Ararat Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Mission Hills, California.
- Location
- 15099 Mission Hills Road, Mission Hills, California 91345
- CMS Provider Number
- 555579
- Inspections on file
- 75
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 57 (2 serious)
Citation history
Health deficiencies cited at Ararat Nursing Facility during CMS and state inspections, most recent first.
A resident with osteoporosis, dementia, and hypertension experienced hip pain and received PRN Tylenol, but the RN documented the assessment the next day without identifying it as a late entry. Social services recorded the resident’s hospital transfer on the wrong date, and an LVN failed to document a given dose of Tylenol on the MAR. These actions resulted in incomplete and inaccurate medical records that did not comply with facility policies for timely, accurate documentation of assessments, transfers, and medication administration.
A resident with multiple medical conditions, including atherosclerotic heart disease, GERD, and osteoporosis, had their electronic medical record left open and unattended on a medication cart computer at a nurse station, displaying their name, photo, and medication list while staff and others passed by. An LVN admitted not locking the computer before leaving to assist another resident, and the DON acknowledged that this allowed potential unauthorized access, contrary to facility policy requiring protected health information to remain confidential and inaccessible to unauthorized persons.
A resident with osteoporosis, dementia, and HTN experienced a change in condition with new right hip pain, for which Tylenol was given and the MD ordered a right hip x-ray. Despite this, nursing staff did not initiate or update a comprehensive, person-centered care plan to include measurable objectives and interventions for the new hip pain. During interviews, an RN and the DON confirmed that no care plan addressing the hip pain was created, even though facility policies required the care plan to be updated after a change in condition to reflect the resident’s current status and needed services.
A resident with osteoporosis, dementia, and hypertension reported right hip pain and received Tylenol, and the MD was notified with an order for a right hip x-ray. Facility policy required licensed nurses to assess and document the resident’s status every shift for 72 hours after a change of condition, including detailed nursing notes. However, there was no documentation of monitoring on one overnight shift, and an RN did not document a full assessment of the resident’s right lower extremity, including pain and appearance, meaning required COC monitoring and assessment were not carried out or recorded as required.
A resident with CHF, prior vertebral fracture, muscle weakness, and documented high fall risk experienced multiple falls after the facility failed to implement and maintain appropriate fall-prevention measures. Despite a high fall-risk score and a prior fall, the resident was not promptly placed in the facility’s Falling Star Program, and the care plan was not revised to reflect post-fall interventions. The care plan later indicated that two staff should assist with bed mobility, but a CNA provided morning care and bed mobility alone, did not verify the resident’s ability to hold herself on the bed edge, and turned the resident to her side at the edge of the bed while attempting to place a bed protector. With no floor mats in place, the resident slipped from the CNA’s hold, fell to the floor, and sustained a laceration and skin tears requiring sutures. After this fall, the facility did not complete a post-fall risk assessment, and observations showed that care-planned safety interventions such as bilateral floor mats were not consistently in place.
A resident with chronic diastolic CHF, musculoskeletal injuries, and muscle weakness, who had intact cognition but required extensive assistance with ADLs and bed mobility, had multiple Fall Risk Assessments in which the section assessing systolic BP variation from lying to standing was left uncompleted. During an interview and record review, an RN confirmed that these assessments were incomplete and did not correctly describe the resident’s condition, potentially resulting in a lower fall risk score and affecting care. This documentation did not meet the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate charting that fully describes the resident’s condition and the nursing response.
A resident with dementia, Alzheimer’s disease, severe cognitive impairment, high fall risk, and dependence on staff for ADLs was found in bed with both wrists firmly tied together with a scarf, unable to move or release her hands. An LVN had earlier asked a CNA assigned to the resident to check on the resident after increased chanting and yelling; the CNA reported the resident was fine, but shortly afterward the LVN entered the room and discovered the resident’s blanket on the floor and the resident’s hands bound. Facility policies required a licensed nurse assessment, IDT involvement, and consent before any restraint use, prohibited restraints for discipline or staff convenience, and mandated suspension of staff accused of abuse during investigation. The DON and Administrator identified the scarf as an unauthorized physical restraint and physical abuse, and the Administrator believed the CNA tied the resident’s hands for convenience, yet the CNA remained on duty and continued caring for the resident until the end of the shift.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found during a night shift with both wrists tightly bound together in bed with a scarf after exhibiting increased restlessness and chanting. An LVN discovered and photographed the binding and then removed it, while the assigned CNA denied tying the resident’s hands. Facility leadership later characterized the event as alleged physical abuse and a change of condition that should have triggered a formal change-of-condition (COC) process, including MD and family notification and 72-hour monitoring. However, no COC was initiated for the date of the incident, and there was no documentation that the MD or resident representative were notified at that time, contrary to facility policy requiring prompt notification and documentation of significant changes in condition.
A resident with dementia, Alzheimer's disease, high fall risk, and dependence on staff for most ADLs was found during a night shift by an LVN lying in bed with both wrists firmly bound together in front with a scarf tied multiple times, meeting the facility’s definition of a physical restraint and not supported by any assessment, MD order, or care plan. Earlier in the shift, the resident had been loudly vocalizing in another language, and the assigned CNA, who spoke the same language, told the LVN that the resident always behaved that way and later reported the resident was okay after checking the room. When the LVN entered the room again, she discovered the bound wrists, photographed them, untied the scarf, and assessed the resident with no visible injury, then later observed the CNA asleep at the nurses’ station; the CNA completed the shift and continued caring for the resident. Despite facility policy requiring immediate reporting of suspected abuse and notification to the Administrator and external agencies within two hours, the LVN did not notify the DON and RMN until several hours after discovering the bound wrists, resulting in a delay in reporting the suspected abuse.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence, who lacked decision-making capacity, was found in bed with both wrists firmly bound together in front using a scarf after becoming increasingly restless and vocal during a night shift. An LVN, unable to understand the resident’s language, relied on the assigned CNA—who spoke the same language—to assess the situation; the CNA reported the resident was fine. When the LVN later entered the room, she discovered the resident’s hands tightly tied, photographed the bindings, and then removed the scarf. The CNA, who had been assigned to the resident, remained on duty for the rest of the shift and continued caring for the resident and others, contrary to the facility’s abuse policy that requires suspension of staff accused of abuse pending investigation.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found in bed with her wrists tied together with a scarf after being reported as restless and yelling. An LVN discovered the restraint after re-entering the room when the resident continued yelling, untied the scarf, and noted no visible injury. Review of records showed there was no comprehensive, person-centered care plan addressing restraint use for this resident, despite her cognitive impairment and dependence on staff, and the facility’s policy required care plan updates following significant changes in condition.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found by an LVN in bed with both wrists tied together with a scarf after being reported as restless and yelling. The CNA assigned to the resident had earlier stated the resident was fine, but no Change of Condition (COC) evaluation was initiated at the time of the alleged physical abuse. Facility leadership, including the DON and RMN, later confirmed that alleged abuse constitutes a change of condition requiring a COC, MD and family notification, and 72‑hour monitoring per facility policy. Documentation showed that the COC and 72‑hour monitoring were not started until days later and focused on restlessness and possible infection rather than the abuse incident, and there was no documentation that the MD or family were notified on the date of the event.
A resident with multiple risk factors for falls experienced an unwitnessed fall, and the facility failed to ensure that fall prevention interventions and documentation were complete and accurate. Key forms, including the SBAR and Incident Note, lacked essential details about the incident, and the IDT documentation was inconsistent, potentially impacting staff awareness and care planning.
A resident with multiple medical conditions and moderate cognitive impairment was allegedly subjected to verbal and physical abuse by a staff member, witnessed by another staff member. The incident was not reported to the DON or authorities within the required two-hour timeframe, resulting in a 24-day delay before the allegation was reported to the State Survey Agency, contrary to facility policy.
Three staff members, including an LVN, an RN, and a CNA, were found to have no documented criminal background checks in their employee files. Leadership interviews confirmed that background checks were not conducted for these employees, despite current policy requiring such screening prior to employment.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Residents were not provided with sufficient information to understand their health status, care, and treatments, resulting in a lack of informed decision-making.
Three residents received psychotropic medications without adequate monitoring or documentation of specific target behaviors, duration of therapy, or adverse effects. Orders for medications such as clonazepam, Ativan, and Remeron lacked clear behavioral indications and appropriate time limits, and pharmacy recommendations for clarifying diagnoses and limiting therapy duration were not followed up. Nursing staff did not consistently document required monitoring, leading to prolonged and potentially unnecessary use of these medications.
The facility did not develop or implement comprehensive care plans for four residents, including those with infections, high fall risk, and involvement in a resident-to-resident altercation. In each case, required care plans addressing new diagnoses, medication use, behavioral refusals, or incidents were either missing or not created in a timely manner, as confirmed by staff and record review.
The facility did not ensure that services provided met professional standards of quality, as observed through practices that did not align with established guidelines for care delivery.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. Observations and record reviews showed that interventions for pressure ulcer management and prevention were not consistently implemented.
Three residents did not receive respiratory care in accordance with professional standards, including a resident whose oxygen concentrator was not turned on while using a nasal cannula, a resident with nebulizer tubing and mask left on the floor, and another resident with nasal cannula tubing touching the floor and overdue for replacement. Staff interviews and facility policy confirmed these practices did not meet required standards for respiratory care.
A resident with cognitive impairment and multiple health conditions did not receive a scheduled dose of an ordered antibiotic, with no documentation or physician notification of the missed dose. Additionally, staff failed to reconcile controlled medications in six emergency medication kits across three medication rooms, as required by facility policy, resulting in missing accountability logs for the month.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Three residents experienced significant medication errors, including repeated insulin injections at the same site without rotation, a missed and late dose of azithromycin due to a transcription error, and the administration of nine doses of an expired fluticasone/salmeterol inhaler. Nursing staff and leadership confirmed these errors through record review and interviews, citing failures to follow physician orders, manufacturer guidelines, and facility policies.
Staff failed to remove expired hand sanitizer from a resident's bedside and did not discard an expired inhalation medication from a medication cart. The expired hand sanitizer was left accessible to a resident with dementia, and the expired inhaler was administered multiple times to a resident with COPD. Facility policies required removal and proper disposal of expired items, but these were not followed.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
Several residents with cognitive impairments did not have complete COVID-19 screening forms or fully filled vaccination consent forms, missing key information such as temperatures and representative details. For residents receiving RNA services, actual ambulation abilities and missed treatments were not accurately documented, with staff confirming discrepancies between records and care provided. These failures resulted in incomplete and inaccurate medical records, as acknowledged by nursing leadership.
Staff did not follow Enhanced Barrier Precautions or proper hand hygiene when providing care to two residents with indwelling urinary catheters. Gowns were not worn during high-contact care, and hand washing was not performed as required. Facility staff misunderstood when EBP should be implemented, leading to lapses in infection control for residents at risk.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or review antibiotic administration among residents, indicating a lack of oversight for antibiotic stewardship.
The facility did not assign a qualified infection preventionist to oversee the infection prevention and control program, resulting in a lack of designated responsibility for infection control practices.
Three residents with significant cognitive and physical impairments, including high fall risk, were found with call lights placed out of reach, despite care plans and facility policy requiring call lights to be accessible at all times. Staff interviews confirmed the call lights were not within reach, which could delay residents' ability to summon assistance.
Nine residents attending a council meeting were unaware of the location or availability of the facility's latest survey results and corrective actions. Staff interviews and observations confirmed that the survey result binder was either missing or incomplete, and facility policy requiring survey results to be readily accessible was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by policy.
Two residents did not receive care according to professional standards: one was not kept in an upright position after meals as required for dysphagia management, and another did not have required 72-hour shift charting completed after a significant weight loss, resulting in unmonitored oral intake. Facility staff did not follow established care plans, SLP recommendations, or documentation policies.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Two residents at high risk for falls did not receive necessary accident prevention measures. For one, a wheelchair was left on a floor mat intended to reduce injury from falls, despite staff awareness of the hazard and lack of care plan documentation addressing the resident's refusal to keep the mat clear. For another, no fall risk assessment was completed after a fall, contrary to facility policy. These actions increased the risk of accidents and injury.
A resident who required pain management did not receive care that met professional standards for safety and appropriateness.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
Nurses and nurse aides lacked the appropriate competencies to care for every resident in a manner that maximizes each resident's well-being, resulting in care that did not meet required standards.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its policies for reporting irregularities found during the review.
Two residents with significant cognitive and mobility impairments were found to have floor mats in disrepair, with peeling and damaged covers, despite care plans and facility policy requiring a safe and homelike environment. Staff confirmed that the mats should have been replaced to maintain safety and quality of life.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required by regulations.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, in violation of requirements to prevent unnecessary drug use.
A resident with a history of sexually inappropriate behaviors was not properly assessed, monitored, or care planned, leading to an incident where this resident sexually abused another cognitively impaired resident. Staff were aware of the behaviors but did not consistently document or report them, and after the incident, required assessments and monitoring were not performed as per facility policy.
A resident with dementia and multiple comorbidities was repeatedly assessed as high risk for falls, but staff did not create a care plan or implement fall prevention interventions prior to a fall event. Nursing staff confirmed awareness of the resident's risk, yet no care plan was in place as required by facility policy.
The facility did not timely develop or implement person-centered care plans for four residents with complex medical and behavioral needs, including repeated falls, osteoporosis, self-injurious behaviors, and refusal of ADLs. Staff failed to promptly report or address these issues in care plans, despite documentation and facility policy requiring comprehensive, measurable interventions for changes in condition or new behaviors.
Two residents did not receive required post-fall assessments, including vital signs and neurochecks, after multiple fall incidents. In both cases, staff failed to document or perform these assessments as required by facility policy, even when falls resulted in injuries or required hospital transfer. Staff interviews confirmed that these omissions were not in line with professional standards and facility procedures.
The facility failed to follow physician orders for medication administration for two residents, resulting in missed antibiotic doses and improper insulin administration, and also released all medications, including controlled substances, to a family member without a physician order or proper documentation.
Incomplete and Inaccurate Documentation of Change in Condition, Hospital Transfer, and PRN Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident in accordance with accepted professional standards and its own policies. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia with severely impaired decision-making, and essential hypertension. Physician orders included Tylenol 325 mg, two tablets every four hours as needed for mild pain or general discomfort. On a documented change of condition evaluation, the resident complained of right hip pain, was given Tylenol, and the attending physician was notified, resulting in an order for a right hip x-ray. The resident’s change of condition and subsequent assessment were not documented in a timely or accurate manner by the RN. The RN stated she assessed the resident after the change of condition on one day, but the assessment was documented in the progress notes on the following day without being identified as a late entry. The Director of Nursing confirmed that the progress notes should have indicated that this was a late entry and that documentation was not completed by the end of the assigned shift, contrary to the facility’s documentation policy requiring prompt, dated, timed, and signed entries and clear identification of late entries. Additional inaccuracies were identified in the social services and medication administration documentation. Social services documented that the resident was transferred to a general acute care hospital on one date, while both the RN and the Director of Nursing stated the transfer actually occurred the following day. Furthermore, the RN reported witnessing an LVN administer two tablets of Tylenol 325 mg to the resident for right hip pain, but there was no corresponding entry on the medication administration record for that dose. This lack of documentation conflicted with the facility’s policies requiring that each medication administered be recorded on the MAR and that all entries be complete, accurate, and promptly recorded.
Failure to Protect Confidential Electronic Medical Record on Medication Cart
Penalty
Summary
The facility failed to protect the confidentiality of one resident’s personal and medical records when the resident’s electronic medical record was left visible and unattended on a medication cart computer. The resident had been admitted with diagnoses including atherosclerotic heart disease, gastroesophageal reflux disease, and age-related osteoporosis. During an observation at the nurse station, the medication cart computer was found open with the resident’s medical record displayed, including the resident’s name, picture, and medication list, while staff walked past the cart. In a concurrent observation and interview, an LVN acknowledged that she had not locked the medication cart computer before leaving to assist another resident and confirmed that the resident’s medical information was visible to people walking in the hallway. The DON stated that the resident’s medical records should not be left unattended and that staff not involved in the resident’s care, other residents, and visitors could potentially have unauthorized access to the records. Review of the facility’s policy titled “General Provisions” indicated that protected health information is confidential, will only be released in accordance with HIPAA policies, and that active records are to be located in an area not accessible to unauthorized persons.
Failure to Update Care Plan After Change in Condition With New Hip Pain
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions following a change of condition for one resident. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia, and essential hypertension. An MDS dated 11/24/2025 documented that the resident had severely impaired cognitive skills for daily decision-making. On 2/9/2026, a Change of Condition (COC) Evaluation documented that the resident complained of right hip pain, was given Tylenol, and that the attending physician was notified and ordered a right hip x-ray at 2:45 p.m. During interviews and concurrent record review, RN 1 confirmed that no care plan was created to address the resident’s right hip pain following the COC on 2/9/2026 and stated that a care plan should have been initiated so staff would be aware of interventions to address the change of condition. The DON similarly stated that a care plan is a list of care and services to be provided for residents and acknowledged that a care plan should have been created after the COC, but the resident’s care plan did not include the right hip pain. The DON stated that the facility failed to ensure the resident had a care plan after the COC that addressed the resident’s right hip pain. Review of facility policies showed that the Care Planning policy required a comprehensive, person-centered care plan based on assessed needs, and the Change of Condition Notification policy required a licensed nurse to update the care plan to reflect the resident’s current status.
Failure to Monitor and Document Resident After Change of Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its change of condition (COC) monitoring policy and professional standards of practice for a resident with age-related osteoporosis, unspecified dementia, and essential hypertension. The resident, who had severely impaired cognitive skills for daily decision-making per the MDS dated 11/24/2025, complained of right hip pain on 2/9/2026 at approximately 2:40–2:45 p.m. A COC Evaluation documented the complaint of right hip pain, administration of Tylenol, and notification of the attending physician, who ordered a right hip x-ray. Facility policy required that after a COC, a licensed nurse assess the resident, document observations and symptoms, and chart each shift for at least 72 hours, including the date, time, and pertinent details of the incident and subsequent assessment in the nursing notes. Record review and interviews showed that the resident’s COC status was not monitored or documented on the 11 p.m. to 7 a.m. shift on 2/9/2026, despite the requirement for every-shift monitoring for 72 hours. RN 1 acknowledged that the progress notes contained no documentation of monitoring for that shift and that she did not document her full assessment of the resident’s right lower extremity, including pain on palpation and the appearance of the right lower extremity. RN 1 and the DON both stated that care not documented is considered not done, and the DON confirmed there was no documented evidence of monitoring on the 11 p.m. to 7 a.m. shift and that RN 1 did not document the lower extremity assessment. The facility’s failure to assess and monitor the resident after the COC, as required by its policy, had the potential for the resident’s progress or decline to be missed and had the potential to negatively impact the resident’s health and safety.
Failure to Implement Fall-Prevention Measures and Safe Bed Mobility Assistance for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and fall-prevention measures for a resident with a known high risk for falls. The resident, originally admitted in 2019 and readmitted in 2024, had diagnoses including chronic diastolic CHF, a right shoulder rotator cuff tear/rupture, T11–T12 wedge compression fracture sequela, and muscle weakness. A fall risk assessment completed on 12/20/2024 showed a fall risk score of 28, indicating high risk, and documentation from that date showed the resident experienced a fall while ambulating to the restroom and being assisted to the floor by staff. Despite this, there was no documented evidence that the resident’s care plan was revised after the 12/20/2024 fall, and the resident was not added to the facility’s Falling Star Program until 11/1/2025, even though the program policy stated it was to be used as a post-fall intervention for residents at high risk for falls. The resident’s care plan for functional abilities, initiated on 5/19/2025, indicated the resident required assistance with bed mobility and that two or more staff would assist with bed mobility as needed. The MDS dated 10/27/2025 documented that the resident had intact cognition, was dependent on staff for toileting hygiene, showers, and lower body dressing, required maximal assistance for several bed mobility and ADL tasks, and required partial/moderate assistance for rolling from back to left and right side in bed. On 11/1/2025, during the 11 p.m. to 7 a.m. shift, CNA 1 entered the resident’s room around 6 a.m. to provide morning care, including changing bed linens and incontinence briefs, while the resident was sleeping. CNA 1 reported she did not recall asking the resident if she could hold herself on the side of the bed before starting care, and she proceeded to clean the resident in the supine position and then turn her onto her left side at the edge of the bed while attempting to place a bed protector. During this care on 11/1/2025, CNA 1 held the resident’s right arm with her right hand while trying to place the bed protector with her left hand. Approximately 10–15 minutes after initiating care, while the resident was lying on her left side at the edge of the bed, the resident slipped from CNA 1’s hold and fell to the floor. There was no floor mat next to the bed at the time of the fall, despite later care plan documentation (initiated after the fall) indicating the resident was to have bilateral floor mats. The incident report and nursing documentation described a laceration to the left eyebrow area, skin tears on the left forehead and left wrist/forearm, visible bleeding on the resident’s face and on the floor, and the need for wound cleansing and pain management. The resident was transferred to an acute care hospital, where she received seven sutures to the left eyebrow laceration. Following the 11/1/2025 fall, the facility did not complete a fall risk assessment specific to that episode, even though facility policy required fall risk assessments upon admission, quarterly, and after a fall. Licensed nursing staff later acknowledged there was no fall risk assessment completed after the 11/1/2025 fall and that this could result in incomplete or inaccurate fall-prevention interventions. Multiple nurses also confirmed that the care plan had not been updated after the 12/20/2024 fall to include fall-prevention interventions discussed in the IDT meeting, and that the resident was not placed in the Falling Star Program until 11/1/2025, despite having a high fall risk score and a prior fall. Additionally, during a later observation of the resident’s room, no floor mat was present next to the bed, even though the care plan for a witnessed fall (initiated after the incident) called for bilateral floor mats. Staff interviews consistently indicated that licensed nurses were responsible for ensuring care plan interventions were implemented and that CNA 1 should have requested additional assistance when providing bed mobility and morning care to this resident.
Incomplete Fall Risk Assessments and Inaccurate Nursing Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident by not fully completing required Fall Risk Assessments. The resident had been originally admitted in 2019 and readmitted in 2025 with multiple diagnoses, including chronic diastolic CHF, a right shoulder rotator cuff tear or rupture, wedge compression fracture of T11–T12 vertebra, and muscle weakness. A History and Physical dated 7/1/2025 documented that the resident had the capacity to understand and make decisions, and an MDS dated 1/21/2026 indicated intact cognitive functioning. The MDS further showed the resident was dependent on staff for toileting hygiene, showers, and lower body dressing, and required maximal assistance for bed mobility, transfers between lying and sitting, upper body dressing, and personal hygiene. During an interview and concurrent record review with an RN on 2/18/2026, Fall Risk Assessments dated 7/29/2025, 10/1/2025, and 10/22/2025 were reviewed and found to have section F, which assesses systolic blood pressure variation when changing positions between lying and standing, left unassessed. The RN acknowledged that the Fall Risk Assessments for July and October 2025 were incomplete and stated that the assessments did not correctly describe the resident’s condition, which could potentially lead to a lower score level and affect the resident’s care, leading to a higher risk for falls. The facility’s policy on Nursing Documentation, last reviewed on 1/26/2026, required nursing documentation to be concise, clear, pertinent, and accurate, and described expectations for alert charting to accurately describe the resident’s condition and the nursing response, which was not met in the incomplete fall risk documentation for this resident.
Failure to Protect Resident From Unauthorized Physical Restraint and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical restraints and abuse. A resident with dementia, Alzheimer’s disease, muscle weakness, gait and mobility abnormalities, and no capacity to make decisions was admitted in August 2025. The resident’s MDS dated 12/8/2025 showed severe cognitive impairment, with the resident rarely understanding and rarely being understood, and being dependent or requiring assistance for most ADLs. A fall risk assessment on the same date identified the resident as high risk for falls with a score of 21. These records established that the resident was cognitively impaired, physically vulnerable, and dependent on staff for care and safety. On the night in question, CNA 1 was assigned to the resident during the 11 p.m. to 7 a.m. shift and remained on duty until after 7 a.m. LVN 1 reported that around 2 a.m. the resident began chanting, which became louder and more frequent. LVN 1 asked CNA 1 to check on the resident; CNA 1 returned and stated the resident was okay and always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. At around 2:50 a.m., LVN 1 entered the resident’s room, found the blanket on the floor, and observed the resident lying in bed making wiggly body movements. LVN 1 then saw that the resident’s wrists were firmly tied together in front of her with a long scarf, with no wiggle room and no ability for the resident to move or release her hands. LVN 1 untied the scarf and assessed the resident, noting no visible injury. The facility’s own policies required that any physical restraint be preceded by a licensed nurse’s assessment, IDT involvement, determination of need, identification of the least restrictive device, and appropriate documentation and consent. The restraint policy also stated that residents are to be provided a restraint-free environment and that restraints are not to be used for discipline or staff convenience. The abuse prevention policy stated that each resident has the right to be free from abuse, neglect, and mistreatment, that the facility has zero tolerance for abuse, and that staff accused of abuse, neglect, or mistreatment are to be suspended until the investigation is complete. The DON and Administrator both stated that tying the resident’s hands with a scarf constituted a physical restraint and physical abuse, and the Administrator indicated he believed CNA 1 tied the resident’s hands for the CNA’s convenience because the resident was restless. Despite this, CNA 1, who was suspected of tying the resident’s hands and was found sleeping during that time, was not immediately removed from duty and continued to provide care to the resident until the end of the shift, contrary to the facility’s abuse prevention policy.
Removal Plan
- LVN 1 reported the alleged abuse incident to Human Resources and the Director of Nursing, stating Resident 1 was found with hands bound by a scarf; LVN 1 removed the scarf and notified the Ombudsman.
- The facility suspended CNA 1 pending Human Resources investigation.
- LVN 1 received a written warning for failing to report the incident to the RN Supervisor on duty.
- The facility terminated CNA 1.
- The Director of Staff Development reported CNA 1 to the CNA Licensing Board.
- RN Supervisors conducted rounds on all units to visually observe all residents for any signs of physical restraints, inappropriate devices functioning as restraints, or signs of abuse/neglect; no other residents were identified.
- RN Supervisors conducted another facility-wide sweep of all residents to screen for restraints; no other residents were identified.
- Human Resources and the Administrator suspended LVN 1 for failure to follow facility policy.
- The Assistant Director of Staff Development initiated in-service training for facility staff regarding restraints, with the Assistant DSD and DSD continuing in-services until completion.
- During orientation, the facility will in-service newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy and requirement to report suspected abuse immediately, and documentation requirements.
- The Director of Nursing created a root cause analysis.
- The Administrator and Director of Nursing instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected.
- Shift-to-shift report will include reporting of any suspected abuse and immediate suspension of staff involved.
- Department Managers, Managers of the Day, and the RN Supervisor on duty will conduct daily rounds on every shift (including weekends and holidays) to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.
Failure to Notify MD and Resident Representative After Alleged Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a significant change in condition and alleged abuse involving one resident. The resident was an individual with dementia and Alzheimer’s disease, admitted with diagnoses including muscle weakness and gait and mobility abnormalities. Assessments showed the resident had a high fall risk score of 21, lacked capacity to understand and make decisions, rarely understood and was rarely understood, and required varying levels of staff assistance for ADLs such as showering, dressing, toileting, oral hygiene, and personal hygiene. The resident’s care plan included education of staff about types of abuse, including physical restraint, prevention measures, reporting requirements, and respect for resident rights. On the night in question, during the 11 p.m. to 7 a.m. shift, the resident became restless and was heard chanting or yelling intermittently in a language not understood by the LVN on duty. The LVN asked the CNA assigned to the resident, who spoke the same language, what the resident was saying, and the CNA responded that the resident always did that. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room and then left, and the resident’s vocalizations continued and worsened. Later, at approximately 2:50 a.m., the LVN entered the resident’s room, observed the blanket on the floor, and when picking it up noted that the resident’s wrists were bound together in front with a scarf tied in a firm figure-eight pattern multiple times, with no apparent wiggle room for the resident to move her hands. The LVN reported that the resident appeared relieved and moved around as if to draw attention to the bound wrists. The LVN took a photograph of the bound wrists and then untied the scarf around 3 a.m. Subsequent interviews and record reviews showed that this incident was treated by facility leadership as alleged physical abuse and use of a physical restraint, and as a change of condition that should have triggered formal documentation and notifications. The DON and RMN both stated that an allegation of abuse is considered a change of condition and that a Change of Condition (COC) form should have been initiated on the date of the incident to communicate with all staff, the MD, the IDT, and the family, and to start 72‑hour monitoring. However, there was no COC documented for the date of the incident, and the RMN confirmed there was no COC entry for that date in the resident’s record. The MD reported being notified the next morning about the resident having a scarf-like object tied over her wrists and increased confusion, but the RMN stated there was no documentation that the MD was notified on the date of the incident. The DON stated that, because there was no COC documented for that date, the facility could not say that the MD or family were notified of the change in condition related to the alleged abuse, contrary to the facility’s policy requiring prompt notification and documentation of significant changes in condition.
Failure to Timely Report and Protect Resident After Discovery of Bound Wrists
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program by not reporting an allegation of abuse to the State Survey Agency, local law enforcement, adult protective services, and the Ombudsman within two hours as required by policy. During the night shift, an LVN discovered a resident with dementia and Alzheimer's disease lying in bed with her wrists firmly bound together in front of her with a long scarf tied in a figure-eight pattern multiple times, which the LVN described as having no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound wrists, untied the scarf at approximately 3:00 a.m., and later notified the DON and Resident Care Manager (RMN) around 7:15–7:20 a.m., resulting in a delay of about three hours in reporting the suspected abuse to the Administrator and triggering external reporting. The resident involved had been admitted with diagnoses including dementia, Alzheimer's disease, muscle weakness, and gait and mobility abnormalities. A prior H&P documented that the resident did not have capacity to understand and make decisions. The MDS indicated the resident rarely understood and was rarely understood, and required staff assistance with most ADLs, including showering, dressing, toileting, and personal hygiene. A fall risk assessment showed a high fall risk score of 21. The facility’s Restraints policy defined physical restraints as any device that the resident cannot easily remove that restricts freedom of movement or access to one’s body, and required assessment, physician orders, informed consent, and care planning before use; the resident’s wrists being bound with a scarf was not associated with any such assessment, order, or care plan. On the night of the incident, the LVN heard the resident chanting in another language and asked the assigned CNA, who spoke the same language, what the resident was saying; the CNA responded that the resident always behaved that way. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room, spoke with the resident, and then left, telling the LVN that the resident was okay. When the chanting worsened, the LVN entered the room around 2:50 a.m., found the blanket on the floor, and upon picking it up observed the resident’s wrists bound with the scarf. After untying the scarf and assessing the resident with no visible injury noted, the LVN later found the CNA asleep and snoring at the nursing station; the CNA subsequently completed the shift and continued caring for the resident. The RMN later confirmed seeing the photograph of the resident’s hands tied on top of each other and stated that the LVN should have immediately reported the incident to the Administrator and immediately removed the CNA from the assignment and premises, but instead the reporting to leadership was delayed and the CNA remained on duty with the resident.
Failure to Protect Resident From Abuse and Remove Alleged Perpetrator From Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to immediately remove an alleged perpetrator from resident care after an incident was discovered. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, gait and mobility abnormalities, and was assessed as a high fall risk. A recent MDS documented that the resident rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, toileting, and personal hygiene. The resident did not have capacity to understand and make decisions per the physician’s history and physical. During a night shift, the resident became restless and was heard chanting in a language not understood by the LVN on duty. The LVN asked the assigned CNA, who spoke the same language as the resident, what the resident was saying, and the CNA responded that the resident always did that. As the chanting increased in volume and frequency, the LVN directed the CNA to check on the resident; the CNA went into the room, spoke with the resident, and then left, reporting that the resident was okay. Later, when the chanting worsened, the LVN entered the room and observed the resident’s blanket on the floor. When the LVN picked up the blanket to cover the resident, she saw that the resident’s wrists were firmly bound together in front with a scarf, tied in a figure-eight pattern multiple times, with no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound hands and then untied the scarf at approximately 3 a.m. Afterward, the LVN found the assigned CNA asleep and snoring at the nursing station. The CNA’s timecard showed she remained on duty from late evening through the end of the night shift and, by her own account and that of facility staff, she continued to work with the resident and other residents for the remainder of the shift and was not removed from the resident’s care at that time. The RMN and Administrator later characterized the tying of the resident’s hands with a scarf as physical abuse and a form of restraint, and the facility’s abuse prevention policy stated that staff accused of abuse are to be suspended until the investigation is complete.
Failure to Care Plan for Restraint Use After Resident Found with Wrists Tied
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing the use of restraints for a resident with dementia, Alzheimer’s disease, muscle weakness, and gait and mobility abnormalities. The resident was admitted with significant cognitive impairment, as the physician history and physical documented that she did not have the capacity to understand and make decisions. A fall risk assessment showed a high fall risk score of 21, and the MDS indicated she rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, oral hygiene, toileting, footwear, and personal hygiene. Despite these conditions and her dependence on staff, there was no care plan in place addressing the use of restraints for this resident. On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA to check on the resident; the CNA later reported the resident was okay and that she always behaved that way. About 10 minutes later, the resident again yelled out, prompting the LVN to enter the room. The LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf while she was in bed. The LVN untied the scarf and assessed the resident, noting no visible injury. Subsequent review of the care plan with the resident care manager revealed that there had been no prior care plan for the use of restraints, and the manager acknowledged that the scarf had been used as a restraint and should have been care planned. The facility’s change of condition policy required updating the care plan to reflect the resident’s current status after significant changes, but the report indicates the lack of a comprehensive care plan addressing restraint use at the time of the incident.
Failure to Initiate Change of Condition Evaluation and 72‑Hour Monitoring After Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to create a Change of Condition (COC) evaluation and to initiate 72‑hour monitoring following an alleged physical abuse incident involving a resident. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, and gait and mobility abnormalities, and had been assessed as a high fall risk with significant dependence on staff for activities of daily living. The resident’s MDS indicated she rarely understood and was rarely understood, and her physician’s H&P documented that she did not have capacity to understand and make decisions. On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA assigned to the resident to check on her. The CNA reported back that the resident was okay and that she always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. When the LVN entered the room, the LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf. The LVN untied the scarf and assessed the resident, noting no visible injury at that time. The DON and RMN later reviewed a photograph of the resident’s wrists tied with a scarf and both described the wrists as bound in such a way that the resident could not pull her arms apart, and the DON characterized this as physical abuse and use of a physical restraint. Despite this alleged abuse incident, there was no COC evaluation initiated on the date the resident was found with her wrists tied. The RMN confirmed that alleged abuse is considered a change of condition and that a COC form should have been completed on that date to communicate with all staff, the MD, IDT, and family. The RMN and DON both stated there was no COC for the date of the allegation, and the RMN acknowledged that the RN supervisor should have started the COC at that time. The facility’s policy on Change of Condition Notification requires prompt notification of the physician, resident, and representative for significant changes in physical, cognitive, behavioral, or functional status, and requires licensed nurses to document the incident, physician notification, family notification, care plan updates, and to document each shift for at least 72 hours. In this case, the 72‑hour monitoring and COC documentation were not initiated until two days later, and the RMN stated there was no documentation that the MD was notified on the date of the incident, meaning the required timely COC evaluation and 72‑hour monitoring following the alleged abuse did not occur as required by policy. The RMN further explained that the COC form is used to identify the change in condition and to initiate 72‑hour monitoring, which includes checking the resident’s psychosocial well‑being, assessing for new skin issues such as bruising from restraints, and monitoring the resident’s overall status. However, the COC completed later focused on restlessness and possible infection, not specifically on the abuse incident that occurred earlier. The Health Status Note indicating monitoring status post abuse incident and the initiation of 72‑hour monitoring were dated two days after the alleged abuse, confirming a delay in both recognition and documentation of the change in condition related to the abuse. The facility’s own leadership acknowledged that, because there was no COC documented for the date of the allegation, they could not confirm that the MD or family were notified of the change in condition at the time it occurred.
Failure to Ensure Accurate Fall Prevention Documentation and Interventions
Penalty
Summary
The facility failed to ensure that interventions to prevent falls were properly implemented and documented for a resident identified as high risk for falls. The resident, who had diagnoses including osteoporosis, glaucoma, and generalized muscle weakness, was readmitted with a high fall risk score. The care plan included interventions such as keeping the bed in the lowest position, placing floor mats next to the bed, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall. Upon review, it was found that the SBAR Communication Form and Incident Note related to the fall were incomplete and inaccurate. Specifically, the SBAR form did not include the physician's recommendations, and neither the SBAR nor the Incident Note provided clear details on how the fall occurred. Additionally, the Interdisciplinary Care Conference documentation was inconsistent, with conflicting information about whether the fall was witnessed and lacking specific details about the incident. The Director of Nursing acknowledged during an interview that the documentation across the SBAR, Incident Note, and IDT did not match and failed to provide essential information regarding the circumstances of the fall. Facility policies required nursing documentation to be concise, clear, pertinent, and accurate, and for investigations to identify contributing factors to falls. The lack of accurate and complete documentation had the potential to impact the staff's ability to implement appropriate interventions for the resident.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident verbal and physical abuse within the required two-hour timeframe to the State Survey Agency (SSA). A Certified Nursing Assistant (CNA) reported to the Director of Nursing (DON) that a Life Enrichment Coordinator (LEC) allegedly threw a towel or sweater at a resident's face and yelled at the resident, which was considered verbal and physical abuse. The incident was witnessed by a Restorative Nursing Assistant (RNA), who reported the event to the DON on 8/29/2025, even though the alleged abuse occurred on 8/5/2025. The facility subsequently reported the allegation to the SSA 24 days after the initial incident. The resident involved had a history of hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, and dysphagia, and was assessed as having moderately impaired cognition. Interviews with facility staff, including the Assistant Administrator (Abuse Coordinator) and the DON, confirmed that the abuse allegation was not reported within the required two-hour window as outlined in the facility's Abuse Prevention and Prohibition Program policy. The delay in reporting was attributed to the RNA not promptly informing the DON, which led to the facility's late notification to the appropriate authorities.
Failure to Complete and Document Staff Background Checks
Penalty
Summary
The facility failed to complete and document criminal background checks for three sampled employees: a Licensed Vocational Nurse, a Registered Nurse, and a Certified Nurse Assistant. Review of their employee files showed no evidence of background checks, despite all three being currently employed. The employees were hired in 1997, 1998, and 2021, respectively, and their files lacked documentation of any criminal background screening at the time of hire or thereafter. Interviews with facility leadership revealed that background checks were reportedly not conducted prior to 2014, but no policy was provided to support this claim. The facility's current policy, dated August 1, 2023, requires criminal background screening for all prospective staff, contractors, and volunteers prior to employment. The absence of background checks for these employees was confirmed by both the Director of Staff Development and the Administrator during interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure adequate monitoring and documentation for three residents. For one resident with diagnoses including psychosis, depression, anxiety, insomnia, and dementia, the facility did not monitor specific, measurable target behaviors related to the use of clonazepam, a psychotropic medication prescribed for anxiety. The medication order lacked a specific duration, and the manifestations of the behaviors being treated were not clearly defined, leading to inconsistent monitoring and documentation by nursing staff. Interviews with nursing staff confirmed that the absence of specific target behaviors and duration in the medication order could result in inaccurate assessments and prolonged, unnecessary use of the medication. Another resident with Alzheimer’s disease, dementia, and anxiety disorder was prescribed Ativan (lorazepam) as needed for anxiety. The orders for this medication did not specify a duration or clearly define the target behaviors for which the medication was to be administered. Consultant pharmacist recommendations to clarify the diagnosis and add a 14-day duration to the therapy were not acted upon or documented as addressed with the physician. The lack of follow-up on these recommendations and the absence of specific, measurable behaviors in the orders resulted in the resident being at risk for prolonged and unnecessary use of psychotropic medication. A third resident with Alzheimer’s disease, dementia, and depression was prescribed Remeron (mirtazapine) for depression. The facility failed to monitor and document the resident’s pulse rate and adverse effects on the medication administration record when the medication was administered. Nursing staff and administration confirmed that monitoring for adverse effects and pulse rate was required but not completed, which could lead to inaccurate assessment of the medication’s necessity and effectiveness. Facility policies required specific indications, manifestations, and monitoring for psychotropic medications, but these were not consistently followed for the residents involved.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four out of five sampled residents, as required by their own policies and regulatory standards. For one resident with a diagnosis of pneumonia, there was no care plan created to address the infection, despite physician orders for antibiotic treatment and documentation of severely impaired cognitive skills. Both the Infection Preventionist and nursing leadership confirmed that a care plan should have been developed to guide nursing care and ensure continuity. Another resident, who was prescribed azithromycin for bronchitis, also did not have a care plan addressing the use of this antibiotic. The resident had a history of Parkinson’s disease, dementia, and fluctuating decision-making capacity. Nursing leadership acknowledged that the absence of a care plan for antibiotic use could result in a lack of guidance for staff and potentially impact the resident’s care. A third resident, identified as high risk for falls and with a history of Alzheimer’s disease and osteoporosis, refused to remove a wheelchair from atop a floor mat designed to prevent injury from falls. Although staff were aware of the risks and the resident’s refusal, there was no care plan documenting this behavior or interventions to address it. Additionally, for a fourth resident involved in a resident-to-resident altercation, the care plan addressing the incident was not developed until the day after the event, rather than immediately. Staff interviews confirmed that timely care planning was not performed, which could have delayed appropriate interventions and communication among the care team.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the provision of services, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews, which revealed that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents. For one resident with a history of congestive heart failure, COPD, and pulmonary hypertension, the oxygen concentrator was observed to be turned off on two separate occasions while the resident was wearing a nasal cannula and had orders for PRN oxygen for shortness of breath. Documentation showed that the resident had received PRN oxygen for shortness of breath, but during observations, the oxygen concentrator was not delivering supplemental oxygen as required. Staff interviews confirmed that the concentrator should have been turned on when the nasal cannula was in use, and the facility's policy required oxygen to be administered at the prescribed rate with verification of flow. Another resident, with diagnoses including UTI, E. coli infection, and Alzheimer's disease, was found to have nebulizer tubing and mask on the floor in their room. Staff acknowledged that the tubing and mask should not be on the floor due to the risk of contamination, and that the equipment should be stored in a plastic bag, labeled, and kept off the floor. The facility's policy and staff interviews confirmed that using contaminated respiratory equipment could lead to respiratory infections. A third resident, with heart failure, COPD, and Alzheimer's disease, was observed with nasal cannula oxygen tubing touching the floor. The tubing was also overdue for replacement according to the facility's policy, which required weekly changes. Staff interviews indicated that the tubing should have been stored properly and not allowed to touch the floor to prevent infection. The facility's policy specified that all oxygen delivery items are for single resident use, must be changed weekly or when soiled, and stored in a labeled plastic bag at the bedside.
Failure to Administer Ordered Antibiotic and Reconcile Controlled Medications in eKITs
Penalty
Summary
The facility failed to ensure that an antibiotic medication, sulfamethoxazole-trimethoprim, was administered as ordered by the physician for a resident with a history of atherosclerotic heart disease, generalized muscle weakness, and a urinary tract infection. The resident, who was cognitively impaired and required maximum assistance for daily activities, did not receive the scheduled 9 a.m. dose on 7/13/2025. Documentation in the Medication Administration Record (MAR) and progress notes did not confirm administration of the medication, and staff interviews confirmed that the dose was missed and not documented. The nurse responsible did not notify the physician about the missed dose or obtain further orders, resulting in an incomplete antibiotic course for the resident's abscess. Additionally, the facility failed to reconcile controlled medications (CMs) stored in emergency medication kits (eKITs) at every shift change in three medication rooms. Observations revealed that six eKITs containing CMs lacked accountability logs for July 2025, and staff interviews confirmed that these kits were not reconciled as required by facility policy. Nurses acknowledged the importance of reconciling CMs at each shift to ensure accountability and prevent diversion, but admitted that this was not done for the identified eKITs. Review of facility policies confirmed that all CMs, including those in emergency kits, must be physically inventoried and documented by two licensed nurses at each shift change. The Director of Nursing and Assistant Director of Nursing acknowledged that the facility did not follow its own procedures for CM reconciliation, and that the required documentation and accountability for these medications were not maintained during the period in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Significant Medication Errors Involving Insulin Administration, Antibiotic Dosing, and Expired Inhaler Use
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration and adherence to physician orders and manufacturer guidelines. One resident with type 2 diabetes and chronic kidney disease received insulin injections at the same anatomical sites repeatedly, rather than rotating injection sites as required by standard of care and facility policy. This practice was confirmed through review of administration records and interviews with nursing staff, who acknowledged that site rotation was not performed as required. Another resident with chronic obstructive pulmonary disease (COPD) and a recent diagnosis of bronchitis was prescribed a course of azithromycin. The physician's order specified a dosing schedule that was not correctly transcribed into the Medication Administration Record (MAR), resulting in the omission of a scheduled dose. The Assistant Director of Nursing admitted to the transcription error, which led to the antibiotic dose being administered late, contrary to the physician's instructions. A third resident, also with COPD, was administered nine doses of an expired fluticasone and salmeterol inhalation powder Diskus. The inhaler had been opened and stored beyond the manufacturer-recommended one-month period, but was not removed from the medication cart as required by facility policy. Multiple nurses administered the expired medication, and staff interviews confirmed awareness of the expiration guidelines and the error in not removing the medication from use.
Expired Medications and Hand Sanitizer Not Removed from Use
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not removing expired hand sanitizer from a resident's bedside and by not discarding an expired inhalation medication from a medication cart. In the first instance, a resident with a history of urinary tract infection, E. coli, and dementia was found to have two hand sanitizers on the bedside table, one of which had expired several years prior. Staff interviews confirmed that hand sanitizers should not be left at the bedside due to the risk of accidental ingestion and that expired sanitizers are ineffective and should be discarded according to facility protocol. The facility's policy also requires the environment to be free of hazards, including expired sanitizing agents. In the second instance, an expired fluticasone and salmeterol inhalation powder Diskus, used for treating COPD, was found in a medication cart. The medication had been opened and marked with the date, but was not removed after the one-month expiration period as required by both manufacturer guidelines and facility policy. Multiple licensed nurses, including the one interviewed, failed to remove the expired medication, resulting in nine doses being administered to a resident after the expiration date. Staff acknowledged that expired inhalers lose potency and are not effective in treating the resident's condition. Facility policies reviewed indicated that expired or discontinued medications must be immediately removed from stock and stored in a designated area for disposal. The policies also specify that medications should be stored and disposed of according to manufacturer recommendations. Despite these policies, the expired hand sanitizer and inhalation medication remained accessible and in use, contrary to both facility procedures and professional standards.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Incomplete and Inaccurate Medical Record Documentation for Infection Control and Restorative Nursing Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For several residents with cognitive impairments or lacking decision-making capacity, COVID-19 screening forms were incomplete, specifically missing required temperature documentation at the time of screening. Additionally, vaccination informed consent forms for COVID-19, influenza, and pneumococcal vaccines were not fully completed, lacking essential information such as the name and relationship of the resident’s representative, and in some cases, the resident’s name. These omissions were confirmed by both nursing staff and facility leadership, who acknowledged that incomplete consent forms constitute incomplete medical records. For residents receiving Restorative Nursing Aide (RNA) services, the facility did not accurately document the actual care provided. In one case, a resident’s RNA Weekly Progress notes did not reflect the resident’s true ability to ambulate, with discrepancies between the recorded ambulation distances and what was observed or reported by staff. The RNA daily treatment records also inaccurately indicated that ambulation was provided on certain days when, in fact, it was not performed due to the resident requiring assistance from two staff members, which was not available. Staff interviews confirmed that the documentation did not match the care delivered, and that the electronic documentation system was not used correctly to indicate when services were missed or not performed. Additional documentation failures included not recording missed RNA treatments for several residents and not documenting a resident’s inability to participate in sit-to-stand transfers. Facility policies required accurate and timely documentation of restorative nursing services and complete informed consent forms, but these standards were not met. The Director of Nursing and Assistant Director of Nursing confirmed that these documentation lapses resulted in incomplete and inaccurate medical records, which could lead to confusion regarding the care and services provided to residents.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to implement appropriate infection control practices for residents with indwelling urinary catheters, specifically by not following Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. For one resident with significant medical conditions including metabolic encephalopathy, carcinoma in situ of the vulva, breast cancer, and Alzheimer's disease, staff did not don gowns while providing indwelling catheter care, despite the resident being dependent on staff for all activities of daily living. Observations showed that staff entered the resident's room wearing only masks and gloves, and did not use gowns as required by EBP during catheter care. Interviews revealed that staff believed EBP was not necessary unless a resident had a known multidrug-resistant organism (MDRO), and the Infection Prevention Nurse confirmed that EBP had been discontinued based on a misunderstanding of guidance, which was later acknowledged as incorrect. Another resident with Alzheimer's disease, dementia, and neuromuscular bladder dysfunction, also dependent on staff for personal care and with an indwelling catheter, did not have EBP signage or PPE available in the room. During peri-care, a CNA did not wear a gown, used a double-gloving technique not in line with facility policy, and failed to perform hand hygiene at appropriate times during the care process. The CNA was unaware of EBP requirements and stated that isolation precautions were not in place for the resident. The Infection Preventionist and Director of Nursing later confirmed that EBP should have been implemented for residents with indwelling devices, regardless of MDRO status, and that hand hygiene and proper glove use were expected but not followed. Review of facility policies confirmed that EBP should be used for residents with indwelling devices during high-contact care activities, and that hand hygiene is required before and after resident care and glove changes. The failure to implement EBP and proper hand hygiene as outlined in facility policy and CDC guidance led to deficient infection control practices for residents with indwelling catheters.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff members were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist responsible for the infection prevention and control program. This omission indicates that the required oversight and management of infection control practices were not assigned to a qualified individual as mandated.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to keep the call light within reach for three residents who were reviewed for accommodation of needs and preferences. For one resident with a history of osteoporosis, traumatic fracture, chronic delirium, and high fall risk, the call light was observed placed on the foot of the bed, out of reach while the resident was in a wheelchair. Staff interviews confirmed that the call light was not accessible and acknowledged that the resident could not reach it, which was contrary to the care plan intervention requiring the call light to be within easy reach and answered promptly. Another resident, admitted with mild cognitive impairment, a left shoulder fracture, and osteoporosis, was also found with the call light placed on the foot of the bed while in a wheelchair. The resident's care plan included an intervention to keep the call light within easy reach due to high fall risk. Staff interviews confirmed the call light was not accessible and that the resident could not reach it, despite the facility's policy requiring call cords to be placed within the resident's reach. A third resident, diagnosed with Alzheimer's disease, dementia, and functional quadriplegia, was observed lying in bed with the call light placed at the uppermost edge of the bed, out of reach. The resident's care plan required the call light to be within easy reach to minimize the potential for falls or injury. Staff acknowledged that the call light was not within reach and that this oversight could delay meeting the resident's needs. Facility policies reviewed indicated that all residents should have immediate access to a functioning call light at all times, and that call cords must be placed within reach in resident rooms.
Failure to Provide Accessible Survey Results to Residents
Penalty
Summary
The facility failed to ensure that residents were aware of the availability and location of the most recent survey results, as well as the corrections made for identified deficiencies. During a Resident Council Meeting attended by nine residents, it was revealed through interviews and observations that none of the residents knew where to find the survey results or how to access information about the facility's corrective actions. Activity staff confirmed that all present residents were unsure of the survey results' location, and this was further corroborated by direct questioning and translation for non-English speakers. Subsequent observations showed that the survey result binder was either missing from its designated location or did not contain the latest survey results and plan of correction. The Administrator acknowledged that the binder was being updated in his office and that staff had not followed instructions regarding its maintenance. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the survey results and corrective actions should be accessible to residents, families, and staff without the need to request them from facility personnel. A review of facility policy also indicated that survey results should be posted in a readily accessible location.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Safe Swallowing Precautions and Incomplete Monitoring After Change in Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident with diagnoses including subdural hemorrhage, Alzheimer’s disease, dementia, muscle weakness, and dysphagia, the care plan and speech language pathology (SLP) evaluation required safe swallowing precautions, a puree diet, and maintaining an upright posture for more than 30 minutes after meals. Observations revealed that after a breakfast meal, the resident’s head-of-bed (HOB) was lowered to a flat position immediately after eating, contrary to SLP recommendations and facility policy. The staff member acknowledged that the HOB should have remained elevated after eating, even if the resident consumed only a small amount, but proceeded to lower the bed for comfort during range of motion exercises. The resident remained flat in bed for a period after eating, and the HOB was only slightly elevated after the exercises were completed. For another resident with dementia, psychosis, dysphagia, and generalized muscle weakness, the care plan required monitoring of food tolerance and oral intake by percentage at each meal, with interventions to prevent further weight loss. The resident experienced a significant weight loss, triggering a change of condition (COC) and a requirement for 72-hour shift charting to monitor the resident’s intake and response. However, there was no documented evidence that this monitoring was completed for the required period. Progress notes did not reflect the necessary 72-hour monitoring, and staff interviews confirmed that the required documentation and monitoring were not performed. Facility policies required staff to promote safe swallowing through proper positioning and to document resident status and care, especially during changes in condition. The failure to maintain the resident’s HOB in an elevated position after meals and the lack of required 72-hour monitoring and documentation for a resident with significant weight loss demonstrate noncompliance with professional standards and facility policy.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Prevent Accident Hazards and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with a history of repeated falls and diagnoses including Alzheimer's disease and osteoporosis, a floor mat intended to prevent injury was found with a wheelchair placed on top of it. Staff interviews confirmed that the resident placed the wheelchair on the mat himself, and that this practice was known to be hazardous. The care plan for this resident did not address the resident's refusal to keep the mat clear, and staff acknowledged that the mat should be free of objects or furniture to prevent injury and maintain its effectiveness. For another resident with chronic congestive heart failure, Alzheimer's disease, and dementia, who was identified as high risk for falls, there was no fall risk assessment completed after a fall incident. Progress notes indicated the resident was found on the floor mat after sliding off the bed, but no post-fall assessment was documented. Staff interviews revealed that fall risk assessments are required after such incidents to evaluate the resident's risk and determine necessary interventions, but this was not completed in this case. Facility policies reviewed indicated requirements for maintaining a hazard-free environment and for completing comprehensive, individualized care plans and fall risk assessments upon admission, quarterly, and after significant events such as falls. Manufacturer specifications for the floor mat also stated that heavy objects should not be left on the mat, as this could damage its protective function. The failure to follow these procedures and policies resulted in increased risk of accidents and injuries for the residents involved.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards for safety and appropriateness. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified through surveyor observation and documentation review.
Failure to Maintain Safe and Homelike Environment Due to Damaged Floor Mats
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents by not ensuring that their floor mats, which are intended to prevent injury from falls, were free from rips, peeling, and disrepair. For one resident with Alzheimer's disease, dementia, and depression, the floor mat next to the bed was observed to have peeling edges and was in disrepair. Staff interviews confirmed that the mat should have been replaced, as its condition was not homelike and could affect the resident's quality of life. The care plan for this resident included keeping the environment free of hazards and maintaining floor mats as interventions to minimize falls or injury, but these interventions were not properly implemented. Another resident, who had a history of falls, impaired vision, moderately impaired cognition, and required assistance with mobility and ADLs, also had a fall mat with peeling covers at the edges. Staff, including the Director of Staff Development and the DON, acknowledged that the mat's compromised condition could reduce its effectiveness in preventing injury and did not provide a homelike environment. The resident's care plan specifically aimed to ensure a homelike environment, but the presence of a damaged mat was inconsistent with this goal. Facility policy required maintaining a homelike environment and ensuring the quality of life for all residents, and manufacturer specifications for the mats included instructions to avoid damage. Despite these guidelines, the facility did not ensure that the floor mats for these two residents were maintained in good condition, resulting in a deficiency related to the residents' right to a safe, clean, comfortable, and homelike environment.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documented follow-up with the appropriate external agencies. The report specifically notes the failure to meet regulatory requirements for reporting and investigation communication, but does not provide further details about the individuals involved or the nature of the incident.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Assessment and Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known history of masturbatory and sexually inappropriate behaviors was not adequately assessed, monitored, or care planned to address the risk these behaviors posed to other residents. Despite documentation in the care plan that the resident exhibited masturbatory behavior, there were no interventions or monitoring in place to evaluate or manage the impact of these behaviors on others. Staff, including CNAs and nurses, observed and were aware of the resident's inappropriate sexual behaviors, but these observations were not consistently documented or reported to supervisory staff or the physician. This lack of assessment and intervention led to an incident where the resident with sexually inappropriate behaviors was found on top of another resident, with exposed breasts, rubbing against the other resident and sucking the resident's chin, resulting in a visible red mark. The resident who was victimized was documented as having moderate cognitive impairment, lacking capacity to make decisions, and requiring substantial assistance with activities of daily living. Staff interviews confirmed that the victimized resident was unable to provide consent for any sexual activity, and the incident was recognized by staff as sexual abuse. Following the incident, there was no evidence that a head-to-toe assessment or vital signs were taken for either resident, nor was there documentation of monitoring the victimized resident's condition for 72 hours as required by facility policy. The facility's abuse prevention policy required assessment and monitoring of residents after such incidents, but these steps were not followed. The Director of Nursing acknowledged the failure to provide safety for the victimized resident and the lack of documentation, monitoring, and reporting of the perpetrator's sexually inappropriate behaviors.
Failure to Develop Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing fall risk for a resident who was identified as high risk for falls. The resident, who had diagnoses including atherosclerotic heart disease, hypertension, and dementia with fluctuating decision-making capacity, was assessed multiple times with fall risk scores significantly above the threshold for high risk. Despite these assessments, no care plan was created to address the resident's fall risk prior to a fall incident. Record reviews showed that the resident required substantial to partial assistance with activities of daily living and had moderate cognitive impairment. Interviews with nursing staff confirmed that the resident's high fall risk status was known for several months, but appropriate interventions and a care plan were not put in place. The facility's own policy required a comprehensive, person-centered care plan based on assessed needs, which was not followed in this case.
Failure to Develop and Implement Timely, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement timely, person-centered care plans for four out of five sampled residents, resulting in deficiencies related to the assessment and management of their medical and behavioral needs. For one resident with a history of heart failure, dementia, psychosis, and repeated falls, staff observed frequent episodes of the resident getting up unassisted and being found on the floor multiple times. Despite these incidents and documentation by staff, the care plan addressing this behavior was not created promptly when the behavior was first observed, as confirmed by the Director of Nursing. Another resident with a diagnosis of osteoporosis did not have an active care plan addressing this condition, even though the diagnosis was documented in the medical record and physician notes. The care planner acknowledged missing the development of a new care plan for osteoporosis, and the risk management nurse confirmed that such a care plan was necessary to address the risk of fractures. Similarly, a third resident with Parkinson's disease, Alzheimer's, and osteoporosis exhibited repeated behaviors of throwing himself on the floor, which were documented by nursing staff over several weeks. However, this behavior was not reported to the care planning team, and no care plan was developed to address the risk of falls associated with this behavior. A fourth resident with atrial fibrillation, epilepsy, and osteoporosis also lacked a care plan for osteoporosis. Additionally, this resident exhibited a persistent behavior of banging the call light on the table, resulting in injury, and had a documented pattern of refusing activities of daily living, including showers. Despite these ongoing behaviors and refusals, care plans addressing these issues were not developed in a timely manner, and the care planning team was not informed promptly. The facility's own policy required comprehensive, person-centered care plans to be developed and updated for changes in condition, new problems, or resident behaviors, but these requirements were not met for the residents involved.
Failure to Perform and Document Post-Fall Assessments and Neurochecks
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for two residents by not performing and documenting required assessments following fall incidents. For one resident with a history of heart failure, dementia, psychosis, and repeated falls, staff did not take or document vital signs after a witnessed fall that resulted in a laceration above the right eyebrow. Additionally, neurological assessments (neurochecks) were not performed or documented after multiple falls, despite facility policy requiring such assessments following any fall involving head trauma or unwitnessed falls. Interviews with facility staff, including the Performance Improvement Quality Improvement Nurse, Risk Management Nurse, and Director of Nursing, confirmed that vital signs and neurochecks are essential components of post-fall assessment. The staff acknowledged that these assessments were not completed or documented as required. The facility's policies specify that vital signs must be included in the assessment and communicated to the physician after any change in condition, such as a fall, and that neurochecks must be performed and documented for 72 hours following any unwitnessed fall or fall with head injury. A second resident, admitted with diagnoses including atherosclerotic heart disease, Alzheimer's disease, and osteoporosis, also experienced falls for which neurochecks were not performed or documented, even when the falls resulted in injury and required transfer to an acute care hospital. Review of the facility's policies and interviews with staff confirmed that these omissions were contrary to established procedures. These failures had the potential to delay care and services for both residents.
Failure to Follow Physician Orders and Medication Release Protocols
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. For one resident with diagnoses including heart failure, dementia, psychosis, and diabetes mellitus, the facility did not follow the physician's order to administer cephalexin for five days. The medication was not available in the medication cart, resulting in three missed doses, and staff did not notify the physician or pharmacy to obtain the antibiotic from the emergency kit. The resident's medication administration record was left blank for the missed doses, and interviews with facility staff confirmed that the physician's order was not followed. Additionally, the same resident received Humulin R insulin on three occasions despite blood sugar readings below the threshold specified in the physician's order, which directed the medication to be held for blood sugar less than 120 mg/dl. Staff interviews and record reviews confirmed that the insulin was administered contrary to the order, and the facility's policy required nurses to know and follow all aspects of medication administration, including holding medications based on vital signs or test results. For another resident with multiple diagnoses and moderately impaired cognitive skills, the facility allowed a family member to take possession of all the resident's medications, including controlled substances, without a physician's order. The family member refused to sign the narcotic sheet, and staff provided all medications without proper documentation or authorization. Interviews with staff and review of facility policy confirmed that medications should only be released upon discharge with a physician's order, and controlled substances require additional authorization. The facility did not have a policy for therapeutic leave, and the incident was not properly documented in the resident's medical record.
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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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