Arden Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 3400 Alta Arden Expressway, Sacramento, California 95825
- CMS Provider Number
- 055855
- Inspections on file
- 69
- Latest survey
- March 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arden Park Post Acute during CMS and state inspections, most recent first.
A resident with COPD was receiving continuous oxygen therapy without a physician's order, contrary to the facility's policy. Despite being cognitively intact, the resident's records showed conflicting information about oxygen use, and interviews with nursing staff revealed a lack of clarity on the initiation of the therapy.
A resident with mild memory impairment and hemiplegia was physically abused by a CNA, resulting in a cut on the nose and a bruise under the eye. The incident occurred after the resident requested assistance and expressed a preference not to be helped by the CNA due to rough handling. The CNA allegedly became angry, yanked the call button from the resident's hand, and subsequently hit the resident with it, followed by a punch to the face. The resident's roommate confirmed the altercation and derogatory remarks made by the CNA.
A facility failed to ensure proper infection control when an LPN did not disinfect a shared glucometer between uses for two residents with diabetes mellitus. The LPN was unaware of the requirement, and the DON confirmed the expectation to disinfect with bleach to prevent cross-contamination. The facility's policy also required cleaning and disinfecting between uses.
A resident with dementia and a G-tube experienced two incidents of G-tube dislodgement during ADL care due to the facility's failure to follow the care plan. The care plan required a licensed nurse to be present during ADL care to monitor the G-tube, but on both occasions, the G-tube was dislodged, leading to the resident's transfer to the hospital. The nurse on duty was not supervising the CNA during the second incident, contributing to the deficiency.
A resident, identified as high risk for falls, fell from a power chair in an unsafe area of the facility's driveway, resulting in a head injury and hospital transfer. Despite the facility's policy for supervision and safety, the resident was unsupervised and allowed to use a power chair, which was later removed after a previous fall. Staff acknowledged the area was hazardous and in need of repair.
The facility failed to maintain food safety standards, with an unclean ice machine, improperly stored kitchenware, and incorrect food labeling and storage. The resident's food refrigeration unit had expired and improperly stored food, and staff were unable to correctly perform dishwashing and sanitizing procedures. These issues were confirmed by the dietary manager and registered dietitian, indicating a lapse in adherence to food safety protocols.
The facility failed to maintain proper pharmaceutical services, as expired glucagon emergency medications, ear wax drops, and COVID test kits were found in the medication room. Additionally, a discharged resident's medication was not properly disposed of, and a discrepancy in narcotic administration records was identified. The DON and ADON were responsible for monitoring these areas but failed to address these issues until discovered during the survey.
A facility failed to maintain a medication administration error rate below five percent, with errors involving two residents. One resident did not receive insulin and bowel care medication as ordered, and another resident did not receive the correct dose of Vitamin D. The errors were confirmed by an LPN and the DON emphasized the importance of verifying medication orders and documentation.
Two residents experienced significant medication errors in an LTC facility. A resident received only 2 units of Humalog insulin instead of the ordered 4 units, while another resident received five duplicate doses of Baclofen due to unclarified duplicate orders. The facility's policies on medication administration and error reporting were not followed.
The facility failed to ensure food service personnel had the necessary skills for safe and effective food and nutrition services. Dietary Aide 2 was observed using improper cleaning procedures and could not verify sanitizer concentration. The Dietary Manager confirmed incorrect practices, and the Registered Dietitian acknowledged the need for better staff education. Despite having completed job competency and orientation training, DA 2 was unable to demonstrate the required skills during the survey.
The facility failed to follow prescribed dietary menus, affecting residents with specific dietary needs. Residents on CCHO diets received incorrect bread and dessert portions, while those on fortified diets missed additional nutrients. Mechanical soft and regular diet residents received inappropriate dessert textures. These discrepancies were confirmed through staff interviews and menu reviews.
The facility failed to maintain proper infection control for eight residents, with issues such as undated and improperly stored medical equipment, lack of hand hygiene by staff, improper disposal of sharps, and a visitor not using PPE in an isolation room. These deficiencies posed potential infection risks, as confirmed by staff and observations.
The facility failed to meet the required 80 square feet per resident in 45 rooms, with most rooms measuring only 74.3 square feet. Despite this, residents and staff reported no issues with space, although one nurse noted potential difficulties with mechanical lifts. The Administrator acknowledged some rooms were not included in the waiver, and the Department recommended continuing the waiver for these rooms.
A resident experienced verbal abuse from a roommate, leading to emotional distress and a delayed room change. Despite reporting the incident, the facility staff did not immediately separate the residents or report the abuse, contrary to the facility's policies. The affected resident, with a history of anxiety and depression, felt unsafe until the room change was facilitated the next day.
The facility failed to ensure informed consent for medications was correctly obtained for two residents. One resident received Clozapine for schizophrenia, but the consent form incorrectly indicated it was for anxiety. Another resident's Buspirone dosage was increased without documented informed consent. These errors were confirmed by the Pharmacy Consultant and DON, highlighting a lapse in following the facility's policy on psychotropic medication use.
Two residents experienced deficiencies in their living conditions due to the facility's failure to maintain a homelike environment. One resident's bathroom was in disrepair with a torn baseboard and discoloration, while another resident's bedside table was chipped and peeling. Both issues were not reported in the maintenance log, and the DON confirmed these conditions were unacceptable.
The facility failed to develop timely care plans for two residents, one using Clozapine for Schizophrenia and another with a hearing impairment. The care plan for the antipsychotic medication was delayed by nearly two months, while the hearing impairment care plan was developed 16 days post-admission. These oversights could impact the residents' well-being and care.
The facility failed to meet professional standards in medication administration and disposal. A nurse administered incorrect insulin dosage to a resident and improperly disposed of used medical supplies. Another resident with cognitive impairment was left with medication at bedside, contrary to policy.
A resident with diabetes and vision impairment did not receive timely vision services as ordered, including a referral to ophthalmology. Despite physician orders for glaucoma management and a referral to optometry, there was no follow-up on the ophthalmology referral. Staff interviews revealed a lack of communication and documentation regarding the resident's vision changes.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident developed a pressure injury after admission due to delayed intervention and inadequate repositioning, while another resident's existing wounds were not properly assessed upon admission, lacking necessary measurements. These failures increased the risk of infection and health decline.
A resident with osteoarthritis and upper extremity contractures did not receive necessary services to maintain mobility, as outlined in her care plan. Despite an OT evaluation recommending further services, no RNA order was in place, and the facility's policy on maintaining range of motion was not followed.
Two residents were administered psychotropic medications without proper monitoring and evaluation. One resident received Clozapine for schizophrenia without appropriate behavior and side effect monitoring, while another was prescribed Quetiapine for BPSD without adequate indication. Despite recommendations for dose reduction and psychiatric evaluation, these actions were not documented or implemented, leading to the continued use of potentially unnecessary medications.
The facility failed to maintain written agreements for dialysis services for two residents with chronic kidney disease and end-stage renal disease. Despite attempts by the Administrator to obtain the necessary contracts, they were not in place, contrary to the facility's policy requiring such agreements for outside services.
A resident was discharged from a facility without proper arrangements for home health services, resulting in an 8-day delay in receiving wound care and therapy. The case manager nurse claimed to have faxed the referral documents, but there was no evidence of this, and the home health agency did not receive the referral until six days later. The facility's discharge plan lacked specific details on when services were to begin, leading to a miscommunication and failure to meet the resident's needs.
A resident with ESRD missed multiple dialysis appointments due to transportation issues, and the facility failed to notify the responsible party or physician. The resident's severe memory loss and dependence on dialysis increased the risk of complications. Facility staff acknowledged the communication failure and the need for emergency intervention if treatments were missed.
A resident with chronic lung disorders was not provided care according to a physician's fluid restriction order, leading to excessive fluid intake. The facility failed to monitor and document the resident's fluid intake accurately, and the kitchen staff was unaware of the restriction. The resident's condition worsened, resulting in hospitalization. The facility's policy on fluid restriction was not adhered to, and no care plan was developed to address the resident's needs.
A resident with a history of wandering and cognitive impairment engaged in inappropriate behavior, including entering other residents' rooms unsupervised, leading to incidents of abuse and emotional distress. Despite complaints from residents about feeling unsafe, the facility failed to investigate or address these concerns adequately, resulting in a deficiency in protecting residents' rights.
A resident reported being slapped by another resident and later witnessed the same resident entering her room unsupervised, masturbating, and defecating on the floor. Despite the presence of staff during the first incident and video evidence of the second, the facility failed to report these allegations to state agencies as required by their policy.
The facility failed to investigate abuse allegations involving multiple residents, leading to feelings of fear and helplessness. Despite reports of incidents, staff did not take action, and the administrator was unaware of the allegations. The facility's policy on reporting and investigating abuse was not followed.
A resident with multiple sclerosis and paraplegia was unable to access a phone to contact her significant other or receive calls from a State Agency. Despite the facility having sufficient cordless phones, staff failed to provide one to the resident or connect her with outside callers. The facility's policy required residents to have access to telephones and assistance if needed, but this was not followed.
A facility failed to provide accurate documentation of ADL services for a resident, particularly regarding bathing. The resident's records showed missing documentation, and interviews revealed inconsistent charting of refusals and services offered. The resident appeared unkempt and reported not having a shower in eight weeks.
A resident with a high fall risk fell and sustained severe injuries due to inadequate supervision and an uneven surface in the smoking area. Despite being marked with caution signs, the area was not safe, leading to the resident's wheelchair tipping over and causing multiple cervical fractures.
The facility failed to ensure that a resident was treated with respect and dignity when a CNA was on the phone while providing care. The resident, who required assistance with toileting hygiene, reported that the CNA rolled his eyes and walked out without saying anything when she tried to explain her concerns. Other staff members were also reported to frequently use their phones during shifts. The facility's policy prohibits cell phone use in resident care areas and emphasizes treating residents with respect and dignity.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality for a resident who was receiving ongoing oxygen therapy without a physician's order. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), was observed using oxygen via nasal cannula at 2 liters per minute. Despite the resident's cognitive intactness, as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, there was no physician order documented for the oxygen use. The resident's clinical records showed conflicting information, with a weekly summary note indicating PRN (as needed) oxygen use and another note indicating continuous oxygen use. Interviews with licensed nurses revealed a lack of clarity and communication regarding the initiation and continuation of the resident's oxygen therapy. One nurse confirmed the absence of a physician's order and acknowledged that an order should have been in place. Another nurse, responsible for the resident's care, was unable to identify who initiated the oxygen therapy and confirmed that the resident had been on continuous oxygen for weeks. The facility's policy on oxygen administration, which requires a physician's order and proper documentation, was not followed, leading to this deficiency.
Resident Abuse by CNA Resulting in Physical Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in physical harm and emotional distress. A certified nursing assistant (CNA) was reported to have hit a resident in the face, causing a cut on the nose bridge and a bruise under the left eye. The incident occurred after the resident, who had mild memory impairment and hemiplegia, requested assistance and expressed a preference not to be helped by the CNA due to rough handling. The CNA allegedly became angry, yanked the call button from the resident's hand, and subsequently hit the resident with it, followed by a punch to the face. The resident reported feeling demeaned and expressed that the CNA mocked him, exacerbating his emotional distress. The incident was corroborated by the resident's roommate, who witnessed the altercation and confirmed the CNA's derogatory remarks. Staff interviews and record reviews indicated that the resident's injuries were not present prior to the incident, as confirmed by multiple staff members who had interacted with the resident before the event. The facility's policy on abuse prevention, which mandates residents' right to be free from abuse, was not adhered to, leading to this deficiency.
Failure to Disinfect Shared Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper infection control practices when a Licensed Nurse (LN 1) did not sanitize a shared glucometer between uses for two residents diagnosed with diabetes mellitus. Resident 1 was admitted in February 2025, and Resident 2 in January 2024, both requiring blood sugar monitoring as part of their diabetes management. On March 3, 2025, LN 1 used the same glucometer to check the blood sugar levels of both residents without disinfecting it between uses, which was observed during a survey. During an interview, LN 1 confirmed the failure to disinfect the glucometer and was unaware of the requirement to do so. The Director of Nursing (DON) stated that the expectation was for nurses to disinfect the glucometer with bleach between uses to prevent cross-contamination. The facility's policy, dated 2001, also indicated that blood glucose meters intended for reuse should be cleaned and disinfected between resident uses.
Failure to Follow Care Plan Results in G-Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the comprehensive person-centered care plan was not followed. The resident, who was admitted to the facility with multiple diagnoses including dementia, was dependent on assistance for Activities of Daily Living (ADLs) and had a gastrostomy tube (G-tube) for feeding. The care plan required a licensed nurse to be present during ADL care to monitor the G-tube and prevent it from being dislodged. On two occasions, the resident's G-tube was dislodged during ADL care. The first incident was documented in a Change in Condition Evaluation on January 27, 2025, when the G-tube was dislodged during ADL care. The responsible party expressed concern, and it was explained that licensed nurses would be instructed to be present during ADL care. Despite this, on February 16, 2025, the G-tube was again accidentally pulled out by a CNA while changing the resident's diaper, necessitating the resident's transfer to the hospital. Interviews with the licensed nurse on duty at the time of the second incident revealed that she was on a lunch break when the CNA notified her of the dislodged G-tube. The nurse confirmed that a licensed nurse was not supervising the CNA during the ADL care when the G-tube was dislodged. This lack of supervision and failure to adhere to the care plan contributed to the deficiency in care provided to the resident.
Resident Fall Due to Inadequate Supervision and Unsafe Environment
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident, resulting in the resident's fall and subsequent transfer to an acute care hospital. The resident, who was cognitively intact and used a motorized scooter, was identified as high risk for falls due to decreased muscular coordination, history of falls, visual impairment, and poor safety awareness. Despite these risks, the resident was allowed to use a power chair, which was later removed after an unwitnessed fall outside the facility. On the day of the incident, the resident was found on the ground with a bump and cut on the right forehead after falling from the power chair. The fall occurred in the facility's driveway, where a sewer cap was lower than the surrounding concrete surface, creating a hazard. The resident was returning from a convenience store and was not supervised, despite the facility's policy requiring residents to sign out when leaving the building. Interviews with staff revealed that the area where the fall occurred was known to be unsafe, and the Maintenance Supervisor acknowledged the need for repairs. The facility's policy emphasized the importance of making the environment free from accident hazards and providing appropriate supervision based on individual resident needs, but these measures were not effectively implemented for the resident involved.
Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain food safety standards in several areas, leading to potential food contamination risks for all 153 residents. The ice machine was found to be unclean, with a buildup of slimy and grainy substances, despite being scheduled for regular cleaning by both the maintenance supervisor and an outside vendor. The dietary manager and maintenance supervisor confirmed the presence of these substances, which were also verified by an outside vendor technician. The facility's policy required monthly cleaning of the ice machine, but the actual condition of the machine indicated a lapse in adherence to these standards. In the kitchen, various kitchenware items were improperly stored, with some being stacked while still wet and others containing food debris. Cooking pans were found with black substance buildup and deep scratches, rendering them unsuitable for use. Additionally, opened food packages in the dry storage, walk-in refrigerator, and freezer were not properly dated, and some were improperly stored, leading to freezer burn and potential contamination. The registered dietitian and dietary manager acknowledged these issues, which were in direct violation of the facility's policies on food storage and sanitation. The resident's food refrigeration unit also exhibited several deficiencies, including improper labeling and dating of food items, storage of partially eaten and expired food, and the presence of frozen foods in the refrigerator. The interior of the refrigerator was unclean, with a foul odor, and the dietary aide was unable to correctly verbalize the manual dishwashing process. Furthermore, the dietary aide improperly cleaned and sanitized food contact surfaces, failing to maintain the correct concentration of sanitizer solution. These failures were confirmed by the dietary manager and registered dietitian, highlighting a lack of adherence to established food safety protocols.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to maintain proper pharmaceutical services for its residents, as evidenced by several deficiencies. During an observation, expired glucagon emergency medications were found in the emergency supply kit, with expiration dates ranging from June to November 2024. Licensed Nurse 9 confirmed the presence of these expired medications and stated that best practice required nurses to check expiration dates before administering medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for monitoring medication rooms, but the expired glucagon was not removed until after it was discovered during the survey. Additionally, expired ear wax drops and COVID test kits were found in the central station medication room. Licensed Nurse 9 confirmed the presence of 12 boxes of expired ear wax drops and 28 expired COVID test kits. The facility's policy required nursing staff to maintain storage areas and contact the dispensing pharmacy for instructions on returning or destroying outdated medications. However, these expired items were not addressed until identified during the survey. The facility also failed to properly manage medications for discharged residents. Diclofenac sodium gel for a resident who had been discharged over a month ago was found in the medication room. The DON confirmed that the expectation was for licensed nurses to place discharge medications in a destruction bin. Furthermore, a discrepancy was found in the narcotic administration record for a resident, where a tablet of oxycodone-acetaminophen was not documented as administered in the electronic Medication Administration Record (eMAR). The DON stated that licensed nurses were expected to document narcotic administration on both the narcotic log and the eMAR.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as evidenced by five medication errors occurring out of 31 opportunities during medication administration for two residents. Resident 28 did not receive insulin according to physician orders, receiving only 2 units of Humalog insulin instead of the prescribed 4 units. Additionally, Resident 28 was administered only one Senna plus tablet instead of the ordered two tablets, and did not receive the prescribed Advair medication due to its unavailability. These errors were confirmed by Licensed Nurse 14 during interviews and record reviews. Resident 3 also experienced a medication error when they were given only one tablet of Vitamin D instead of the two tablets as ordered. The Director of Nursing confirmed that the expectation is for licensed nurses to check medication orders prior to administration and to document medication in the electronic medication administration record after administration. The facility's policy and procedure for administering medications emphasizes verifying the right resident, medication, dosage, time, and method of administration before giving the medication.
Medication Errors in Insulin and Baclofen Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 28, a licensed nurse administered only 2 units of Humalog insulin instead of the 4 units as ordered. The nurse signed for both insulin orders but only administered 2 units, which was confirmed during a follow-up interview. The facility's policy requires checking the medication order, preparing the insulin, and signing the medication record after administration, which was not followed in this case. Resident 56 received five duplicate doses of Baclofen due to a failure to clarify a duplicate order. The resident's clinical record showed that Baclofen was administered at a higher dose than ordered on multiple occasions. Despite nursing progress notes indicating a need for clarification of the duplicate order, there was no documented evidence that the facility reported the issue to the physician or clarified the order for five days. The facility's policy requires contacting the physician to discuss concerns about inappropriate or excessive dosages, which was not adhered to. The Director of Nursing confirmed that the nursing staff were expected to hold the medication and contact the physician immediately to clarify the dose. The facility's policy on administering medications emphasizes the importance of administering medications safely and documenting and reporting medication errors, which was not done in these instances.
Deficiency in Food Service Personnel Training and Sanitation Procedures
Penalty
Summary
The facility failed to ensure that food service personnel had the necessary skills to safely and effectively carry out the functions of the food and nutrition services. During an observation, Dietary Aide (DA) 2 was seen using a rag from a red bucket, which contained sanitizer solution, to wipe a heavily soiled countertop. DA 2 was unable to verbalize or demonstrate the correct procedure for cleaning and sanitizing food contact surfaces and could not verify the sanitizer concentration. The Dietary Manager (DM) confirmed that DA 2 should have used soapy water from a green bucket before using the sanitizer solution from the red bucket and that the sanitizer solution should be changed every two hours or when it becomes cloudy. Further interviews revealed that the facility had not conducted an in-service training for staff on the procedure for cleaning and sanitizing food contact surfaces. The Registered Dietitian (RD) acknowledged the need for improved staff education and stated that the sanitizer concentration should be at least 200 ppm. A review of DA 2's employee file showed that DA 2 was hired with a valid food handler certificate and had completed job competency and orientation training. However, the facility's documents indicated that the Food and Nutrition Services Director is responsible for instructing employees in sanitation fundamentals, and each employee should know how to clean equipment in their work area. Despite this, DA 2 was not able to demonstrate the required competency during the survey.
Dietary Menu Non-Compliance
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents with specific dietary needs during lunch meals on two consecutive days. On the first day, five residents on consistent or controlled carbohydrate (CCHO) diets received a full slice of bread instead of the prescribed half slice. Additionally, a resident on both CCHO and renal diets was served white rice instead of the required brown rice. These discrepancies were observed during a dining observation and confirmed through interviews with the registered dietician (RD) and a review of the facility's menu spreadsheet. On the following day, further dietary inconsistencies were noted during meal service distribution. Four residents on fortified diets did not receive the additional butter and cheese specified for their meals. Twenty-one residents on CCHO diets were given a full serving of dessert instead of the prescribed half serving. Furthermore, six residents on mechanical soft texture diets received regular texture desserts, while nineteen residents on regular diets were served mechanical soft texture desserts. These issues were confirmed through interviews with dietary staff and a review of the facility's menu documentation. The dietary manager (DM) acknowledged the errors in meal preparation and distribution, confirming that the meals served did not align with the dietary requirements outlined in the facility's menu spreadsheet. The RD also noted the need for staff to follow the recipes and menu guidelines to ensure compliance with residents' dietary needs. The facility's job descriptions for the dietary manager and registered dietician emphasize the importance of adhering to nutritional and quality standards, which were not met in these instances.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control for eight residents, leading to potential infection risks. Resident 129's nebulizer mask and tubing were found on the floor and not labeled with the date of change, which was confirmed by multiple staff members as a contamination risk. Similarly, Resident 13's nasal cannula was undated and improperly stored, and Resident 361's BIPAP machine and mask were found on the floor and not stored in a protective bag, increasing the risk of infection. Resident 14's oxygen mask was undated and improperly stored, and the oxygen humidifier was outdated by six months, posing a risk of contamination. Resident 41's nebulizer mask and tubing were also found on the floor and undated, while Resident 96's nasal cannula was observed on the floor, both situations confirmed by staff as potential infection risks. Additionally, licensed staff failed to sanitize equipment and perform hand hygiene when entering and exiting Resident 28's room, and used lancets and glucose strips were not disposed of in biohazard sharps containers. A visitor entered and exited Resident 16's room without proper PPE, despite the room being under isolation precautions, which was confirmed by staff as a risk for spreading infections. The facility's policies and procedures for infection control, hand hygiene, and PPE use were not adhered to, leading to these deficiencies and potential risks of infection among residents.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 45 resident rooms met the required 80 square feet per resident, as observed during a survey. The Client Accommodation Analysis indicated that multiple rooms were below the required space, with most rooms measuring only 74.3 square feet per resident. Despite this, during interviews, several residents and staff members reported no issues with the space available in the rooms. However, one Licensed Nurse mentioned that CNAs might struggle in certain rooms when using mechanical lifts, and another resident expressed a desire to be moved to a different bed for better visibility. The Administrator acknowledged that some rooms were not included in the approved waiver, which had been the case since his tenure began. The Department recommended the continuation of the waiver for the rooms that did not meet the space requirement. Despite the lack of complaints from most residents and staff, the deficiency was noted due to the potential impact on care provision and quality of life, as the rooms did not meet the regulatory space requirements.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 311, from verbal abuse by another resident, Resident 312. Resident 311, who was admitted with diagnoses including prostate cancer, seizures, anxiety disorder, and depression, reported feeling unsafe and emotionally distressed after being subjected to racial slurs by Resident 312. The incident occurred during a verbal altercation over the television being on at night, which Resident 311 preferred due to claustrophobia. Despite Resident 311's request to be moved immediately, the room change did not occur until the following afternoon. Resident 312, who was moderately cognitively impaired with a history of stroke and traumatic brain injury, allegedly used racial slurs during the altercation. The facility's staff, including a Licensed Nurse (LN 5), were informed of the incident shortly after it occurred. However, the night nurse did not report the incident immediately or evaluate the need for an immediate room change, citing a lack of available rooms. The incident was only reported to Social Services the following day, and the room change was facilitated after Resident 311's family intervened. The facility's policies on abuse prevention and resident-to-resident altercations were not adequately followed. The policies require immediate reporting and investigation of abuse allegations and protection of residents from further harm. In this case, the night nurse's failure to report the incident promptly and assess the need for immediate separation of the residents contributed to the deficiency. The facility's response did not align with its policy to protect residents from verbal abuse and ensure their safety during investigations.
Failure to Obtain Correct Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed of the risks and benefits of their medications. For one resident with schizophrenia, the informed consent for Clozapine incorrectly indicated that the medication was for anxiety, not schizophrenia, and listed the target behavior as restlessness instead of auditory hallucinations. This error was confirmed by both the Pharmacy Consultant and the Director of Nursing, who acknowledged that the consent form provided incorrect information to the resident and their family. For another resident with an anxiety disorder, there was no informed consent obtained for an increase in the dosage of Buspirone from twice a day to three times a day. The Director of Nursing confirmed the absence of documented informed consent for this dosage change, which was contrary to the facility's policy requiring verification of informed consent for psychotropic medication changes. This oversight was identified during a review of the resident's clinical records and confirmed through interviews with facility staff.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, leading to deficiencies in their living conditions. Resident 142's bathroom was in disrepair, with the baseboard coming off and blackish discoloration observed, which the resident identified as mold. The Maintenance Supervisor confirmed the disrepair but denied the presence of mold, stating the baseboard needed replacement. There was no record of this issue in the maintenance log, indicating a lack of reporting and follow-up on maintenance concerns. Resident 109's bedside table was chipped and peeling, with the resident having used it for two months. A Certified Nursing Assistant confirmed the table's poor condition and acknowledged it was used for meals and drinks. However, this issue was also not reported in the maintenance log. The Director of Nursing confirmed the findings and stated that the conditions were unacceptable and not in line with the facility's policy for maintaining a homelike environment.
Failure to Develop Timely Care Plans for Antipsychotic Use and Hearing Impairment
Penalty
Summary
The facility failed to develop timely and person-centered care plans for two residents, which could potentially impact their well-being. Resident 147, who was admitted with a diagnosis of Schizophrenia, began receiving Clozapine for auditory hallucinations. However, the care plan for the use of this antipsychotic medication was not developed until nearly two months after the medication was started. The Director of Nursing acknowledged that the care plan should have been initiated as soon as the medication order and consent were obtained to ensure proper monitoring and intervention. Similarly, Resident 361, who was admitted with depression and muscle weakness, was noted to have a hearing impairment and used a hearing aid. Despite this, a care plan addressing the resident's hearing needs was not developed until 16 days after admission. Observations showed that the resident was not wearing the hearing aid, which affected communication. The Director of Nursing confirmed that the care plan should have been developed upon admission to ensure staff awareness and appropriate monitoring of the resident's hearing needs.
Deficiencies in Medication Administration and Disposal Practices
Penalty
Summary
The facility failed to ensure professional standards of quality in the administration of insulin for Resident 28. During an observation, a licensed nurse administered 2 units of Humalog insulin to Resident 28 based on a sliding scale, despite the physician's order indicating 4 units were required. The nurse signed the medication administration record before administering the insulin, contrary to best practices and facility policy, which state that the record should be signed after administration. This discrepancy was confirmed during interviews with the nurse and the Director of Nursing. Additionally, the facility did not adhere to proper disposal protocols for used medical supplies. During an observation, the same licensed nurse was seen discarding used glucose strips and lancets into a regular trash bin instead of a biohazard sharps container. This practice was acknowledged by the nurse and confirmed by the Director of Nursing, who stated that used lancets and strips should be disposed of in designated sharps containers, as per the facility's policy. The facility also failed to ensure the safe administration of medication for Resident 116, who has moderate cognitive impairment. A licensed nurse left an iron pill at the resident's bedside, which the resident later dropped and could not identify. The nurse confirmed leaving the medication at the bedside, which is against facility policy that prohibits leaving medications unattended. This incident was observed and confirmed during interviews, highlighting a lapse in following established medication administration procedures.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with type 2 diabetes mellitus and vision impairment, received timely vision services as ordered. The resident had several physician orders for ophthalmic solutions to manage glaucoma and a referral to optometry for an examination. Despite these orders, there was a lack of follow-up on the referral to ophthalmology after the resident was seen by an optometrist. The resident reported worsening vision, and interviews with staff revealed that there was no communication or documentation regarding changes in the resident's vision from October to November. The Director of Nursing stated that staff are expected to notify the physician of any changes or complaints and to follow through with physician orders. However, the Social Services Assistant confirmed that no follow-up was made on the ophthalmology referral, and the Medical Records Director could not find any nursing progress notes regarding the resident's vision during the specified period. The facility's policy on hearing and vision services requires employees to refer any identified need for vision services to the social worker, who is responsible for assisting residents in accessing necessary resources, but this process was not followed in this case.
Deficiencies in Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident 311, who was admitted with multiple diagnoses including prostate cancer and diabetes, developed a pressure injury to the sacrum after admission. Despite being identified as at risk for pressure injuries upon admission, the resident did not receive a low air loss mattress until several days later, which may have contributed to the development of the pressure injury. The resident reported not being repositioned every two hours as required, and the wound was not documented until several days after admission. Resident 318 was admitted with multiple diagnoses and had existing deep tissue injuries (DTIs) upon admission. However, the facility failed to conduct an accurate skin assessment, as no wound measurements were taken on the day of admission. The lack of initial wound measurements meant that changes in the condition of the wounds could not be accurately tracked. The facility's policy required skin assessments, including wound measurements, to be conducted upon admission, but this was not followed. The Director of Nursing acknowledged the deficiencies in both cases, confirming that the pressure injury for Resident 311 was facility-acquired and that the lack of timely intervention may have contributed to its development. For Resident 318, the failure to take wound measurements upon admission was recognized as a deviation from the facility's policy. These failures placed both residents at increased risk for infection and health status decline.
Failure to Maintain Range of Motion for a Resident
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion for Resident 27, who was admitted with unspecified osteoarthritis and had functional limitations in her upper extremities. The resident's care plan, revised in August 2024, indicated a self-care performance deficit related to left side weakness and contractures in the right hand, requiring extensive assistance. However, the intervention only included encouraging the resident to participate to the fullest extent possible, without specific therapeutic measures to address the contractures. Observations and interviews revealed that Resident 27 had been in the facility for many years and was unable to open her hands due to contracted fingers. An OT evaluation from March 2023 noted bilateral upper extremity contractures and recommended further OT services, which were not authorized by insurance. Despite the resident's expressed desire for therapy and worsening condition, there was no RNA order in place to address her needs. The facility's policy on resident mobility and range of motion, revised in July 2017, stated that residents with limited range of motion should receive treatments to prevent further decrease, which was not adhered to in this case.
Inadequate Monitoring and Evaluation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 147 was administered Clozapine for schizophrenia without appropriate monitoring of target behaviors and side effects. The orders for monitoring were incorrectly focused on anxiety rather than the intended schizophrenia symptoms, leading to a mismatch in the monitoring process. This oversight was confirmed by both the Pharmacy Consultant and the Director of Nursing, who acknowledged that the monitoring was not aligned with the medication's intended use. Resident 30 was prescribed Quetiapine for behavioral and psychological symptoms of dementia (BPSD) without adequate indication for its use. The resident's behavior monitoring was initially for physical aggression but was later changed to verbalization of terrifying dreams. Despite recommendations for a gradual dose reduction (GDR) and a psychiatric evaluation, there was no documented evidence of these actions being implemented. The Pharmacy Consultant and the Director of Nursing confirmed the lack of dose reduction and the absence of a psychiatric evaluation after the recommendation. The facility's policies on psychotropic medication use were not adhered to, as evidenced by the lack of proper monitoring and evaluation of the residents' conditions and medication needs. The interdisciplinary team failed to implement necessary evaluations and adjustments to the residents' medication regimens, resulting in the continued use of potentially unnecessary psychotropic medications. This failure to follow established protocols and guidelines contributed to the deficiency identified in the report.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources had written agreements in place, specifically for dialysis services for two residents. Resident 41, who was admitted with chronic kidney disease and required dialysis, was receiving dialysis services from a clinic without a formal agreement. Similarly, Resident 50, diagnosed with end-stage renal disease and dependent on dialysis, was also receiving dialysis services without an existing agreement with the dialysis center. This lack of agreements was identified during a review of the residents' records and confirmed through interviews with the facility's Administrator. The Administrator acknowledged the absence of contracts with the dialysis clinics and made attempts to obtain them, but was unsuccessful. The facility's policy required maintaining written agreements with agencies providing services to residents, which was not adhered to in these cases. The absence of these agreements could potentially lead to a lack of responsibility and accountability in the dialysis services provided to the residents.
Failure in Discharge Planning Leads to Delay in Home Health Services
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was discharged home without proper arrangements for home health services. The resident, who had a recent colostomy and a large surgical wound, was discharged with the expectation that home health services would be provided for wound care and therapy. However, the necessary arrangements were not confirmed, and the resident did not receive the required care for over eight days after discharge. The case manager nurse (CMN) was responsible for ensuring a safe discharge and claimed to have verbally discussed the resident's needs with the home health agency (HHA) and faxed the referral documents. However, there was no documented evidence of the fax being sent, and the HHA reported not receiving the referral until six days after the resident's discharge. The facility's nurse practitioner and assistant director of nursing were unaware of the delay in services, and the resident ran out of wound supplies provided upon discharge. The facility's discharge policy required a post-discharge plan to be developed with arrangements for follow-up care and services. However, the discharge plan for the resident did not specify when home health services were to begin, and there was a lack of communication and documentation to ensure the resident's needs were met. The administrator acknowledged a miscommunication and the inability to locate fax confirmation of the referral being sent.
Failure to Provide Consistent Dialysis Care
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with end-stage renal disease (ESRD). The resident missed multiple scheduled dialysis appointments due to transportation issues, specifically because transportation did not arrive or the resident was not transported due to being in a wheelchair instead of a gurney. These missed appointments were not communicated to the resident's responsible party or physician, which is a failure to adhere to the facility's policy on notifying changes in a resident's condition or status. The resident, who had severe memory loss and was dependent on renal dialysis, was at risk for serious medical complications due to these missed treatments. The facility's staff, including the unit clerk, licensed nurse, nurse practitioner, and director of nursing, acknowledged the lack of communication and the need for immediate action, such as sending the resident to the emergency room if multiple dialysis treatments were missed. The facility's policies on change in condition and care for residents with ESRD were not followed, contributing to the deficiency.
Failure to Follow Fluid Restriction Order for Resident
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following a physician's order for fluid restriction for a resident with chronic lung disorders. The resident was admitted in 2022 and had a physician order dated 6/28/24 for a fluid restriction of 1500 ml per day due to pulmonary edema. However, the resident's fluid intake flow sheet from 6/28/24 to 7/6/24 showed that the daily fluid intake consistently exceeded the prescribed limit. Additionally, the eMAR indicated that extra fluids were administered with medications, further surpassing the fluid restriction. The resident's nutritional risk assessment did not reflect the fluid restriction, and the kitchen staff was unaware of the order, leading to unrestricted fluid provision. The deficiency was further compounded by the lack of a care plan to address the resident's fluid restriction needs. On 7/6/24, the resident exhibited signs of fluid overload, including low blood pressure, reduced oxygen saturation, and lethargy, resulting in a transfer to the hospital. Interviews with the Registered Dietician and the Corporate Consultant confirmed the oversight in monitoring and documenting the resident's fluid intake. The facility's policy on fluid restriction, which required verification of physician orders and accurate documentation, was not followed, contributing to the resident's condition worsening.
Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect the rights of five out of eight sampled residents from mental and physical abuse by another resident. Resident 2, who had a known history of wandering and severe cognitive impairment, entered the rooms of other residents unsupervised, leading to incidents of inappropriate behavior. Despite complaints from residents about feeling unsafe and fearful due to Resident 2's actions, the facility did not adequately investigate or address these concerns. Resident 1 reported being slapped by Resident 2 in the hallway, and other residents, including Resident 3 and Resident 5, expressed fear and distress due to Resident 2's behavior. Resident 2's actions included entering rooms uninvited, attempting to touch residents, and causing emotional distress. The facility staff were aware of these incidents, but there was a lack of appropriate response and investigation, leaving residents feeling unprotected and vulnerable. On one occasion, Resident 2 entered the room of Resident 1 and Resident 4, where he engaged in inappropriate behavior, including masturbation and defecating on the floor. This incident was captured on video by Resident 1, who reported feeling scared and stressed. Despite the known risks associated with Resident 2's behavior, the facility did not implement adequate supervision measures, such as one-on-one supervision, until after the incident occurred. The facility's policies on abuse prevention and resident supervision were not effectively followed, contributing to the deficiency.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of abuse in accordance with section 1150B of the Act. This deficiency involved two incidents concerning Resident 1. In the first incident, Resident 1 reported being slapped by another resident, Resident 2, on the arm while walking in the hallway near the Nurse's Station. Despite staff being present and aware of the incident, no action was taken by the facility staff, and the incident was not reported to state agencies. Resident 1 expressed fear of Resident 2 and concern over what he might do. In the second incident, Resident 1 reported to the Assistant Director of Nursing (ADON) that Resident 2 entered her room unsupervised, masturbated, and defecated on the floor. Resident 1 provided video evidence of the incident, which showed Resident 2 standing inside her room with his pants down. The ADON claimed to have reported the incident to the state agency, but no fax receipt of the report was provided despite multiple requests. Resident 1 had a history of bipolar disorder, major depressive disorder, and chronic pain, with an intact cognitive status as per her Minimum Data Set (MDS) assessment. Resident 2 had diagnoses of dementia and brief psychotic disorder, with severely impaired cognitive skills for daily decision-making. The facility's policy required immediate reporting of abuse allegations to local, state, and federal agencies, but this was not adhered to in these cases.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy for four of seven sampled residents. Specifically, the facility did not ensure that an allegation of abuse and mistreatment involving one resident was timely and thoroughly investigated. This failure resulted in several residents feeling emotionally unsafe, violated, and helpless, as the alleged perpetrator was not restricted from accessing other vulnerable residents. Resident 1, who had an intact cognition, reported being slapped on the arm by another resident while walking in the hallway. Despite staff being present and aware of the incident, no action was taken to investigate or protect Resident 1, who expressed fear and a sense of being unprotected. Other residents also reported incidents involving the same alleged perpetrator, including being grabbed and having objects thrown at them, but did not report these incidents to staff due to a lack of confidence in the facility's response. Interviews with staff revealed a lack of awareness and action regarding the allegations. The facility's administrator was not informed of the incidents and had not reported them to state agencies. The facility's policy required all reports of resident abuse to be reported to local, state, and federal agencies and thoroughly investigated, which was not adhered to in this case.
Failure to Provide Resident Access to Telephone
Penalty
Summary
The facility failed to ensure reasonable access to a telephone for a resident, preventing her from contacting her significant other and being reached by the State Agency. The resident, who was admitted in the summer of 2023 with multiple sclerosis, paraplegia, and major depressive disorder, was observed without a phone in her room. Despite expressing a desire to make a call, the facility's phone was not brought to her. Multiple attempts by a surveyor to contact the resident through the facility's main line were unsuccessful, as calls were either placed on hold indefinitely or dropped. The facility had four cordless phones available, but the staff failed to provide one to the resident or connect her with outside callers. The receptionist confirmed that the issue was not a shortage of phones but rather the nurses not picking up calls at the stations. The facility's policy indicated that residents should have access to telephones and receive assistance if needed, but this was not adhered to, as evidenced by the resident's report of having to wait for extended periods to access a phone.
Inconsistent Documentation of ADL Services
Penalty
Summary
The facility failed to provide accurate documentation of Activities of Daily Living (ADL) services for a resident, specifically regarding bathing services. The resident's clinical record did not reflect that bathing services were offered according to the facility's protocol. This discrepancy was identified through a review of the resident's shower/skin assessments and shower task reports, which showed missing documentation for several periods. Additionally, the resident's care plan indicated a risk for skin breakdown due to refusal of ADL care, but there was no consistent documentation to support that bathing services were offered or refused during the specified periods. During observations and interviews, it was noted that the resident appeared unkempt, with oily and uncombed hair and long hairs on her face. The resident reported not having had a shower in eight weeks and stated that bed baths were not offered. Interviews with CNAs and licensed nurses revealed that the resident frequently refused showers, but the refusals were not consistently documented. The Director of Staff Development (DSD) acknowledged the inconsistency in shower sheet documentation and the lack of available records after a certain date. Further interviews with the Nurse Consultant and the Administrator confirmed that the electronic records marked bathing tasks as 'Not Applicable' without indicating whether the resident refused the services. The facility's policy on ADLs emphasized the importance of providing necessary care to maintain hygiene, but the documentation did not align with this policy. The inconsistency in documentation and the lack of clear records contributed to the deficiency in providing appropriate bathing services to the resident.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for Resident 2, resulting in a fall and subsequent transfer to an acute care hospital. Resident 2, who had a history of hemiplegia, hemiparesis, and cognitive impairment, was identified as a high fall risk. Despite this, the resident was allowed to navigate an uneven surface in a wheelchair without proper supervision, leading to the fall and severe injuries, including multiple cervical fractures requiring surgical intervention. On the day of the incident, Resident 2 was observed propelling herself in a wheelchair towards the smoking area, which had an uneven surface due to recent removal of a large palm tree. The area was marked with a caution sign and cones, but these measures were insufficient to prevent the accident. The resident's wheelchair tipped over the edge of the uneven pavement, causing her to fall and hit her head. Multiple staff members, including the Social Services Director and a CNA, witnessed the aftermath of the fall but were unable to prevent it. Interviews with staff and other residents revealed that the uneven surface had been a known hazard, and the facility had not taken adequate steps to ensure the safety of residents in this area. The Director of Nursing and the Administrator were unable to confirm if the fall was preventable, but other staff members, including a Licensed Nurse and the Maintenance Supervisor, indicated that the fall could have been avoided if the surface had been even and proper supervision had been provided. The facility's policy on safety and supervision was not effectively implemented, leading to this serious incident.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure that Resident 1 was treated with respect and dignity when a Certified Nursing Assistant (CNA 1) was on the phone while providing care. Resident 1, who was admitted with diagnoses including aftercare following joint replacement surgery, was cognitively intact and required assistance with toileting hygiene. The resident reported that CNA 1 rolled his eyes and walked out without saying anything when she tried to explain her concerns and was on the phone most of the time while giving care. Another resident also reported that several staff members frequently used their phones during mid and evening shifts, often making phone calls in resident rooms. Licensed Nurse 1 confirmed that CNA 1 was often disappearing during the PM shift, and the Human Resources Manager noted that CNA 1 had previous disciplinary actions for poor customer service and cell phone use while on the floor, which detracted from his responsibilities and professionalism. The facility's policy prohibits cell phone use while working in resident care areas and emphasizes the importance of treating residents with respect and dignity. The Director of Nursing (DON) and the Administrator (ADM) were informed of Resident 1's concerns, which included the way CNA 1 communicated with her and his use of the phone during care. The DON stated that CNAs are only to use their cellphones in case of a family emergency and that good customer service includes providing explanations to residents during care. The facility's policy on dignity, revised in February 2021, mandates that each resident be cared for in a manner that promotes their well-being, satisfaction with life, and self-worth. Staff are expected to speak respectfully to residents at all times and promptly respond to requests for toileting assistance. The failure to adhere to these policies and standards compromised Resident 1's dignity and sense of well-being.
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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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