Arbor Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 1200 Springfield Drive, Chico, California 95928
- CMS Provider Number
- 555304
- Inspections on file
- 61
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Arbor Post Acute during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, essential tremor, and muscle weakness was assessed on admission as needing bed canes to assist with bed mobility and maintain independence in ADLs. The MDS and care plan documented limited leg function and a need for assistance with rolling and sitting up in bed, and a bed rail/entrapment assessment recommended bed canes. However, repeated observations showed the bed had no bed canes or rails, and the resident reported being quite dependent on staff for bed mobility and unable to roll without something to hold. Staff confirmed the recommendation for bed canes, but a work order was not submitted until many days after admission, and the bed still lacked bed canes because it was not compatible and no alternative bed was available at full facility capacity.
A resident admitted with essential tremor, dysphagia, and a cognitive communication deficit had a physician order and care plan for speech therapy (ST) three times weekly for four weeks following an initial ST evaluation. Despite facility policies requiring that physician orders be carried out, the resident received only the initial evaluation and no subsequent ST treatments, and was not placed on the ordered treatment schedule. The resident later reported expecting ongoing ST for speech but confirmed no further visits occurred, while therapy leadership acknowledged that the ordered visit frequency was not followed.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
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.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
A resident who was totally dependent on staff for ADLs and at risk for skin breakdown was not turned or repositioned every two hours as ordered. Despite care plans and physician orders, staff interviews and observations confirmed the resident remained on her back for extended periods, leading to red areas and indentations on her skin from prolonged pressure and wrinkled linens.
The facility failed to ensure the safety of residents at high risk for wandering and elopement due to non-functional TEC and Wanderguard systems. A resident eloped undetected and was found across the street. The facility's monitoring logs were incomplete, and staff did not follow policy for checking Wanderguard functionality. Interviews revealed maintenance issues with the TEC system, contributing to its failure to alarm.
A resident in an LTC facility was subjected to G-tube feeding for 24 days despite having signed a POLST refusing artificial nutrition. The resident, who was capable of making his own healthcare decisions, expressed a desire to eat regular food and was distressed by the continued G-tube feeding. The facility's Director of Nursing confirmed the failure to honor the resident's documented wishes.
A resident with a surgical wound experienced a change in condition that was not reported to the physician, as required by facility policy. Weekly skin wound evaluations were not conducted, and an antibiotic prescribed by the resident's vascular surgeon was not administered. The Director of Nursing and Administrator confirmed these oversights, which could have delayed necessary interventions.
The facility failed to provide adequate care plans and supervision for two residents, leading to repeated falls and potential hazards. One resident, at high risk for falls, experienced multiple falls and a severe head injury due to ineffective interventions and lack of supervision. Another resident, a smoker, was not properly evaluated for smoking safety, and the path used for smoking had a large pothole, posing a hazard. The facility's policies were not effectively implemented, resulting in increased risks for the residents.
A resident with contractured legs experienced severe pain during brief changes due to the facility's failure to follow its pain management policy. Staff forced the resident's legs apart, causing distress and pain, without evaluating alternative methods for managing incontinence. The care plan lacked specific interventions, and there was inadequate communication with the hospice team, leading to ongoing pain and distress for the resident.
The facility failed to provide a safe and comfortable environment for residents, with issues such as an uncomfortable mattress and inadequate room temperatures. A resident reported a mattress with a hole, which had not been replaced despite new mattresses being available. Additionally, shower rooms and the dining room had temperatures below the recommended range, with heating systems requiring manual operation, leading to inconsistent temperatures. Maintenance staff acknowledged unfinished projects, contributing to the discomfort.
The facility failed to maintain an effective infection prevention and control program, with unclean wheelchairs, improper storage of oxygen tubing, and inadequate hand hygiene practices observed. Wheelchairs were visibly soiled, oxygen tubing was not stored in anti-microbial bags, and personal hygiene products were improperly placed. A CNA was seen touching her face and assisting residents without washing hands, breaching infection control protocols.
A resident found a pain pill at her bedside, causing anxiety due to improper medication administration by an LN who failed to verify ingestion. The facility also had expired medications in carts and incomplete narcotic disposal logs, risking drug diversion.
Two residents experienced a lack of dignity and privacy in an LTC facility. One resident was left exposed in her room, while another did not receive necessary assistance with toileting and meal preferences. Staff failed to provide adequate care, leading to discomfort and disrespectful interactions. Interviews with facility leaders confirmed these actions were inappropriate and against policy.
Two residents in a facility were found with call lights out of reach, despite their care plans indicating the need for accessible call lights due to severe cognitive impairments and fall risks. Observations showed call lights on the floor, and staff confirmed the oversight, highlighting a failure to accommodate resident needs.
A resident with severe cognitive impairment was subjected to sexual abuse by another resident during an activity. The incident was not reported immediately, delaying family notification. The offending resident had a history of inappropriate behavior, and despite interventions, the incident occurred, highlighting a deficiency in protecting residents from abuse.
A facility failed to report a sexual abuse incident involving two residents within the mandated timeframes, delaying the investigation. Resident 22, with severe cognitive impairment, was involved in the incident with Resident 120, who has a history of inappropriate behavior. The delay was due to a staff member not reporting the incident immediately, despite having attended abuse report training.
Two residents were inaccurately assessed in a facility, leading to potential care planning issues. One resident was documented as continent despite evidence of occasional incontinence, while another was incorrectly marked as a non-smoker despite being observed smoking outside the facility. Staff interviews and documentation confirmed these inaccuracies.
The facility failed to provide necessary services for two residents. One resident, with multiple health issues, did not receive a wheelchair despite being measured for it, leading to discomfort and immobility. Another resident, suffering from osteoarthritis and other conditions, did not receive needed medical referrals for knee pain and an IUD removal, despite repeated physician recommendations. These deficiencies were due to a lack of follow-up by the therapy department and the failure of licensed nurses to arrange appointments.
Two residents in an LTC facility did not receive necessary assistance with ADLs. One resident was unable to get out of bed due to a missing wheelchair and missed scheduled showers, while another was not assisted with toileting needs, leading to discomfort. Staff misjudged the residents' abilities, resulting in inadequate care.
A resident with multiple health conditions, including COPD and chronic kidney disease, did not receive adequate foot care, resulting in dry, cracked, and peeling feet. The facility's policy required daily skin checks and lotion application, but these were not consistently performed. Staff interviews revealed a lack of consistent care and communication regarding the resident's condition.
A resident with severe cognitive deficits and multiple diagnoses was not repositioned every two hours as required, leading to redness and indentations on her skin. Despite facility policies and physician's orders, staff interviews and observations confirmed the resident was left on her back for extended periods, increasing the risk of skin breakdown.
The facility failed to conduct annual performance evaluations for a CNA, with the last evaluations recorded in 2021 and 2022. The Director of Staff Development confirmed the absence of evaluations for 2023 and 2024, indicating the facility was behind on these evaluations. This deficiency could prevent CNAs from receiving necessary ongoing education and inservices.
A facility was found to have a medication error rate of 19.2%, with errors in nebulizer and eye drop administration, and improper documentation. A Respiratory Therapist failed to follow nebulizer procedures, leading to medication escape. Licensed Nurses did not adhere to eye drop policies, and a Registered Nurse left a resident before confirming medication intake. The Director of Nursing acknowledged the need for improved competencies.
The facility failed to properly store medications, leading to disorganization in two medication storage rooms. In one room, expired and non-expired medications were stored together, while another room had enteric food supplies next to probiotics and multivitamins, against policy. The DON acknowledged the issue and stated that reorganization had occurred.
A resident kept perishable food at bedside against facility policy, risking foodborne illness. Staff efforts to store food properly were refused by the resident. Additionally, the facility used incorrect products for ice machine maintenance, not following manufacturer's instructions, risking contamination.
A facility failed to implement smoking safety policies for a resident who smoked off property. The resident was not identified as a smoker, leading to unsecured smoking materials in his room and a delayed smoking evaluation. This resulted in an unsafe environment, as evidenced by cigarette burn holes in the resident's clothing.
A resident with a history of COPD and heart issues experienced a significant change in condition, including low blood pressure and refusal to eat. Despite reports from CNAs, the LPN did not retake the blood pressure or notify the physician, assuming an error. The resident's condition worsened, leading to a hospital transfer. The DON confirmed the LPN's failure to document the change timely and noted a lack of competency evaluation.
A resident who only spoke Spanish was not provided with a certified interpreter during a room change, leading to confusion and distress. The facility relied on Spanish-speaking CNAs instead of using a professional language line service, contrary to their policy requiring competent oral translation of vital information.
A resident was moved to a different room without receiving the required one-day written notice, as per facility policy. The resident was informed verbally about the move due to COVID-19 cases and given only a one-hour notice, leading to confusion and emotional distress. Staff confirmed the resident was upset, and the Social Services Director admitted the facility had stopped issuing written notices.
A resident was denied privacy during a call with the Ombudsman when a Business Marketer entered the room and took over the conversation. This violated the facility's policy on providing private telephone access, as the resident was unable to discuss her concerns about a room change without staff interference.
The facility failed to maintain clean and safe bathrooms for eight residents, as observed in various rooms. Bathrooms were found with dark splatter, gouged doorframes, dirt, and improperly stored personal items. Despite a policy for daily cleaning, observations revealed deficiencies such as stained linoleum, chipped paint, and dirty bedpans, contradicting the facility's cleaning claims.
A resident received ENT treatment without the knowledge or consent of their Responsible Party (RP), despite being unable to make healthcare decisions. The facility's staff failed to notify the RP or obtain consent, resulting in unauthorized procedures. The Social Service Assistant and Director confirmed the lack of documentation and orders for the consultation, which violated the facility's policy on resident rights.
A resident experienced a change in condition, leading to a physician ordering medications, but the facility failed to document the resident's condition in the nurse's notes. Additionally, an ENT visit for the resident and 20 others was not documented until two months later. The ADON and SSD confirmed these documentation lapses.
The facility failed to maintain safe and sanitary shower rooms on Station 1 and Station 2. Observations revealed broken tiles and black substances in the grout and corners, confirmed by CNA A, HSK, DON, and IP. The facility's policies on safety and cleaning were not followed, leading to unsanitary conditions.
A resident with multiple health conditions was verbally abused by a CNA, causing emotional distress. Despite being instructed to avoid the resident, the CNA re-entered the room and continued the abuse. The facility failed to follow its abuse policy, allowing the CNA to continue working until the following Monday when they were suspended and later terminated.
Failure to Provide Recommended Bed Canes to Support Resident Mobility
Penalty
Summary
The facility failed to reasonably accommodate a resident’s assessed need for bed canes, which had been recommended to support mobility and independence. The resident was admitted with Parkinson’s disease, essential tremor, and muscle weakness, and the admission MDS showed limited function of both legs, a need for touching assistance to roll in bed, and moderate assistance to sit up in bed. The care plan identified the resident as at risk for decline in ADLs and mobility and directed staff to encourage participation in ADLs to promote independence. On admission, a Bed Rail and Entrapment Risk Observation/Assessment was completed and recommended bed canes due to mobility limitations. Despite this, observations on multiple dates showed the resident’s bed had no bed canes or bed rails. Staff interviews and record reviews confirmed that the resident remained without the recommended bed canes and was dependent on staff for bed mobility. The resident reported needing bed rails/bed canes to pull themselves around in bed and stated they were quite dependent on staff for bed mobility without them. During care, when a CNA asked the resident to roll in bed, the resident stated they could not because there was nothing to hold on to, and the CNA had to assist the resident to roll. The DON and nursing staff confirmed that the assessment recommending bed canes was completed on admission, but a work order for bed canes was not entered until 18 days later, and the bed still did not have bed canes. The Maintenance Director and DON stated the resident’s bed did not accommodate bed canes and there was no compatible bed available because the facility was at maximum capacity, resulting in the resident not receiving the recommended assistive device.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered specialized rehabilitative services, specifically speech therapy (ST), to a resident. Facility policies on Physician Orders required that treatment orders be carried out in accordance with the physician’s order, and the Speech Therapy policy described the purpose of identifying, assessing, and treating speech, language, and swallowing disorders. The resident was admitted with essential tremor, dysphagia in the oropharyngeal phase, and a cognitive communication deficit, and was their own responsible party. The admission MDS showed a BIMS score of 12/15, indicating intact memory, and documented difficulty or pain with swallowing. A physician’s order dated shortly after admission, based on an ST evaluation and plan of treatment, specified that the resident required ST services three times a week for four weeks. During interviews and record reviews with the Director of Rehab and the Regional Director of Therapy Services, it was confirmed that the ST evaluation was completed and that the ordered frequency of three ST visits per week for four weeks was established, but the resident was only seen once for the initial evaluation and was not placed on the ordered treatment schedule. The resident’s care plan for cognitive communication deficit documented that ST would provide skilled treatments three times a week for four weeks, including voice and breathing exercises, group treatment, and speech and hearing interventions, with a goal of improving functional skills to return home safely. On observation, the resident was seen lying in bed with shaking hands, speaking slowly, pausing between words, and reporting that they expected the ST to work with them on speech but had only received the evaluation and no further visits. The Regional Director of Therapy Services confirmed that no ST visits were provided in accordance with the physician-ordered frequency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency 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 Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Reposition Dependent Resident as Ordered, Resulting in Skin Redness and Indentations
Penalty
Summary
The facility failed to ensure that a resident who was totally dependent on staff for all activities of daily living, including turning and repositioning, was provided care as ordered to prevent skin breakdown. The resident, who had severe cognitive impairment, dementia, diabetes, and other significant medical conditions, had a care plan and physician's order requiring turning and repositioning every two hours. Despite these orders and facility policies emphasizing the importance of repositioning to prevent pressure ulcers, staff did not consistently turn or reposition the resident as required. Multiple interviews and observations revealed that the resident remained on her back for extended periods, with staff and family members confirming that turning and repositioning were not performed as ordered. Observations showed the resident lying on wrinkled bed linens, and staff interviews confirmed that the resident had not been turned or repositioned during the day shift. Documentation and direct statements from CNAs and the DON further confirmed the lack of adherence to the turning schedule. As a result of this failure, the resident was observed with multiple red areas, indentations, and red lines on her upper thighs, buttocks, and lower back, attributed to prolonged pressure and wrinkled sheets. The lack of timely repositioning and failure to follow the care plan and physician's orders directly contributed to the resident's skin changes and increased risk for pressure ulcer development.
Plan Of Correction
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified was turned upon identification and transferred to her wheelchair. Additionally, a task was added to the POC charting to turn and reposition every 2 hours. 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: Any dependent resident has the potential to be affected by the practice. On 3/19/25, Director of Staff Development educated on repositioning and turning of this resident to the CNA on duty. On 3/20/25, this resident was picked up by therapy to assist with increased range of motion and activity. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/19/25, Director of Staff Development initiated education on repositioning and turning policy. Director of Staff Development will conduct daily visual audits, Monday through Friday, of three residents turning and repositioning. How the facility plans to monitor its performance to make sure that the solutions are sustained: Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. If 95% compliance is achieved after 90 days, the issue will be resolved within QAPI. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 20th, 2025.
Failure to Ensure Safety of Residents at Risk for Elopement
Penalty
Summary
The facility failed to ensure the safety and security of seven residents identified as high risk for wandering and/or elopement. The Touchpad Exit Controller (TEC) system, which is supposed to alarm when a resident wearing a Wanderguard passes through an exit, did not function properly, allowing a resident to elope undetected. This resident was later found across the street with his wheelchair stuck in a sidewalk crack. The facility's monitoring check-off log for the TEC system and exit door alarms was incomplete, missing documentation for certain days and not including all exit doors. The TEC system on one of the exit doors was found to be non-functional during a surveyor's test, and the facility's policy for checking Wanderguard functionality was not followed. The policy required checks every shift, but the orders for residents only required daily checks. Additionally, staff members were not using the available tool to test the functionality of the Wanderguards, relying instead on less effective methods such as placing residents near exit doors to see if alarms would sound. The facility's lack of oversight and failure to ensure that their TEC and Wanderguard systems were fully operational resulted in a resident eloping and endangered the safety of other residents known to wander. Interviews with staff revealed that the TEC system was not properly maintained, with issues such as missing screws and unplugged components, contributing to the failure of the system to alarm as intended.
Plan Of Correction
Accidents and Hazards How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified experienced no adverse effects and does not recall the incident. The resident was moved to a new room on 2/26/25, further from an exit door with no new incident noted. 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: Any resident who has been identified as an elopement risk had the potential to be affected. No other residents were affected. 1. On 2/25/25, the nurse on duty addressed the loose wire on the identified door. Maintenance conducted an assessment on 2/26/25 and secured the wiring further. Additionally, on 2/26/25, Maintenance installed a Velcro stop sign on the identified door as a deterrent. A fire alarm box was added to this door on 3/13/25 as an additional safety measure. 2. Maintenance log/audit was updated on 3/13/25 to include all doors and the device that is being checked on each door. 3. The TEC system on station 3 door is working but showing a slight delay when alarming. TEC systems have been contacted to address the need for increased sensitivity. Additionally, this door includes a locked alarm box that alarms, and the Wanderguard sensor was an additional backup alarm. 4. Wanderguard Process Guide was edited to match the physician orders. 5. On 3/12/25, nurses identified as not knowing how to check the Wanderguard functionality were in serviced by the nurse manager. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/17/25, the Administrator provided in-service training to the Director of Maintenance during the routine inspection of doors equipped with Wanderguard sensors. The inspection will now also include checks for loose wiring and whether the sensor is secure. On 3/17/25, the Nurse Manager initiated in-service training for licensed nurses on the proper method to check the functionality of the Wanderguard system for their residents. Maintenance will complete a daily audit (Monday through Friday) of the exit doors alarm systems including Wanderguard system and/or Red Fire Box. This audit will include a review for potential loose wires, Wanderguard sensor and functionality, and Red Fire Box sensor and functionality. Medical Records will check weekly that the Wanderguard orders match the policy. The Director of Nursing (or designee) will audit two nurses weekly to ensure they can correctly verbalize the process for checking a resident's Wanderguard functionality. How the facility plans to monitor its performance to make sure that the solutions are sustained: Results of the audit will be brought to the Quality Assurance Performance Improvement (QAPI) monthly. If 95% compliance is met after 90 days, QAPI will be resolved. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 18th, 2025.
Facility Failed to Honor Resident's Refusal of G-Tube Feeding
Penalty
Summary
The facility violated a resident's right to refuse treatment when they continued to provide artificial nutrition through a G-tube for 24 days after the resident had signed a Physician Order for Life Sustaining Treatment (POLST) indicating his wish to refuse such treatment. The resident, who was capable of making his own healthcare decisions, had a BIMS score of 15, indicating intact cognitive function. Despite the resident's clear wishes documented on the POLST form, the facility continued to administer enteral feeding, causing the resident distress, frustration, and pain. The resident had been readmitted to the facility with a G-tube due to dysphagia and aspiration risks. However, he expressed a desire to eat regular food and drink liquids, and he was non-compliant with the NPO diet by consuming oral snacks and beverages. The nursing progress notes documented the resident's distress and his explicit statements about wanting the G-tube removed. The Director of Nursing confirmed that the facility failed to honor the resident's wishes as documented in the POLST, continuing the G-tube feedings against his will for nearly a month.
Plan Of Correction
F 578 Request/Refuse/Dscntnue Trmnt; Formite Adv Dir How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident's rights were followed on 2/10/25 when the diet order was updated by the physician to align with the resident's wishes. The Gastrointestinal Tube was removed on 3/11/25 during an outpatient appointment. 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: Any resident who updates their POLST (Physician Orders for Life-Sustaining Treatment) to include no artificial means of nutrition following the surgical implementation of a Gastrointestinal Tube may be affected by this practice. No other residents were affected by this practice. On 3/13/25, Medical Records completed a facility-wide audit of resident POLSTs, identifying and correcting any issues. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/17/25, the Medical Records Director initiated in-service training for nursing staff on the proper POLST process, including order updates. Medical Records will conduct daily audits, Monday through Friday, of the POLST Binder at each station to ensure the timely completion of any updated POLST orders. How the facility plans to monitor its performance to make sure that the solutions are sustained: Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. If 95% compliance is achieved after 90 days, the issue will be resolved within QAPI. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 18th, 2025.
Failure to Report Change in Condition and Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to recognize and report a change in condition for a resident with a surgical wound on her upper left leg. On 3/29/24, the resident's left lower extremity was noted to be swollen, hard to touch, and red, indicating a potential infection. However, the physician was not notified of this change, which was a requirement according to the facility's policy. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the physician should have been informed. Additionally, the facility did not conduct weekly skin wound evaluations as required by their policy. The resident's weekly skin and wound evaluations were incomplete, with no documentation for the week of 4/1/24. This lapse in monitoring meant that changes in the resident's wound condition were not consistently tracked, potentially delaying necessary interventions. The Director of Nursing confirmed that the evaluations were not performed as required. Furthermore, the facility failed to carry out a physician's order for an antibiotic prescribed by the resident's vascular surgeon. On 4/10/24, the surgeon ordered Augmentin for the resident, but this order was never implemented. There was also no documentation of the resident's departure for or return from the appointment with the vascular surgeon, nor any follow-up on the new orders. The Administrator confirmed that the antibiotic order was not started, and there was a lack of documentation regarding the resident's appointment and subsequent orders.
Inadequate Care Plans and Supervision Lead to Resident Hazards
Penalty
Summary
The facility failed to ensure that the care plans for two residents, Resident 250 and Resident 303, were adequately developed and implemented to prevent accidents and hazards. Resident 250, who was known to have restless and aggressive behaviors, was at a high risk for falls due to dementia and an active urinary tract infection. Despite multiple falls and a severe head injury requiring hospitalization, the facility did not re-evaluate past interventions or develop individualized strategies to address the root causes of the falls. The use of Ativan for restlessness was not effective, and the facility did not consider 1:1 supervision until after multiple falls had occurred. Resident 303, who was not identified as a smoker upon admission, was observed smoking on the sidewalk and off-campus without the facility's knowledge. The facility failed to conduct a smoking safety evaluation upon admission, and Resident 303 was not provided with a smoking apron despite being identified as needing one. Additionally, the path used by Resident 303 to smoke off the property had a large pothole, posing a potential hazard. The facility's lack of safety interventions for Resident 303 increased the risk of injury related to smoking. The facility's policies and procedures were not effectively implemented, as evidenced by the lack of timely assessments and interventions for both residents. The Director of Nursing and Assistant Director of Nursing confirmed that the interventions in place were not effective and that the interdisciplinary team meetings did not adequately address the residents' needs. The facility's failure to provide adequate supervision and safety measures resulted in repeated falls and potential hazards for the residents involved.
Failure in Pain Management for Resident with Contractures
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with contractured legs, leading to severe pain during brief changes. The resident, who had poor cognition and was dependent on staff for toileting hygiene, experienced significant pain and anxiety when her brief was changed. Staff were observed forcing the resident's contractured legs apart, causing her to scream in pain, breathe heavily, and exhibit signs of distress such as grimacing and crying. Despite the resident's clear expressions of pain, staff continued to handle her in a manner that exacerbated her discomfort. The facility's pain management policy required staff to identify causes of pain, implement strategies to manage it, and monitor or modify approaches to ensure adequate control. However, the staff did not evaluate alternative methods for managing the resident's incontinence that would minimize pain. Interviews with various staff members, including CNAs and nurses, confirmed that the resident's pain during brief changes was a known issue, yet no effective measures were taken to address it. The care plan for the resident did not include specific interventions to manage her pain during brief changes, and there was no evidence of staff training on handling residents with contractures. The facility's lack of communication and coordination with the hospice team further contributed to the deficiency. The hospice nurse was unaware of the resident's pain level during brief changes, indicating a breakdown in communication between the facility and hospice care providers. The Medical Director acknowledged the ineffective communication and expressed the need for better problem-solving strategies. Overall, the facility's failure to adhere to its pain management policy and lack of appropriate interventions resulted in ongoing pain and distress for the resident.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. One resident reported an uncomfortable mattress with a hole in the middle, which had been an issue since their admission. Despite the resident's complaints, the facility had not replaced the mattress, even though new mattresses had been ordered and received. This indicates a lack of timely response to the resident's needs, contributing to their discomfort. Additionally, the facility did not maintain appropriate room temperatures in resident areas, such as shower rooms and the dining room, which were below the recommended range of 71-81 degrees Fahrenheit. The heating systems in these areas were not connected to thermostats, requiring manual operation by staff, which led to inconsistent temperatures. The maintenance team acknowledged the issue and the presence of unfinished projects, such as exposed walls and insulation, and broken tiles in shower rooms, further contributing to an uncomfortable environment for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Wheelchairs for multiple residents were found visibly unclean, with dried food substances, crumbs, and dust, indicating a lack of regular cleaning and maintenance. The facility's policy required that resident-care equipment be cleaned according to CDC recommendations, but records showed that wheelchairs had not been cleaned for several months. Interviews with staff confirmed the unclean state of the wheelchairs and the need for regular cleaning to prevent infection. Additionally, the facility did not appropriately store oxygen tubing for a resident with chronic respiratory conditions. The tubing was observed lying on the floor instead of being stored in an anti-microbial bag as per the facility's policy. This improper storage was confirmed by staff, who acknowledged the need for proper storage to prevent contamination. Furthermore, personal hygiene products for residents were not stored correctly, with items left uncovered and in inappropriate locations, such as beside food and water, contrary to the facility's infection control policy. The facility also failed to ensure proper hand hygiene practices among staff. A CNA was observed touching her face and then assisting residents with their meals without washing her hands, which was against the expected hand hygiene protocol. This lapse in hand hygiene was acknowledged by the CNA and the Infection Preventionist, highlighting a breach in infection control practices. These deficiencies collectively posed a risk for the spread of infection within the facility.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications, resulting in several deficiencies. One incident involved a resident who found a pain pill at her bedside upon waking. The resident, who had a history of dysphagia, aphasia, and anxiety disorder, was on a pureed diet and required assistance with medication administration. A Licensed Nurse (LN) had left a Norco pill at the resident's bedside without verifying its ingestion, causing the resident anxiety and concern over the lack of supervision during medication administration. The Director of Nursing (DON) confirmed that the nurse should have stayed with the resident until the pill was swallowed. Additionally, the facility did not implement its medication storage policy for two out of five sampled medication carts, leading to expired medications being available for use. Observations revealed expired insulin pens and ophthalmic ointments in the carts. Furthermore, the facility's narcotic disposal logs were inaccurately maintained, with missing signatures of licensed nurses in several instances, which could potentially allow for drug diversion. The DON acknowledged the missing signatures and the presence of expired medications in the carts.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident 44, who was observed lying in bed with her back and chest exposed due to an open room door and privacy curtains. Despite the resident's intact cognition and preference for privacy, staff did not adequately cover her after wound treatment, leaving her exposed to passersby and her roommate. This lack of privacy was acknowledged by a CNA who later covered the resident with a blanket, admitting that the exposure was inappropriate. Resident 68 experienced a lack of assistance with toileting and meal preferences, which compromised her dignity and comfort. Despite requiring staff assistance for toileting due to her medical conditions, including osteoarthritis and muscle weakness, staff failed to provide necessary help, resulting in the resident waking up wet and cold. Additionally, during breakfast, a CNA refused to accommodate the resident's request for a biscuit instead of an English muffin, leading to a loud argument that was not intervened by the observing LN. Interviews with staff, including the DON and DSD, confirmed that the actions and inactions of the staff were inappropriate and did not align with the facility's policies on resident dignity and respect. The DON acknowledged that arguing with the resident and failing to assist her with ADLs was disrespectful, while the DSD confirmed the resident's dependency on staff for daily activities, highlighting the lack of accommodation provided by the staff.
Call Light Accessibility Deficiency for Residents
Penalty
Summary
The facility's direct care staff failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 39, who has severe cognitive deficits and requires maximum assistance with activities of daily living due to conditions such as Parkinson's disease and dementia, was observed on multiple occasions with the call light out of reach, lying on the floor. Despite the care plan intervention to encourage the use of the call light for assistance, the resident was unable to access it when needed. Similarly, Resident 87, who has a severe cognitive impairment and is at risk for falls, was also found with the call light on the floor, out of reach. The resident's care plan included interventions to keep the call light within reach and to use a reminder sign to encourage its use. However, during observations, the call light was not accessible, and the resident was unable to call for assistance if needed. Staff interviews confirmed the oversight, acknowledging the importance of having the call light within reach, especially for residents at risk of falls.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident was observed holding the resident's hand inside his unzipped pants. This incident occurred during an ice cream social, where an Activities Assistant witnessed the inappropriate behavior. The assistant separated the residents and moved the offending resident away from other female residents. However, the incident was not reported to a superior until the following day, delaying the notification to the affected resident's family. The affected resident, who was unable to consent to sexual contact due to severe cognitive impairment, was admitted with diagnoses including dementia, anxiety disorder, and major depressive disorder. The resident's Brief Interview for Mental Status (BIMS) score indicated severe cognitive impairment, confirming the lack of mental capacity to consent. The resident's family was upset about the delay in notification, expressing that they would have come to the facility immediately if informed sooner. The resident responsible for the inappropriate behavior had a history of similar incidents, with a care plan addressing behaviors of touching female residents inappropriately. Despite interventions in place, such as separating the resident from female residents during activities, the incident still occurred. The facility's policy required immediate reporting of abuse, which was not followed, contributing to the deficiency in protecting residents from abuse.
Delayed Reporting of Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving Resident 22 and Resident 120 to the State Agency and the family within the mandated timeframes. The incident occurred when Resident 22 was seen with her hand in Resident 120's pants during an ice cream social. The abuse was not reported to the State Agency until more than 24 hours later, delaying the investigation and potentially allowing for ongoing abuse. Resident 22, who has severe cognitive impairment and lacks the mental capacity to consent to sexual contact, was involved in the incident. Her medical records indicate diagnoses of dementia, anxiety disorder, transient cerebral ischemic attack, and major depressive disorder. Resident 120, who has moderate cognitive impairment, has a history of inappropriate sexual behavior towards female residents and staff, as documented in his care plan. The delay in reporting was due to AA B, who witnessed the incident, not informing a supervisor immediately. The facility's policy requires immediate reporting of abuse, but AA B only reported the incident the following day. The family of Resident 22 was also not notified until a day and a half after the incident, causing distress to the family. Despite attending an abuse report training, AA B failed to adhere to the facility's internal reporting policies and procedures.
Inaccurate Resident Assessments for Continence and Smoking Status
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to potential inaccuracies in care planning and adverse health outcomes. Resident 68 was inaccurately assessed as continent in the Minimum Data Sets (MDS) despite documentation and interviews indicating she was occasionally incontinent, particularly at night. Certified Nursing Assistants (CNAs) documented instances of incontinence, and both the resident and staff confirmed her night-time incontinence. The Director of Nursing (DON) acknowledged the inaccuracy in the MDS assessments, confirming that Resident 68 was not continent of urine. Resident 303 was incorrectly assessed as a non-smoker in the Nursing-Admission/Readmission Evaluation/Assessment (NAREA), despite being a smoker who went off property to smoke. Interviews and observations confirmed that Resident 303 smoked outside the facility, and the Licensed Nurse (LN) responsible for the assessment admitted to documenting incorrectly due to the facility's non-smoking policy. The Administrator confirmed that the NAREA should accurately reflect a resident's smoking status to ensure appropriate treatment and care.
Failure to Provide Necessary Equipment and Medical Referrals
Penalty
Summary
The facility failed to meet professional standards of quality for two residents. Resident 69, who was admitted with right side hemiplegia following a stroke, dysphagia, an acquired absence of the left leg, heart disease, and major depressive disorder, did not receive the necessary Durable Medical Equipment (DME). Despite being measured for a wheelchair in September, the equipment was never delivered, and there was no follow-up by the therapy or nursing staff. This oversight resulted in Resident 69 remaining in bed due to discomfort and the inability to move independently, as confirmed by interviews with the resident, a CNA, the Rehabilitation Therapy Director, and the Administrator. Resident 68, admitted with bilateral osteoarthritis of the knee, morbid obesity, chronic respiratory failure, and muscle weakness, did not receive needed medical referrals. Despite expressing concerns about knee pain and the need for an IUD removal, the facility failed to arrange the necessary appointments. The Director of Nursing confirmed that the resident's physician had provided gynecology referrals on three occasions, but the appointments were never made, and no referrals were obtained for the resident's knee pain. This lack of action was attributed to the licensed nurses' responsibility to arrange the appointments, which they did not fulfill.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance for Activities of Daily Living (ADLs) for two residents, leading to deficiencies in care. Resident 69 was unable to get out of bed due to not having an appropriate wheelchair that met his specific needs. Despite being measured for a new wheelchair in September, it was not delivered, and there was no follow-up by therapy or nursing staff. As a result, Resident 69 remained in bed except for showers, which were also not provided as scheduled. The resident's medical record indicated he required substantial assistance with transfers, and his cognitive status was intact, allowing him to express his needs and frustrations. Additionally, Resident 69 did not receive the scheduled showers for January 2025, with only one shower documented and one refusal noted. The Director of Nursing confirmed the resident did not receive all scheduled showers, which were supposed to occur twice a week. The facility's policy indicated that residents should receive care to enable them to carry out ADLs, including hygiene and mobility, but this was not adhered to in Resident 69's case. Resident 68 also experienced a lack of assistance with toileting needs. Despite being dependent on staff for mobility and requiring assistance with a bed pan, staff members, including a CNA and a Licensed Nurse, believed she could manage independently. This led to instances where Resident 68 was left in discomfort due to incontinence at night. Interviews with staff revealed a misunderstanding of Resident 68's needs, with some staff members incorrectly assuming she could manage her toileting needs without assistance. The Director of Staff Development confirmed that telling Resident 68 to manage on her own was inappropriate and not in line with the facility's standards for resident care.
Inadequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for Resident 44, resulting in discomfort and dry, cracked, and peeling feet. The resident, who has a history of chronic obstructive pulmonary disease, morbid obesity, muscle weakness, reduced mobility, chronic pain, atrial flutter, and chronic kidney disease, was observed with dry, cracked, and peeling feet. The resident expressed a preference for Aquaphor cream to be applied to her feet and legs, but this was not done regularly by the staff. The facility's policy on Activities of Daily Living (ADLs) requires that residents receive appropriate care and services to support their ADLs, including skin care. However, the care plan for Resident 44, which included daily skin checks and lotion application, was not consistently followed. Nursing summaries indicated no new skin issues, but observations and interviews revealed that the resident's feet were in poor condition, and the resident reported that family members sometimes applied the cream instead of the staff. Interviews with staff members, including a Licensed Nurse, a Certified Nurse Assistant, and the Director of Staff Development, highlighted a lack of consistent foot care and communication regarding the resident's condition. The staff acknowledged the resident's dry and scaly feet but did not consistently follow through with the necessary care or documentation. The Director of Staff Development stated that chronic conditions should be care-planned and documented, but this was not adequately done for Resident 44.
Failure to Reposition Resident Leads to Skin Breakdown Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 123, was turned and repositioned as ordered to prevent skin breakdown and promote circulation. The facility's policy on repositioning, revised in 2013, outlines the importance of repositioning for residents who are immobile or dependent on staff for repositioning. Despite this, observations and interviews revealed that Resident 123 was not repositioned every two hours as required by her care plan and physician's orders. Resident 123 was admitted with multiple diagnoses, including dementia, diabetes, and severe cognitive deficits, making her totally dependent on staff for all activities of daily living. Her care plan specifically indicated the need for regular turning and repositioning to prevent skin breakdown. However, during observations, Resident 123 was found lying on her back for extended periods, with visible signs of redness and indentations on her skin from lying on wrinkled bed linens. Interviews with family members and staff, including CNAs and the Director of Nursing, confirmed that Resident 123 was not repositioned as required. Family members expressed concerns about the lack of repositioning, and staff admitted to not following the prescribed schedule. The Director of Nursing acknowledged the importance of repositioning to prevent pressure wounds and confirmed that the resident had not been turned as ordered.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to conduct annual performance evaluations for one of the two sampled Certified Nursing Assistants (CNAs), specifically CNA M. A review of CNA M's performance evaluations revealed that she had evaluations on November 10, 2021, and July 15, 2022. However, there were no evaluations found for the years 2023 and 2024 in her employee file. During an interview and record review on January 24, 2025, the Director of Staff Development confirmed that CNA M had not received an annual performance review since 2022, indicating that the facility was behind on conducting annual performance evaluations for CNAs. This deficiency had the potential to prevent CNAs from receiving ongoing education and inservices based on the outcomes of their annual reviews.
Medication Administration Errors in Facility
Penalty
Summary
The facility was found to have a medication error rate of 19.2%, significantly exceeding the acceptable threshold of 5%. This was observed during a survey where five medication errors were identified out of 26 opportunities. One notable incident involved a Respiratory Therapist (RT) who failed to follow the facility's policy for administering medications through a nebulizer. The RT did not wash hands before or after the procedure, did not explain the procedure to the resident, and failed to ensure the nebulizer mask was properly fitted, resulting in medication escaping for three minutes. The resident reported that the medication was ineffective, indicating a potential impact on their treatment. Another incident involved the administration of eye drops, where Licensed Nurses (LNs) failed to adhere to the facility's policy and manufacturer guidelines. The LNs did not instruct residents to look up or close their eyes, did not hold the inner canthus after administration, and did not wash their hands post-procedure. One LN admitted to forgetting the policy, while another did not follow it due to the resident's preference, despite the resident expressing a desire for the procedure to be done according to policy. Additional errors included a Registered Nurse (RN) leaving a resident's room before ensuring the resident had swallowed their medication, and a Licensed Nurse (LN) documenting the administration of a medication that was not given. These actions were confirmed as medication errors by the staff involved. The Director of Nursing (DON) acknowledged the need for staff to improve their medication administration competencies, highlighting a systemic issue in adherence to medication administration protocols.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in two sampled medication storage rooms, leading to disorganization and potential medication errors. During an observation, it was found that medication room number three contained both expired and non-expired medications stored together in the medication discard cabinet, along with medications intended for an incoming resident admission. A Licensed Nurse indicated that facility supervisors are responsible for checking and maintaining medication storage rooms but was uncertain about the frequency of these checks. In another observation, medication room number one was found to have enteric food supplies stored next to probiotics, multivitamins, and alcohol swabs, which is against the facility's policy. Additionally, wooden sticks and gauze were stored next to over-the-counter medications, and a current resident's mail package was found unlabeled in the same cabinet. The Director of Nursing acknowledged the disorganization and stated that the facility had reorganized the medication room cabinets following the survey team's findings.
Improper Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure proper storage and labeling of perishable food items for a resident, identified as Resident 98, who was medically vulnerable due to conditions such as stroke, poor nutrition status, and chronic obstructive pulmonary disease. During observations, it was noted that Resident 98 kept various perishable food items, such as sweet pickles, salsa, and mayonnaise, at his bedside instead of in the refrigerator, contrary to the facility's policy. These items were not labeled with opened or use-by dates, and some had expired. Despite staff efforts to encourage Resident 98 to store his food properly, he refused, citing his rights. Additionally, the facility failed to follow the manufacturer's instructions for descaling and sanitizing the ice machine. The maintenance staff used products not approved by the ice machine's manufacturer, Manitowoc, which could lead to contamination. The maintenance team acknowledged using the wrong solutions, which was confirmed during an interview with the Registered Dietitian, who stated that the descaling and sanitizing should adhere to the manufacturer's guidelines. These deficiencies posed a risk of foodborne illness to Resident 98 and other residents using the ice machine. The facility's policies and procedures were not adequately enforced, leading to potential health hazards due to improper food storage and maintenance practices.
Failure to Implement Smoking Safety Policies
Penalty
Summary
The facility failed to establish and implement policies regarding smoking safety for Resident 303, who was not identified as a smoker despite smoking off the facility property. The facility's policy did not account for residents who smoked off property, leading to a lack of identification and management of smoking materials such as cigarettes and lighters. Resident 303 was observed smoking on the sidewalk in front of the facility, and his admission assessment incorrectly documented him as a non-smoker. This misidentification was due to a misunderstanding by the licensed nurse, who believed that all residents should be identified as non-smokers in a non-smoking facility. Additionally, the facility did not monitor or manage Resident 303's smoking materials, which he kept unsecured in his room. The facility also failed to conduct a timely smoking evaluation to assess Resident 303's ability to smoke safely, despite evidence of cigarette burn holes in his clothing. The medical director acknowledged that a smoking evaluation should have been conducted upon admission to ensure safety, but this was not done until 14 days later. These oversights resulted in an unsafe environment for Resident 303.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure competent nursing care for a resident who experienced a significant change in condition. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and hypertension, exhibited a dangerously low blood pressure reading of 70/46, which was not addressed appropriately by the nursing staff. Despite the abnormal vital signs and the resident's refusal to eat lunch, the attending licensed nurse did not retake the blood pressure or notify the physician, assuming the initial reading was an error. The resident's condition continued to deteriorate throughout the day, leading to an emergency transfer to the hospital. Interviews with staff revealed that the certified nursing assistants had reported the resident's poor condition and abnormal vital signs to the licensed nurse, who failed to act on this information. The Director of Nursing confirmed that the licensed nurse did not document the change in condition until twelve days later and had not been evaluated for competency upon hiring. This lack of timely intervention and documentation potentially compromised the resident's safety and well-being.
Failure to Provide Certified Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a resident who only spoke Spanish, as they did not provide a certified interpreter during a room change. The resident, who had difficulty walking and multiple fractures, was moved from one station to another due to COVID-19 cases. However, she did not understand the reason for the move and was confused because there were also COVID-19 cases in the new location. The facility's policy required competent oral translation of vital information, but the staff used Spanish-speaking CNAs who were not certified interpreters. Interviews revealed that the facility relied on staff members who spoke Spanish rather than using a professional language line service. The administrator admitted that while many staff members could speak Spanish, there was no certification to prove their competence or training in medical terminology. The administrator also acknowledged uncertainty about the availability of Spanish-speaking staff on every shift and whether adequate training had been provided for using the language line service.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a written notice to a resident regarding a room change, as required by their policy. The policy mandates that residents receive at least a one-day advance written notice, including the reason for the change. However, the resident was only informed verbally about the move due to COVID-19 cases on her previous station and was given approximately a one-hour notice instead of the required one-day written notice. This lack of proper notification led to the resident being confused and upset about the move. Interviews with staff members, including a Certified Nursing Assistant and the Business Marketer, confirmed that the resident was visibly upset and crying after the room change. The Social Services Director acknowledged that the facility had stopped providing written notices for room changes because residents were reluctant to sign them, despite the policy requirement. This deviation from the policy negatively impacted the resident's emotional and psychosocial well-being.
Resident Privacy Violation During Ombudsman Call
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to a telephone for private communication, specifically when speaking with the Ombudsman. The facility's policy on resident telephone use, revised in February 2021, states that telephones should be available in areas that offer privacy. However, during an incident, a Business Marketer (BM) overheard a resident's conversation with the Ombudsman from the hallway and entered the resident's room, taking over the call. This action was witnessed by a Certified Nursing Assistant (CNA), who noted that the resident was unable to speak privately about her concerns regarding a room change. The resident, who had been admitted with diagnoses including difficulty in walking and multiple fractures, expressed her upset over the room change to the Social Services Director (SD). The SD confirmed that the resident's right to privacy was violated when BM entered the room and took the phone. The Administrator also acknowledged that the resident was on speakerphone with the Ombudsman when BM intervened. This series of actions and inactions led to the deficiency, as the resident was not afforded the privacy to communicate her concerns without staff interference.
Facility Fails to Maintain Clean and Safe Bathrooms for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for eight residents, as observed in their bathrooms, which appeared dirty and in disrepair. The facility's policy, revised on 2/1/20, stated that bathrooms should be cleaned and disinfected daily, ensuring a sanitary environment for residents. However, during observations and interviews conducted on 8/1/24, several deficiencies were noted. Housekeeper C mentioned that rooms and bathrooms were cleaned daily, with inspections every other day, but the findings contradicted this claim. Specific observations included dark-colored splatter, gouged doorframes, and dirt on the floor in Resident 9's bathroom. In the shared bathroom of Residents 6 and 3, reddish-brown material was found on the light switch, and there were stained linoleum edges and chipped paint. The bathroom shared by Residents 4 and 2 had chipped paint, black scuff marks, and red-colored splatter. Resident 5's bathroom contained dirty bedpans, a toilet plunger, and cracked linoleum. Lastly, the bathroom shared by Residents 8 and 1 had dirty bedpans, a commode bucket, and various personal items improperly stored, along with dirt and cobwebs.
Failure to Obtain Consent for ENT Treatment
Penalty
Summary
The facility failed to involve a resident and their Responsible Party (RP) in a treatment decision, resulting in the resident receiving treatment from an Ear, Nose, and Throat (ENT) specialist without the RP's knowledge or consent. The resident, who was diagnosed with dementia, muscle weakness, dysphagia, anxiety, and depression, was deemed unable to make healthcare decisions, necessitating the involvement of an RP. Despite this, the RP was not informed of an ENT consultation, nor was consent obtained prior to the treatment, which included cerumen removal, nasal endoscopy, and laryngoscopy. Interviews and record reviews revealed that the Social Service Assistant (SSA) and Social Service Director (SSD) were unaware of the ENT visit and confirmed that there were no orders or documentation for the consultation in the resident's chart. The SSA admitted that the resident should not have been on the list for the ENT visit, as the RP had previously expressed a desire for the resident not to be seen by consulting physicians. The SSD confirmed that the treatment occurred without an order, RP notification, or consent, which was against the facility's policy on resident rights.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident, which is not in accordance with accepted professional standards. The deficiency involved a resident who experienced a change in condition, leading to a physician ordering medications. However, there were no nurse's notes documenting the resident's condition at the time of the medication order. The Assistant Director of Nursing confirmed that there was a lack of documentation regarding the resident's condition and the reason for the medication order. Additionally, a Licensed Nurse admitted to not documenting the resident's condition in the nurse's notes, despite recognizing the need for such documentation. Furthermore, the facility did not document a visit by an Ear Nose and Throat Practitioner for the resident, as well as for 20 other residents seen on the same day. The Social Service Director confirmed the absence of documentation for the ENT consult, which was only realized two months after the appointment. This lack of documentation could potentially prevent accurate information regarding the resident's medical care and condition from being available to the resident, their representatives, and other care providers.
Unsanitary and Unsafe Shower Rooms
Penalty
Summary
The facility failed to ensure that resident shower rooms on Station 1 and Station 2 were safe, sanitary, and comfortable. Observations revealed that the floor tiles had black and brown areas in the grout, and the wall tiles in the shower corners were cracked and covered with a black substance. Certified Nursing Assistant (CNA) A confirmed the presence of broken tiles and a black substance in the cracks and corners of the wall tiles and the shower floor. Housekeeper (HSK) also confirmed the presence of a black substance in the corners and cracks in the tiles, noting that the caulking had worn away. The Director of Nurses (DON) and Infection Preventionist (IP) confirmed the unsanitary conditions during their observation. The facility's policies on safety and cleaning were reviewed, indicating that environmental surfaces should be disinfected regularly and that the facility should comply with governmental health and safety requirements. However, the observations and interviews revealed that the shower rooms were not maintained according to these policies. The Assistant Director of Nursing (ADON) and DON confirmed that the shower rooms on both stations were in poor condition due to broken tiles and mold, which had not been addressed for some time.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to provide a safe environment free from abuse for Resident 10 when Certified Nursing Assistant 2 (CNA 2) verbally abused the resident. Resident 10, who had diagnoses including hemiplegia and hemiparesis following a stroke, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, reported that CNA 2 made hurtful comments about their weight, health status, and personal hygiene, causing emotional distress. This incident was witnessed by CNA 1, who provided therapeutic listening to the upset resident and reported the abuse to Registered Nurse 1 (RN 1). Despite being instructed by RN 1 to avoid Resident 10, CNA 2 re-entered the resident's room and continued to speak harshly, further distressing the resident. RN 1, who was the Charge RN on the day of the incident, heard raised voices from Resident 10's room and intervened by consoling the resident and instructing CNA 2 to stay away from the resident. However, RN 1 did not immediately suspend CNA 2 or notify other administrators, allowing CNA 2 to continue working the rest of the shift and the following day. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the incident until the following Monday, at which point CNA 2 was suspended and later terminated. The facility's policy on abuse investigation and reporting was not followed, as it requires immediate suspension of any employee accused of resident abuse pending investigation. CNA 2 had a history of complaints and disciplinary actions, including a recent write-up for failure to perform walking rounds. Despite having received training on elder abuse, CNA 2's actions led to significant emotional distress for Resident 10, highlighting a failure in the facility's abuse prevention and response protocols.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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