident with bipolar disorder on a quarterly basis, as required by their policy. The resident, with diagnoses including bipolar disorder, anxiety, and schizophrenia, had a care plan that was not updated despite having moderate cognitive impairment and delusions. The Director of Nursing confirmed the importance of updating care plans to ensure appropriate interventions and goals.
A facility failed to follow its infection control policies when an LVN, who tested positive for COVID-19, continued working for an hour, preparing medications for residents. This was against the policy requiring immediate departure of positive staff. Interviews confirmed the breach, and the facility's COVID-19 Mitigation plan was in use while policies were under review.
A resident with cognitive impairments and a history of wandering left the facility unsupervised, highlighting a failure to implement a comprehensive care plan for elopement risk. Staff witnessed the departure but did not document the incident or notify the physician, contrary to facility policies.
A resident with a history of wandering and cognitive impairment eloped from the facility due to inadequate supervision and failure to follow elopement policies. Despite being observed leaving, staff did not document the incident or notify the resident's physician. The resident was later found with chest pain and required hospital transfer.
The facility failed to ensure a CNA had the required BLS/CPR certification, as revealed during a record review. The DON acknowledged the need for updated staff files and certifications. Facility policies and job descriptions require CNAs to be CPR certified, posing a risk to residents in emergencies.
A resident's psychotropic medication regimen was not properly managed, as the facility failed to implement behavior monitoring for anxiety and psychosis related to the use of Ativan and Depakote. Despite physician orders and facility policies requiring specific behavior monitoring, these were not followed, potentially leading to unnecessary medication use and adverse consequences.
A resident with a high risk of falls was not provided with necessary supervision and assistance when ambulating to the bathroom, resulting in a fall and head injury. Despite a care plan indicating the need for assistance, the resident attempted to walk without help and was observed by a CNA who did not intervene. The resident suffered a laceration and subdural hematomas, highlighting a failure in the facility's fall management policy.
A resident with difficulty swallowing was given regular food instead of a pureed diet, leading to vomiting, congestion, and eventual death. Staff failed to follow physician's orders, assess diet tolerance, develop a dysphagia care plan, and notify the physician of condition changes.
A resident with difficulty swallowing and at risk for aspiration consumed regular textured food brought in by a family member, which was not consistent with the prescribed pureed diet. The CNA observed the resident eating the food but did not report it to the Charge Nurse. The resident became congested, had difficulty breathing, and was pronounced dead shortly after. The facility failed to implement its policy for food brought in from outside sources and did not educate the family on the resident's special diet.
The facility failed to prevent falls and accurately assess fall risks for three residents. One resident suffered a hip fracture due to an inaccurate fall risk assessment and inappropriate footwear. Two other residents did not have quarterly fall risk assessments completed, increasing their risk of recurrent falls.
The facility failed to submit MDS assessments for four residents within the required 14-day period, leading to potential delays in care. The delay was due to the MDS Nurse being busy with admissions, resulting in assessments being opened but not submitted on time. The residents involved had various severe medical conditions and required significant assistance for daily activities.
The facility failed to develop comprehensive care plans for three residents, including one with a gastrostomy tube, another with chronic pain, and a third on antipsychotic and antidepressant medications. This led to potential inadequate care and unmonitored side effects.
The facility failed to perform required annual competency evaluations for an RN and two LVNs, potentially affecting the quality of care provided to residents. The DSD and Administrator confirmed the absence of these evaluations, which are mandated by the facility's policy.
The facility failed to follow its policy for the disposal of medications, resulting in unused medications being stored insecurely. Various medications were found in a container bin in the medication room, which should have been disposed of immediately. The Administrator and RN confirmed the risk of misuse due to this oversight.
The facility failed to conduct annual fit tests for N95 masks for six staff members, with the last fit test completed in 2022. Despite a COVID-19 outbreak in 2023, no subsequent fit tests were conducted, which could spread respiratory disease to residents. The facility's policy required annual fit testing, but none were done since the former Infection Preventionist resigned.
The facility failed to employ an Infection Preventionist Nurse (IP) as required by their assessment. The designated IP, an LVN, was actually working as a charge nurse. The facility Administrator confirmed that the last IP quit after one day, leaving the facility without a designated IP, which could affect infection control.
A facility failed to ensure a resident with an ileostomy received necessary care, including monitoring bowel sounds and the ileostomy site for symptoms like swelling, redness, and pain. Documentation was missing for February, March, and April 2024, and staff did not follow the care plan or physician's orders, risking insufficient care and potential skin breakdown.
The facility failed to monitor a resident's weight weekly as ordered, leading to significant weight loss. Despite physician orders and care plans indicating the need for close monitoring due to the resident's medical conditions, the facility did not document weights after 4/4/2024. Interviews with staff confirmed the oversight, acknowledging the risk it posed to the resident.
A resident with a gastrostomy tube was found with their tube feeding disconnected and not wearing an abdominal binder as required by the care plan. This resulted in the resident's bed being saturated with the feeding formula, indicating that the resident did not receive the full dose of nutrition as ordered by the physician. Staff confirmed the resident's tendency to pull and disconnect the tube, and the absence of the abdominal binder increased this risk.
The facility failed to provide a resident with a prescribed mechanical soft, fortified, finely chopped diet, serving food that was not finely chopped. This was confirmed by an LVN and acknowledged by the facility's Administrator, who stated that staff are required to check meal trays against physician orders.
Failure to Account for Controlled Substances Due to Lapses in Medication Handling and Inventory Procedures
Penalty
Summary
The facility failed to maintain accountability for 17 Percocet tablets, a Schedule II controlled substance, prescribed to a resident with muscle weakness and spina bifida. The medication was ordered to be discontinued, but at the time of discontinuation, 17 tablets were unaccounted for. The medication administration record showed the last dose was given on one date, but additional doses were documented as administered after that date. The narcotic inventory sheets, which are supposed to be signed and checked at each shift change, did not indicate any discrepancies, and the process for handling discontinued medications was not consistently followed. Multiple interviews with nursing staff revealed lapses in the required procedures for controlled substance inventory and handoff. Nurses did not consistently perform or document narcotic counts together at shift changes, and there was confusion about the presence and handling of the discontinued Percocet bubble pack. At one point, the medication cart key was left unattended in a drawer, contrary to facility policy, which increased the risk of unauthorized access to controlled substances. Staff members gave conflicting accounts regarding whether the discontinued medication and its accompanying documentation were present during inventory counts. Facility policies require that controlled substances be stored under double lock, that only authorized personnel have access, and that a physical inventory be conducted and documented by two licensed nurses at each shift change. The policies also state that any discrepancies must be reported immediately to the director of nursing. In this case, these procedures were not consistently followed, resulting in the unaccounted loss of 17 Percocet tablets and a breakdown in the facility's controlled substance accountability system.
Failure to Follow Standardized Menus and Diet Orders During Meal Service
Penalty
Summary
The facility failed to ensure that standardized recipes and menus were followed during lunch service, resulting in multiple dietary errors. Seven residents on fortified diets did not receive the required calorie-enriched foods as indicated on their meal tickets, because the dietary aide did not communicate the fortified diet orders during tray line service and the cook did not add the additional food items per the fortified menu. The dietary aide admitted to forgetting to read the fortified diet orders, resident food preferences, and specific diet requirements, which led to residents not receiving the appropriate meals. Additionally, 14 residents on regular diets did not receive the seasoned peas as specified on the menu, and residents on renal diets received three-bean salad instead of the prescribed wheat roll with margarine. Both the cook and dietary aide were unfamiliar with the menu and did not review the spreadsheet or meal tickets properly, resulting in incorrect food items being served. Observations confirmed that residents on regular diets received plates missing vegetables, and those on renal diets received inappropriate items. Facility policy required menus to be served as written unless substitutions were made for preferences or unavailability, but this was not followed during the observed meal service.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
Dietary staff failed to follow safe and sanitary food preparation practices in the kitchen. One dietary aide was observed rinsing soiled dishes and loading them into the dish machine while wearing gloves, then removing the soiled gloves and immediately handling clean, sanitized dishes without washing hands. The aide acknowledged not washing hands could contaminate clean dishes, and the dietary supervisor confirmed that proper hand hygiene was not followed due to a second staff member being late. Facility policy and FDA Food Code require handwashing after handling soiled equipment and before touching clean items. The kitchen environment was not maintained in a clean and sanitary condition. The coffee machine's glass gauge pipe was found to be stained with dark brown residue, and neither the dietary supervisor nor the cook could locate the special brush required for cleaning it. The cleaning schedule did not specify cleaning the gauge and pipe, and the cook was unaware of how to clean this part of the machine. Additionally, the dry storage area had a dirty floor with food particles, and an open, unsealed bag of pasta was found on the shelf. The dietary supervisor confirmed these conditions and stated that all packages should be sealed and storage areas kept clean to prevent contamination. During tray line service, several serving plates were observed to be dirty with dried food stains. The cook did not notice the dirty plates before service, and the dietary supervisor confirmed the plates were not clean and should have been scrubbed and rinsed before being loaded into the dish machine. Facility policy and FDA Food Code require that food only contact surfaces that are cleaned and sanitized, and the presence of dirty dishes and equipment in the kitchen was directly observed by surveyors.
Failure to Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had properly documented advance directives upon admission or readmission, as required by facility policy and federal regulations. For one resident with quadriplegia and dementia, the admission record showed readmission, but the advance directive acknowledgment (ADA) form was incomplete, lacking the necessary signatures from the resident or their representative. The resident was determined to lack decision-making capacity, and staff interviews confirmed that the ADA was not official without the required signatures. The facility's policy required that advance directives be completed and included in the medical record upon admission and readmission, but this was not done for this resident. Another resident with vascular dementia and metabolic encephalopathy was admitted without an advance directive. The resident was found to be unable to make medical decisions and had no family or friends to act as a representative. The social services director stated that the interdisciplinary team (IDT) could make decisions for the resident per facility policy and had applied for a conservator. However, the process was ongoing, and the resident remained without a documented advance directive. Staff interviews indicated that, in the absence of an advance directive, the resident would be considered a full code, but the facility did not know the resident's wishes. A third resident with dementia and a history of mental and behavioral disorders was also found to lack a completed advance directive. The resident's responsible party was identified, but the ADA form was not signed by the resident or their representative, only by the physician. Key sections of the ADA form were left blank, including those indicating that the resident or representative had been informed of their rights regarding medical treatment and advance directives. Staff confirmed that the ADA was incomplete and should have been filled out upon readmission, as required by facility policy. These failures resulted in the facility not having documentation of the residents' wishes regarding medical treatment and end-of-life care.
Failure to Maintain Proper LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for two residents with significant risk factors for pressure ulcers. For one resident with contractures, diabetes, quadriplegia, and a gastrostomy, the LALM was observed to be set at 230 lbs, despite the resident weighing 153 lbs and manufacturer guidelines indicating a setting between 150-180 lbs. Staff interviews revealed that CNAs were not permitted to adjust the LALM, and there was confusion among nursing and maintenance staff regarding responsibility for the settings and the facility's policy. The Infection Control Nurse and Director of Nursing both acknowledged that incorrect LALM settings could result in the mattress being too hard, potentially causing or worsening pressure ulcers. Another resident, with diagnoses including stage 4 and stage 3 pressure ulcers, diabetes, and quadriplegia, also had a LALM set incorrectly. The resident weighed 135 lbs, but the LALM was observed set at 230 lbs, while a sticker on the pump indicated it should be set to 130 lbs. The treatment nurse stated that the LALM should be set based on the resident's weight and that she evaluated the settings daily, but was unaware of the current setting and was unsure of the facility's LALM policy. The care plan for both residents specified that the LALM should be set according to the resident's weight. Record reviews, observations, and staff interviews consistently showed a lack of adherence to physician orders and manufacturer guidelines for LALM settings. There was also a lack of clarity among staff regarding who was responsible for checking and adjusting the LALM, and insufficient knowledge of the facility's policy on LALM management. These actions and inactions led to the deficiency in providing appropriate pressure ulcer care and prevention.
Failure to Inform Residents of Medications During Administration
Penalty
Summary
The facility failed to inform two residents of the medications being administered to them during medication pass, as required by the facility's policies and procedures. During direct observation, a nurse administered multiple medications to both residents without identifying the medications by name or explaining their purpose and indications. This occurred despite the facility's policy and educational materials, which require that each procedure, including medication administration, be explained to the resident beforehand. One of the residents had a complex medical history, including hypertensive heart disease, iron deficiency anemia, hyperlipidemia, type 2 diabetes mellitus, paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and anxiety disorder. This resident was assessed as having severely impaired cognition and required assistance with activities of daily living. The nurse administered nine different medications to this resident without providing information about the medications prior to administration. The other resident, who was determined to have the capacity to understand and make decisions, was also administered thirteen medications without being informed of their names or purposes. During interviews, the nurse stated that she typically only explained medications if they were new or if the resident was receiving blood pressure medications, believing that long-term residents were already familiar with their medications. However, the Director of Nursing clarified that nurses are expected to identify the name, indication, and possible side effects of medications to residents during administration, especially for those who are alert and oriented. Facility policies and recent in-service education also emphasized the importance of informing residents about their medications as part of ensuring resident rights.
Improper Disposal and Storage of Garbage in Dumpster Area
Penalty
Summary
On 5/20/2025 at 10:30AM, surveyors observed that one of two large garbage dumpsters outside the kitchen back door was overfilled with trash bags and left uncovered. The other dumpster, which was empty, was behind gates and not accessible to staff. During concurrent interviews, both the Dietary Supervisor and Maintenance Supervisor confirmed that trash should be covered to prevent the accumulation of flies and pests. The Maintenance Supervisor also stated that trash pickup occurred three times a week and acknowledged that the accessible dumpster was overfilled while the other, inaccessible dumpster remained empty. A review of the facility's policy from 2023 indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that lids are closed. Additionally, the FDA Food Code 2022 requires that outdoor refuse receptacles be kept covered with tight-fitting lids or doors and stored in a manner that makes them inaccessible to insects and rodents. The facility failed to follow these requirements, resulting in unsanitary conditions in the dumpster area.
Failure to Investigate Resident Elopement from Facility
Penalty
Summary
The facility failed to investigate and determine how a resident with a history of schizophrenia, anxiety disorder, and moderately impaired cognitive skills was able to leave her room unattended and was subsequently found in the facility's parking lot. The resident had been assessed as having intermittent confusion, was ambulatory, and was identified as being at risk for elopement. Despite these risk factors, there was no documentation or investigation into how the resident exited her room and reached the parking lot. Interviews with facility staff, including security guards, an LVN, the DON, and the administrator, confirmed that the resident was found outside on facility property, but none could explain how she left her room. The incident was not documented, and no investigation was conducted because the resident was found within the facility's property. The facility's policy requires individualized safety measures and analysis of risks, but these procedures were not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident 1, who had a history of aggressive behavior and multiple psychiatric diagnoses, including schizophrenia and bipolar disorder, was not properly managed according to the facility's policies. The facility did not document Resident 1's aggressive behaviors consistently, nor did they update the care plan to address the increase in aggression and behavioral changes. This lack of documentation and care plan updates contributed to an incident where Resident 1 physically assaulted Resident 2. Resident 1 had been admitted to the facility with a history of mental health issues, including schizophrenia, generalized anxiety disorder, and bipolar disorder. The resident exhibited aggressive behavior on numerous occasions throughout February 2025, but the facility failed to document the specific types of aggressive behaviors or update the care plan accordingly. Despite the facility's policy requiring regular updates to care plans and documentation of behavioral symptoms, these actions were not taken, leaving Resident 1's aggressive tendencies inadequately managed. On February 25, 2025, Resident 1 approached Resident 2, who was in a wheelchair, and demanded money. When Resident 2 refused, Resident 1 struck Resident 2 on the chest, causing Resident 2 to lose balance and sit on a trash can. The facility's failure to follow its own policies and procedures for behavior management and care planning resulted in this altercation, highlighting the deficiency in protecting residents from abuse.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, as per their policy titled Readmission. The resident, who had quadriplegia and type two diabetes, was initially admitted to the facility and had intact cognitive skills to make daily decisions. After being hospitalized, the resident was ready for discharge back to the facility on 2/12/2025, with orders to continue intravenous antibiotics. However, the facility denied readmission, citing a lack of available female beds and insufficient staffing to manage the resident's intravenous antibiotic needs. The facility's census records indicated that there was a female bed available from 2/12/2025 to 2/18/2025, but it was held for another resident without documented discharge orders. Interviews with facility staff confirmed the denial of readmission due to staffing limitations and bed availability, despite the resident's discharge plan being communicated well in advance. This failure to readmit the resident placed them at risk for psychosocial harm, as they were unable to return to their home in the facility.
Failure to Revise Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to revise the care plan for a resident with bipolar disorder on a quarterly basis, as required. The resident, who was admitted and readmitted with diagnoses including bipolar disorder, anxiety, and schizophrenia, had a care plan that was last revised several months prior. The care plan included interventions such as approaching the resident in a calm manner and administering lithium carbonate as ordered. However, the care plan was not updated quarterly or when there was a change in the resident's condition, as confirmed by the Director of Nursing (DON). The facility's policy mandates that comprehensive care plans be periodically reviewed and revised by a team of qualified persons after each assessment, including quarterly reviews. Despite this policy, the care plan for the resident with moderate cognitive impairment and delusions was not updated as required, potentially affecting the provision of care and services. The DON acknowledged the importance of having an updated plan of care to ensure appropriate interventions and goals for residents.
Failure to Implement COVID-19 Protocols
Penalty
Summary
The facility failed to implement its infection prevention and control policies effectively, leading to a potential risk of COVID-19 transmission. Licensed Vocational Nurse 3 (LVN 3) tested positive for COVID-19 while on duty but continued to work for an additional hour, preparing medications for approximately 20 residents. This action was contrary to the facility's policy, which required staff to leave immediately upon testing positive. Interviews with the Infection Preventionist, Public Health Nurse, Director of Staff Development, and Director of Nursing confirmed that LVN 3 should have left the facility immediately to prevent the spread of infection. The facility's policy and procedures, as outlined in their Infection Prevention and Control Program, were not followed, as LVN 3 remained in the facility after testing positive. The Director of Nursing highlighted the importance of contact tracing, which was not initiated promptly, potentially exacerbating the spread of COVID-19 within the facility. The facility's COVID-19 Mitigation plan was being used as the policy while the current procedures were under review, indicating a lapse in adherence to established guidelines.
Failure to Implement Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident at risk of elopement, which was identified as a deficiency. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was assessed as having moderately impaired cognitive skills and a history of wandering and elopement. Despite these assessments, the care plan did not adequately address the resident's risk of elopement, as evidenced by an incident where the resident left the facility unsupervised. On the day of the incident, the resident expressed a desire to go to the hospital and was observed leaving the facility through the front gate. Staff members, including a Licensed Vocational Nurse and a Treatment Nurse, witnessed the resident's departure but failed to document the incident in the resident's progress notes or notify the resident's physician. The resident was verbally aggressive and walked several blocks away from the facility before complaining of chest pain, prompting staff to call emergency services. The Director of Nursing acknowledged that the incident should have been documented and that an Interdisciplinary Team meeting should have been initiated. The facility's policies and procedures required documentation of elopement incidents and updates to the care plan to prevent recurrence, but these were not followed. This lack of documentation and failure to update the care plan contributed to the deficiency identified in the survey.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure proper supervision and implementation of policies to prevent the elopement of a resident, identified as Resident 1 (R1). R1, who has a history of chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was assessed as having moderately impaired cognitive skills and a history of wandering and elopement. Despite these known risks, the facility did not adhere to its elopement policy or the resident's care plan, which included monitoring R1's whereabouts every hour and investigating reports of wandering. On the day of the incident, R1 was observed leaving the facility unsupervised, and staff failed to document the event or notify the resident's physician. Interviews with staff revealed that R1 was seen walking out of the facility and was not stopped effectively, despite attempts by a treatment nurse to convince R1 to return. The resident became verbally aggressive and walked several blocks before complaining of chest pain, leading to a 911 call and transfer to a hospital. The Director of Nursing acknowledged that the incident should have been documented and reviewed by the Interdisciplinary Team, as per the facility's policy. The lack of documentation and communication with the medical team highlights the facility's failure to follow its procedures for managing elopement risks.
Failure to Maintain CNA BLS/CPR Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had the appropriate competencies to provide nursing and related services, specifically by not maintaining and updating the Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) certification. This deficiency was identified during a record review of the CNA's staff file, which revealed that the BLS/CPR certification was missing. During an interview, the Director of Nursing (DON) acknowledged that staff files should be updated and that BLS/CPR certifications should be current and filed. The facility's policy and procedures, as well as the job description for CNAs, require that CNAs be certified in CPR. This oversight had the potential to place residents at risk of not receiving proper immediate care during a life-threatening situation.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to properly manage and monitor the psychotropic medication regimen for a resident, leading to a deficiency in ensuring the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not implement behavior monitoring for episodes of anxiety related to the resident's use of Ativan, an anti-anxiety medication, and for episodes of psychosis related to the use of Depakote, an anti-psychotic medication. These medications were prescribed to address the resident's conditions, including schizophrenia and bipolar/mood disorders, but the necessary behavior monitoring was not ordered or implemented as required. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was found to have moderately impaired cognitive skills and required assistance with daily activities. Despite having specific physician orders for behavior monitoring related to the use of psychotropic medications, the facility did not ensure that these orders were followed. The Director of Nursing acknowledged that all psychotropic medications should have behavior monitoring specific to the resident's behavior, as ordered, to properly monitor the effects of the medication. The facility's policies and procedures emphasized the importance of individualized care and monitoring of target behaviors, but these were not adhered to in this case.
Failure to Provide Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with a high risk of falls, leading to an accident. The resident, who had a history of falls and was assessed as high risk, was not provided with the necessary assistance and supervision when ambulating to the bathroom. This lack of supervision resulted in the resident being found on the floor with a head injury, including a four-centimeter laceration and subdural hematomas, after attempting to walk to the bathroom without assistance. The resident had a documented history of falls and was admitted with multiple diagnoses that increased their fall risk, including subarachnoid hemorrhage, hemiplegia, hemiparesis, and abnormalities of gait and mobility. The resident's care plan specifically indicated the need for assistance with ambulation and transfers, yet on the night of the incident, the resident attempted to walk to the bathroom without using the call light for help. Despite being observed by a CNA, the resident was not assisted, leading to a fall and subsequent head injury. Interviews with facility staff, including CNAs, a physical therapist, and the director of nursing, confirmed that the resident required assistance and supervision when ambulating. The facility's fall management policy emphasized the importance of providing assistance to high-risk residents, yet this was not adhered to in the case of the resident. The failure to provide necessary supervision and assistance directly contributed to the resident's fall and injury.
Failure to Follow Physician's Orders and Monitor Resident's Condition
Penalty
Summary
The facility failed to follow the physician's order for a resident who had difficulty swallowing and was at risk for aspiration. The resident was supposed to receive a pureed diet, but this was not adhered to, leading to the resident consuming regular textured food brought in by the family. The staff did not assess the resident's tolerance for the diet as required by the care plan, nor did they develop a comprehensive person-centered dysphagia care plan. Additionally, the staff failed to monitor the resident for any changes in condition and inform the physician as stipulated in the care plan. The resident, who had a history of stroke and other medical conditions, was admitted to the facility and was initially stable. However, after consuming regular food, the resident vomited and later became congested, had difficulty breathing, and became cyanotic. The staff did not perform timely assessments or notify the physician about the resident's condition changes. The resident eventually became unresponsive and required CPR, but was pronounced dead shortly after. Interviews with staff revealed that the CNA observed the resident eating the wrong food but did not intervene or notify the nurse immediately. The RN on the prior shift did not document the incident or notify the physician about the resident's vomiting and subsequent condition changes. The facility's policies on change of condition and comprehensive care planning were not followed, contributing to the resident's deteriorating condition and eventual death.
Removal Plan
- The Minimum Data Set (MDS) nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician.
- The Nurse Consultant provided an in-service to Interdisciplinary Team (IDT) members to inform the resident's family about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources.
- The IDT reviewed current residents who were on a therapeutic diet and informed their family members about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources.
- The consultant provided an in-service to RNs, Licensed Vocational Nurses, Certified Nursing Assistants, and Restorative Nurse Aides regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility.
- Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service.
- The Nurse Consultant checked competencies of RNs, LVNs, and CNAs in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies.
- The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources.
- The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources.
- The Nurse Consultant provided an in-service to RNs and LVNs regarding the facility's policy on Change of Condition.
- The Medical Records staff will conduct changes in condition audits to identify changes in condition, determine completeness of documentation, and determine if physician notification had occurred.
- RN 2 was dismissed from the facility.
- The Director of Nursing (DON) or Director of Staff Development (DSD) would evaluate licensed nurses' competencies related to identifying, managing, and notifying the physician, alternate physician, or medical director of any changes in condition upon hire and annually.
- The Nurse Consultant provided a one-to-one in-service with the Administrator regarding the statute on Reporting Unusual Occurrences.
- The Nurse Consultant provided in-service to facility staff regarding the statute on Reporting Unusual Occurrences.
- The Administrator will review changes of condition during the stand-up meeting to identify abuse, suspicious deaths, major injuries, and other types of unusual occurrences and ensure that they are reported timely.
Failure to Monitor and Approve Outside Food Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident with difficulty swallowing and at risk for aspiration received care and monitoring of food consumption within the guidelines of the diet order. The facility did not implement its policy and procedure for food brought in from outside sources, which required that such food be shown to the Charge Nurse for approval to ensure it was within the diet order. Additionally, the facility did not provide the resident's family with the information sheet about bringing in food for a resident, nor did it ensure ongoing communication and coordination among staff to support the resident's nutritional well-being and safety. As a result, the resident consumed regular textured food brought in by a family member, which was not consistent with the prescribed pureed diet. The Certified Nursing Assistant (CNA) observed the resident eating the food but did not report it to the Charge Nurse. Subsequently, the resident became congested, had difficulty breathing, and became cyanotic. The resident became unresponsive and required cardiopulmonary resuscitation (CPR) but was pronounced dead shortly after. Interviews and record reviews revealed that the facility staff did not follow the established procedures for monitoring and approving outside food. The resident's diet and diet texture were not discussed during the initial interdisciplinary team (IDT) conference, and the family was not educated on the resident's special diet. The CNA did not intervene or report the incident when the resident was observed eating the wrong food texture, leading to the resident's adverse health event and subsequent death.
Removal Plan
- The Minimum Data Set (MDS) Nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician. The MDS Nurse completed the clarification of diet orders.
- The Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT) members to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work.
- The IDT reviewed current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed.
- Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. Food brought in by family from outside sources must be consistent with the resident's prescribed diet; Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review.
- Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work.
- The Nurse Consultant checked competencies of RNs, LVNs and CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work.
- The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly.
- The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work.
- The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up.
Failure to Prevent Falls and Accurately Assess Fall Risks
Penalty
Summary
The facility failed to ensure that three residents received the necessary care and services to prevent accidents and falls. Resident 13 was not accurately assessed for a high fall risk on 11/3/2023, and appropriate measures and interventions were not identified before the resident's fall on 1/20/2024. This fall resulted in a left femoral neck fracture, requiring surgery. The facility also did not complete quarterly Fall Risk Assessments for Residents 29 and 36, as per their policy, placing them at increased risk for recurrent falls. Resident 13 had a history of multiple diagnoses, including a previous femur fracture, chronic pain syndrome, schizophrenia, and muscle weakness. Despite these conditions, the resident was inaccurately assessed as having a normal gait and low fall risk. On 1/20/2024, Resident 13 fell while wearing inappropriate footwear, leading to a hip fracture. The facility failed to develop a care plan with person-centered interventions for the resident's fall risk, and staff did not document the resident's weak gait accurately. Resident 29, who had severe cognitive impairment and was on psychoactive medication, did not have a quarterly fall risk assessment completed in March 2023. Similarly, Resident 36, who had a history of repeated falls and severe cognitive impairment, did not have a fall risk assessment completed after 12/15/2023. The facility's failure to adhere to its fall prevention policies and procedures contributed to the increased risk of falls and injuries for these residents.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to submit the required complete information contained in the Minimum Data Set (MDS) for four residents within 14 days of initiation to the Centers for Medicare & Medicaid Services (CMS) System. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments for Residents 2, 29, 32, and 34 were not submitted on time. The delay in submission was attributed to the MDS Nurse being busy with admissions, which resulted in the assessments being opened but not submitted within the required timeframe. Resident 2 was originally admitted on 11/16/2027 and readmitted on 11/27/2023 with multiple diagnoses, including chronic obstructive pulmonary disease, urinary tract infection, type 2 diabetes, anxiety disorder, bipolar disorder, and hyperlipidemia. The MDS indicated that Resident 2 had moderately impaired cognition and required various levels of assistance for daily activities. Resident 29, admitted on 5/22/2020 and readmitted on 5/25/2021, had diagnoses including hepatic failure, atrial fibrillation, chronic kidney disease, and benign prostatic hyperplasia. The MDS showed that Resident 29 had severely impaired cognition and required significant assistance for daily activities. Resident 32, admitted on 3/11/2021 and readmitted on 3/14/2022, had diagnoses including hemiplegia, hemiparesis, chronic obstructive pulmonary disease, gastrostomy, dementia, adult failure to thrive, and benign prostatic hyperplasia. The MDS indicated severely impaired cognition and dependency on staff for daily activities. Resident 34, admitted on 6/24/2022 and readmitted on 1/24/2023, had diagnoses including congestive heart failure, type 2 diabetes, chronic pulmonary edema, adult failure to thrive, chronic kidney disease, bipolar disorder, and major depressive disorder. The MDS showed severely impaired cognition and dependency on staff for daily activities. The facility's policy required MDS assessments to be submitted within 14 days, but this was not adhered to, leading to potential delays in care for the residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for three residents, leading to potential inadequate care. For Resident 9, the care plan did not address the specific type of tube feeding the resident was receiving, despite the resident having a gastrostomy tube and being on a therapeutic diet. Both the Minimum Data Set Nurse and a Registered Nurse acknowledged that the care plan should have been more specific to ensure adequate care for the resident's nutritional needs. Resident 13, who experienced chronic pain and had undergone surgery for a left hip injury, did not have a care plan addressing pain management. The resident's Minimum Data Set indicated almost constant pain that affected daily activities, yet there was no individualized care plan with measurable objectives and interventions for pain. The Director of Staff Development confirmed that a care plan should have been initiated to manage the resident's pain effectively. Resident 28, diagnosed with dementia, paranoid schizophrenia, and major depressive disorder, was prescribed antipsychotic and antidepressant medications. However, the care plan did not include any information about these medications. A Registered Nurse verified the absence of a care plan for the medications, which could lead to unmonitored side effects and impact the resident's overall well-being. The facility's policy emphasized the importance of comprehensive care plans, but this was not adhered to in these cases.
Failure to Conduct Annual Staff Competency Evaluations
Penalty
Summary
The facility failed to perform the required annual staff competency evaluations for three of seven sampled staff members, including a Registered Nurse (RN) and two Licensed Vocational Nurses (LVNs). The RN was hired in 2018 and had a competency evaluation in 2020, but no evaluations were found for 2021, 2022, 2023, or 2024. The LVNs, hired in 2022 and 2008 respectively, also had no competency evaluations on file. The Director of Staff Development (DSD) confirmed the absence of these evaluations and acknowledged that they are supposed to be conducted annually to ensure staff can perform their responsibilities correctly and safely. Interviews with the staff members revealed that they were unsure or could not remember when their last competency evaluations were conducted. The Administrator confirmed that the evaluations for the three staff members could not be located and acknowledged that the lack of annual competency evaluations could negatively affect the quality of care provided to residents. The facility's policy, reviewed in 2023, mandates annual competency evaluations for all employees, but this policy was not followed in these cases.
Failure to Properly Dispose of Medications
Penalty
Summary
The facility failed to ensure professional standards of practice and facility policy and procedures for the disposal of medications and medication-related supplies were followed. During an observation and interview, it was found that the medication room contained a container bin with various unused medications, including Hydralazine, Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution, Latanoprost, Brimonidine, Atorvastatin, Cyclobenzaprine, Gabapentin, Risperidone, Metformin, Mirtazapine, Memantine HCL, Folic Acid, and Celecoxib. These medications were supposed to have been disposed of in the medication waste bin immediately, as per the facility's policy. However, RN 1 admitted that the medications had not been disposed of immediately and did not know how long they had been in the container. The Administrator confirmed that medications awaiting disposal should be stored in a locked, secure area and disposed of immediately to prevent misuse. The facility's policy indicated that medications should be marked as discontinued or stored in a separate location and later destroyed when expired, discontinued, or when a resident is transferred, discharged, or deceased. The failure to follow these procedures had the potential to result in the misuse of medications, as they were not stored securely or disposed of in a timely manner.
Failure to Conduct Annual N95 Fit Tests
Penalty
Summary
The facility failed to maintain a safe, sanitary environment to help prevent the spread of airborne infections by not conducting annual fit tests for N95 masks for six sampled staff members. The last fit test for these staff members was completed on 8/26/2022, and no subsequent fit tests were conducted despite the facility experiencing a COVID-19 outbreak in July 2023. The Director of Staff Development confirmed that fit testing was required to be done yearly and acknowledged that the lack of fit testing could spread respiratory disease to the residents. Interviews with the staff members also confirmed that their last fit test was in 2022 and that fit tests should be completed annually. The facility Administrator admitted that no fit tests were conducted since 8/26/2022 because the fit test was scheduled the day after the former Infection Preventionist resigned. The facility's policy and procedures indicated that fit testing should be conducted annually and before employees are required to wear a respirator. The policy also stated that fit tests should be done when a different size, make, model, or style of respirator is used. The failure to conduct these fit tests as per the policy and procedures led to the deficiency noted in the report.
Failure to Employ Infection Preventionist Nurse
Penalty
Summary
The facility failed to employ an Infection Preventionist Nurse (IP) at least part-time as required by their facility assessment dated January 2024. The assessment indicated that the facility needed a full-time equivalent IP. However, during interviews, it was revealed that the designated IP, a Licensed Vocational Nurse (LVN 3), was actually working as a charge nurse and not fulfilling the IP role. The facility Administrator confirmed that the last IP had quit after one day of work, leaving the facility without a designated IP. The facility's policy and procedure titled 'Scope of Infection Control Program' dated June 2022, stated that the infection preventionist is responsible for the infection prevention and control program. The lack of a designated IP had the potential to affect the facility's ability to prevent and manage the spread of infections and diseases, as highlighted by the interviews with the Medical Records Designee and LVN 3. Both emphasized the importance of having an IP for the safety and health of the residents, including providing updates on immunizations and antibiotics and preventing contamination.
Failure to Provide Necessary Ileostomy Care
Penalty
Summary
The facility failed to ensure that a resident with an ileostomy received the necessary care and services to prevent complications. The resident, who was admitted with an ileostomy and had intact cognition, required partial to maximal assistance with personal hygiene and other activities. The resident's care plan included specific interventions such as assessing bowel sounds and monitoring the ileostomy site for symptoms like swelling, redness, pain, and skin breakdown. However, the Treatment Administration Records (TAR) for February, March, and April 2024 showed no documentation of these assessments being performed or recorded as required by the physician's orders. During interviews, the Registered Nurse Supervisor and the facility's Administrator confirmed that the licensed staff did not document the required assessments and did not follow the physician's orders or the care plan interventions. The lack of documentation and failure to implement the care plan interventions had the potential to result in insufficient care and risk for skin breakdown and injury to the resident. The facility's policy on colostomy and ileostomy care emphasized the importance of monitoring the stoma and surrounding skin, but this was not adhered to in the case of the resident in question.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure that Resident 144, who was at risk for severe weight loss, received the necessary care and services to prevent this condition. Despite physician orders for weekly weight monitoring starting from 4/1/2024, the facility did not implement these orders. Resident 144 experienced significant weight loss, dropping from 109 lbs. on 3/18/2024 to 94 lbs. on 4/4/2024, a 14.55% weight loss in one month. The last recorded weight was on 4/4/2024, and no subsequent weights were documented, indicating a failure to follow the prescribed monitoring schedule. Resident 144 had a history of colon cancer, liver failure, and dementia, and was on speech therapy for dysphagia. The resident's nutritional assessments and care plans indicated a need for close monitoring of weight, intake, and diet tolerance due to significant weight loss over the past six months. Despite these documented needs and physician orders, the facility staff did not consistently monitor the resident's weight, as evidenced by the lack of weight records after 4/4/2024. Interviews with facility staff, including a Registered Nurse Supervisor and a Registered Dietician, confirmed that Resident 144 was on weekly weight monitoring due to poor oral intake and high risk for weight loss. The staff acknowledged that the failure to weigh the resident weekly as ordered placed the resident at risk of continued weight loss and that this oversight was part of the nutrition risk care plan. The facility's policy on unplanned weight loss emphasized the importance of regular weight assessments, which were not adhered to in this case.
Failure to Ensure Proper Tube Feeding Care
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (g-tube) received appropriate treatment and services to prevent complications. Specifically, the resident's tube feeding (TF) was found disconnected, and the resident was not wearing an abdominal binder as required by the care plan. This resulted in the resident's bed being saturated with the TF, indicating that the resident did not receive the full dose of nutrition as ordered by the physician. The resident, who had moderately impaired cognition and a history of pulling out the g-tube, was dependent on facility staff for eating and other activities of daily living. During observations and interviews, it was confirmed that the resident's TF was disconnected, and the resident was not wearing the abdominal binder. Licensed Vocational Nurse (LVN) 4 and the Minimum Data Set Nurse (MDSN) both verified that the resident had a tendency to pull and disconnect the TF and that the abdominal binder was not in place as per the care plan. The MDSN and Registered Nurse (RN 1) acknowledged that the absence of the abdominal binder increased the risk of the resident disconnecting the TF and not receiving the prescribed nutrition. The facility's policies and procedures for comprehensive care planning and enteral feeding via pump administration were reviewed. These policies emphasized the importance of following the care plan, including the use of an abdominal binder to secure the g-tube and ensure the resident received the full dose of TF. The failure to adhere to these policies and the care plan interventions led to the identified deficiency, putting the resident at risk for further complications related to their nutritional needs.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that Resident 6 received a therapeutic diet as prescribed by the physician. The resident, who has diagnoses including dementia, a history of falling, and chronic pain syndrome, was ordered a mechanical soft, fortified, finely chopped diet. However, during an observation in the dining room, Resident 6 was served food that was not finely chopped, including chopped pasta, carrots in a circle shape, and chunks of beef in a sauce. This was confirmed by Licensed Vocational Nurse 3 (LVN3), who acknowledged that the food did not meet the prescribed diet requirements and requested a new lunch tray for the resident. The deficiency was further highlighted during an interview with the facility's Administrator, who stated that staff are required to check residents' meal trays against physician orders to ensure the correct diet is served. The Administrator acknowledged the potential risks of not providing a finely chopped diet, including aspiration and the resident's inability to consume the food. The facility's policy on therapeutic diets, reviewed on 1/18/2024, mandates that therapeutic diets be provided in accordance with physician orders, but this policy was not followed in the case of Resident 6.
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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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