Beachwood Post-acute & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1340 15th Street, Santa Monica, California 90404
- CMS Provider Number
- 056334
- Inspections on file
- 98
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Beachwood Post-acute & Rehab during CMS and state inspections, most recent first.
Two residents did not receive medications in accordance with physician orders and facility policy. One resident's medications were left at the bedside without staff observation, and the nurse documented administration without witnessing ingestion. Another resident received multiple medications over two hours late. The DON confirmed these practices did not follow required procedures for medication administration and monitoring.
A resident with multiple health conditions and assistance needs did not have a documented discharge care plan during admission or quarterly review, despite ongoing discussions about discharge. Staff interviews confirmed that discharge planning was discussed but not formally included in the care plan, contrary to facility policy requiring comprehensive and updated care plans based on resident assessments.
A resident with a recurring rash and the ability to make her own medical decisions was not offered her prescribed topical steroid medication because staff deferred to the refusal of her representative, who was not the authorized decision maker. Staff interviews confirmed that the resident was alert, oriented, and able to communicate, but was not consulted about her treatment, resulting in a violation of her right to participate in care decisions.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with significant cognitive impairment and a legal representative holding durable power of attorney did not receive requested medical records within the facility's required timeframe. The legal representative submitted written requests, but the Medical Record Director delayed release pending approval, contrary to facility policy requiring access within five days.
Two residents receiving enteral nutrition via gastrostomy tube were observed with the head of the bed positioned below the required 30-45 degrees during feedings, contrary to physician orders and facility policy. Nursing staff confirmed the improper positioning, which did not meet established protocols for safe tube feeding.
Staff referred to residents requiring feeding assistance as "feeders," despite facility policy prohibiting such labeling. Multiple residents with significant physical and cognitive impairments were identified in staff documents and discussions using this term. Interviews with CNAs and the DSD confirmed the practice, while the IDON highlighted the importance of addressing residents by name to maintain dignity.
The facility did not complete required annual evaluations and skills competencies for staff, failed to identify medication discrepancies, and had nurses unable to perform basic dosage calculations or use proper measuring tools when administering medications to two residents with severe cognitive impairment and complex medical needs.
Three residents experienced significant medication errors when nursing staff failed to administer insulin as ordered, did not identify discrepancies between prescribed and available medications, and used improper tools to measure and administer fiber supplements. Additionally, sampled nurses were unable to correctly perform basic dosage conversions, increasing the risk of medication errors.
Surveyors found that food in the kitchen and resident storage areas was not properly labeled, dated, or stored, with multiple items left unlabeled or expired, and unsanitary conditions such as dirty equipment and leaking pipes. Staff failed to follow facility policies for food handling, and a resident with complex medical needs was found with perishable food at bedside that should have been refrigerated.
Two residents were placed at increased risk of infection when staff failed to follow standard precautions and safe storage practices. A partially used saline vial was left at the bedside of a resident with respiratory conditions, and another resident's bedside drawer contained improperly stored tube feeding formula, a syringe, and food items next to a urinal with urine. Staff interviews confirmed these actions were not in line with facility infection control and food storage policies.
A broken safety handrail on the left side and a loose handrail on the right side of a shared shower room were observed, with a CNA reporting the left handrail had been broken for about two months and the maintenance supervisor unaware of the issues. Facility policy requires all equipment to be kept safe and operable, but these deficiencies were not addressed in a timely manner.
Three residents with intact cognition and significant ADL needs experienced repeated delays in call light response, especially during overnight shifts. These delays led to missed colostomy care, prolonged periods of being soiled, and residents having to seek help independently, causing distress and embarrassment. Staff and policy confirmed that call lights should be answered promptly, but this was not consistently done.
A resident with a history of cancer, gastrostomy, and chronic respiratory issues was found self-administering Jevity tube feedings without a physician's order or documented assessment of their ability to do so. Nursing staff were unaware of the contents at the bedside, and facility policy requiring assessment and physician approval for self-administration was not followed.
A resident with cognitive impairment and multiple medical conditions was placed in bilateral hand mittens based on a physician's order that lacked a documented reason for their use, contrary to facility policy. Both nursing leadership and record review confirmed the omission, which resulted in incomplete communication and monitoring instructions for staff.
A resident with diagnoses of schizophrenia, major depressive disorder, and diabetes was admitted and readmitted to the facility. Although a PASARR Level I screening indicated the need for a Level II evaluation due to serious mental illness, the evaluation was not completed because staff did not respond to multiple communication attempts. The DON confirmed the lapse, and the facility did not follow its policy to ensure all required screenings and evaluations were completed.
A resident with diabetes, COPD, and heart failure, who was at risk for skin breakdown, was not provided with podiatry services despite a documented referral and care plan intervention. The resident had not seen a podiatrist since admission, experienced pain from toenail growth, and staff interviews confirmed that no podiatry visit was scheduled or documented.
A resident with neuromuscular bladder dysfunction, heart failure, and severe dementia was found to have an unsecured indwelling urinary catheter, despite physician orders and facility policy requiring the use of a stabilization device. Observation and staff interview confirmed the catheter was not anchored, and review of records showed the omission was contrary to both the care plan and established procedures.
The facility failed to ensure a medication error rate below 5% when nurses did not identify a discrepancy between a physician's order and the medication on hand, and were unable to correctly perform basic dosage calculations or use proper measuring tools during medication administration for two residents with severe cognitive impairment and total care needs.
Surveyors found that unopened insulin vials for two residents were stored in a medication cart instead of a refrigerator, contrary to manufacturer requirements and facility policy. Both an LVN and the IDON confirmed that unopened insulin should be refrigerated to maintain its effectiveness.
A resident with significant medical needs and limited decision-making capacity was discharged home, but the facility failed to properly provide the required Notice of Medicare Non-Coverage (NOMNC) to the resident's representative. The responsible nurse left only one voicemail and did not follow up or send the notice by certified mail as required, resulting in incomplete notification and failure to inform the representative of appeal rights.
A resident with multiple serious health conditions experienced a change in condition, including fever, vomiting, and difficulty breathing. Staff failed to monitor and document vital signs every four hours as ordered, did not administer prescribed antibiotics in a timely manner, and did not notify the physician or escalate care when the resident was unable to provide a urine sample for testing. When the resident developed respiratory distress, there was a delay in calling 911 and a lack of assessment by an RN or ADON. The resident was later found in cardiac arrest and could not be resuscitated by paramedics.
A resident with multiple serious diagnoses did not receive a prescribed dose of Amoxicillin-Pot Clavulanate for a possible UTI because the medication was not available in the E-kit and was delayed in being obtained from the pharmacy. Nursing staff failed to administer the antibiotic as ordered, did not document its administration, and did not notify the physician of the missed dose. Staff were also unaware of the resident's change in condition and did not complete required vital sign monitoring.
A resident with multiple chronic conditions was transferred to a hospital, but the facility did not provide the required written notice of its bed-hold policy or offer the option to hold the bed, as confirmed by record review and staff interviews. The facility's policy required such notification regardless of insurance status, but no documentation or communication was provided to the resident or their representative.
A resident with multiple chronic conditions experienced a change of condition involving nausea and vomiting. Despite facility policy requiring 72-hour monitoring and documentation after such events, there was no documented assessment or follow-up during two morning shifts following the incident. Staff interviews and record review confirmed the absence of required monitoring and documentation.
A resident with multiple medical conditions, including a stage II pressure ulcer, was discharged without proper review of discharge instructions with the resident representative (RR). The RR was unsure of follow-up care for the pressure ulcer, as the instructions were not provided at the time of discharge. The facility's policy required discharge instructions to be given to the resident or responsible party, which was not followed.
A resident was not properly informed about their financial obligations and rights to dispute charges, leading to confusion over billing and a threat of eviction. The facility failed to provide monthly statements and information on how to appeal charges, violating the resident's rights.
A resident with a history of hemiplegia and on anticoagulant medication was not thoroughly assessed or monitored after a fall in the facility. The nursing staff failed to communicate and document the incident properly, leading to a delay in necessary medical evaluations. The facility's policy on fall follow-up was not adhered to, resulting in a deficiency in care.
A resident with paraplegia and a history of UTI was not provided timely incontinent care, as her brief was not changed since early morning, leading to a risk of infection. The CNA responsible cited workload as a reason for the delay, which was against the facility's policy requiring frequent changes to prevent UTIs.
A facility failed to monitor a resident's vital signs every shift as ordered by the physician for the entire month of January 2025. The resident, with a history of vascular Parkinsonism and other conditions, required assistance with daily activities. Despite the physician's order, no vital signs were recorded during the night shift. The Quality Assurance Nurse confirmed the oversight, which was contrary to the facility's policy on comprehensive assessments and care delivery.
The facility failed to ensure proper post-dialysis monitoring and documentation for two residents with ESRD. One resident's post-dialysis evaluation forms were left blank, and another resident's cloudy urine was not followed up on, despite communication from the dialysis nurse. This lack of documentation and follow-up was confirmed by the RN and DON, violating the facility's policy for ongoing assessment and communication.
A resident's representative was not informed of the resident's return from the hospital, despite the facility's policy requiring such communication. The resident, with multiple health conditions, was transferred to a hospital due to a low hemoglobin level. Upon return, the representative was not updated for 10 days, despite frequent calls, until the ADON finally provided the information. This was a violation of the resident's rights.
A resident with severe cognitive impairment and high fall risk was left unattended in a common area, resulting in an unwitnessed fall and nasal fracture. Despite the care plan requiring close observation, the resident's companion left without notifying staff, leading to the incident. The facility's policy on resident supervision was not followed.
A resident with a stage 2 pressure ulcer was not repositioned every two hours as required by their care plan, according to a review of the MAR for August 2024. The DON confirmed the lack of documentation meant repositioning was not done, contrary to the facility's policy, increasing the risk of the ulcer worsening.
A resident with spontaneous bacterial peritonitis was incorrectly administered Ciprofloxacin for a UTI due to a transcription error. The medication was intended for prophylactic use after dialysis, but the order was not properly uploaded or verified, leading to a medication error. The facility's policies on medication administration and order verification were not followed.
A resident identified as high risk for falls did not receive adequate fall precautions, leading to a fall and head injury. The resident, who required assistance with transfers and bed mobility, was not provided a two-person assist or fall mats as outlined in their care plan. During care, the resident fell from the bed, resulting in a subdural hematoma and hospitalization. Interviews revealed that fall precautions were not in place, and the CNA did not follow protocol, contributing to the incident.
A resident with a complex medical history was administered an incorrect dose of Heparin by an LVN, who gave 1ml instead of the prescribed 0.5ml for DVT prophylaxis. The error was identified by the resident's representative, leading to an investigation that revealed the LVN did not adhere to the facility's medication administration policy, which requires verifying the correct dose and other details before administration.
A resident with complex medical conditions underwent a straight catheter procedure twice in one week due to the facility's failure to obtain a timely physician order for a urine culture and sensitivity test. The initial urine sample expired because it was not sent to the lab within the required timeframe, delaying the diagnosis of a UTI.
A resident with chronic pain and dependency on staff for daily activities reported being roughly handled by a CNA during morning care. The incident was not reported to the state survey agency within the required two-hour timeframe, as confirmed by facility staff. The delay was attributed to multiple changes in the resident's condition that morning, despite the facility's policy mandating timely reporting of abuse allegations.
A resident with chronic constipation due to a spinal cord injury experienced unnecessary pain due to a delay in receiving Golytely medication. Despite notifying an LVN and obtaining a doctor's order, the medication was not administered timely due to pharmacy delivery schedules. The resident received the medication three days later, alleviating his symptoms. This delay violated the facility's policy for timely medication administration and placed the resident at risk for complications.
A resident with chronic constipation due to a spinal cord injury experienced unnecessary pain when a facility failed to administer Golytely in a timely manner. Despite notifying an LVN of the need for the medication, it took three days for the facility to provide it, due to pharmacy delivery schedules and unavailability. The delay placed the resident at risk for complications, highlighting a deficiency in adhering to the facility's medication administration and bowel management protocols.
A resident suffered a second-degree burn from a hot coffee left unattended by a CNA, who failed to assess or document the injury. Another resident experienced a skin tear and deviated nose due to inadequate accident prevention, with staff misreporting the incident. Additionally, environmental hazards were present, including an oscillating fan in a walkway and an unlocked wheelchair, highlighting the facility's failure to ensure safety.
A facility failed to document and report missing narcotics as per policy, risking medication loss and diversion. An LVN found two hydrocodone tablets missing from the medication cart but did not report it to the DON or RN supervisor. The DON was unaware of the issue and stated an investigation would be conducted. Facility policy requires immediate reporting of such discrepancies.
Expired BD Vacutainer Safety-Lok Blood Collection Sets and Bisacodyl were found in the medication storage area of an LTC facility. The RN Supervisor and DON were unaware of the expired items, which were not removed as per the facility's policy. The DON stated that monthly inspections are conducted to check for expired items.
The facility failed to ensure safe food storage and labeling, with expired and unlabeled items found in the kitchen and resident areas. Additionally, the kitchen environment was not maintained safely, with water leaks and unclean conditions observed. Staff interviews confirmed a lack of routine maintenance and cleaning, posing risks to residents and staff.
A resident's dignity was compromised when a wash basin with a soiled washcloth and toothbrush was placed on a toilet lid, increasing contamination risk. An LVN and the DON confirmed this practice was demeaning and against the facility's dignity policy.
The facility failed to maintain a safe and homelike environment for residents, as evidenced by a resident's room being too cold, another resident's room having removable dark spots on the floor, and a soiled wash towel and toothbrush being improperly placed on a toilet lid. These deficiencies were observed during a survey, highlighting the facility's failure to adhere to its policy of providing a clean, safe, and homelike environment.
A resident with multiple medical conditions, including chronic respiratory failure and dementia, did not receive adequate oral care, resulting in a very dry tongue and chapped lips. Observations and staff interviews confirmed the lack of proper oral care, despite facility policies requiring twice-daily care with chlorhexidine for tracheostomy residents to prevent infections.
The facility failed to reposition residents every two hours as required, increasing the risk of pressure ulcers. Multiple residents, including those with severe conditions like cerebral infarction and hemiplegia, were observed in the same position for extended periods, contrary to physician orders and facility policies. Staff interviews confirmed the lack of adherence to repositioning schedules, highlighting a significant deficiency in care practices.
Failure to Administer and Monitor Medications per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and facility policy for two residents. For one resident with diagnoses including type II diabetes mellitus, respiratory failure, and chronic kidney disease, medications were not administered at the scheduled times, and a medication cup containing three tablets was found at the bedside after the nurse had documented administration. The resident reported that medications were sometimes given late and that staff did not observe her taking them. The nurse confirmed leaving the medications at the bedside without witnessing ingestion and documented them as administered. Additionally, the facility did not complete a Self-Administration of Medication Observation Assessment for this resident upon readmission, as required by policy. The Director of Nursing confirmed that medications should not be left at the bedside and that nurses must witness administration, stating that any refusal or delay should be documented and the physician notified. The facility's policy requires medications to be administered in accordance with orders and within the required time frame, and only allows self-administration if the care team determines the resident is capable. For a second resident with hemiplegia, acute respiratory failure, and diabetes, multiple medications scheduled for administration at a specific time were instead given over two hours late. The Director of Nursing reviewed the records and confirmed the late administration, reiterating the requirement for timely medication administration per physician orders. These findings were based on observation, interview, and record review.
Failure to Document Discharge Planning in Resident Care Plan
Penalty
Summary
The facility failed to initiate and document a resident-specific discharge care plan during both the admission and quarterly review processes for one resident. The resident, who had a history of acute pulmonary edema, muscle weakness, anxiety disorder, type 2 diabetes mellitus, and bilateral primary osteoarthritis of the knee, required varying levels of assistance with activities of daily living, including transfers and toileting. Despite these needs and ongoing discussions about discharge, there was no evidence in the resident's care plan or Minimum Data Set (MDS) assessments that active discharge planning was occurring or documented. Interviews with facility staff, including a Licensed Vocational Nurse, Social Services assistant, MDS coordinator, and the Director of Nursing, confirmed that while discharge planning was discussed with the resident, it was not formally documented in the care plan during admission or quarterly review. The facility's policy required comprehensive care plans, including discharge planning, to be developed and updated based on assessments and changes in the resident's condition. The lack of documentation resulted in the absence of individualized discharge planning for the resident during transitions of care.
Failure to Honor Resident's Right to Self-Determination in Medication Administration
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and participation in care by not administering a physician-ordered topical medication, Triamcinolone Acetonide External Cream 0.1%, to the resident's right elbow. The resident, who was alert, oriented, and able to communicate through lip reading and nodding, had a recurring rash diagnosed as fungal dermatitis. Despite the resident's ability to make her own decisions, staff did not offer the medication to her, instead deferring to the refusal of her representative, who was not the designated decision maker. The resident expressed that the ointment provided relief from itching, but staff did not consult her directly regarding her preference for treatment. Interviews with facility staff, including a treatment nurse and the Assistant Director of Nursing, confirmed that the resident was capable of making her own medical decisions and should have been involved in her care planning and medication administration. The facility's policy on resident rights also emphasized the importance of resident involvement in treatment decisions. The failure to administer the prescribed medication and to involve the resident in her own care planning constituted a violation of her rights as outlined in facility policy and federal and state regulations.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon request, resulting in a violation of the resident's rights. A resident with a history of hemiplegia, hemiparesis following cerebral infarction, and major depressive disorder was admitted to the facility and was determined to be unable to make medical decisions. The resident's family member was appointed as the legal representative through a durable power of attorney for healthcare. The legal representative submitted a written request for the resident's medical records via fax and mail, but did not receive the records as of the date of the interview. The Medical Record Director confirmed that a request for release of medical records was received but had not been fulfilled, citing a need for approval. The facility's policy states that residents or their representatives must be granted access to records within five days of a written or oral request. Despite this policy, the records were not provided within the required timeframe, as confirmed by both the legal representative and the Medical Record Director.
Failure to Elevate Head of Bed During Enteral Feedings
Penalty
Summary
Two residents with gastrostomy tubes (GT) were not provided appropriate care during enteral feedings, as staff failed to elevate the head of the bed (HOB) to the required angle. For one resident with diagnoses including respiratory failure, dysphagia, and severe cognitive impairment, physician orders and the care plan specified that the HOB should be elevated 30-45 degrees during and after tube feedings. However, during observation, this resident was found receiving tube feeding with the HOB at approximately 15 degrees. A registered nurse confirmed that the HOB was too low and did not meet the required elevation. Similarly, another resident with Parkinson's disease, respiratory failure, dysphagia, and severe cognitive impairment was observed receiving tube feeding while lying on their side with the HOB at less than 30 degrees, nearly flat. The registered nurse confirmed the HOB was only about 20 degrees and acknowledged it should be higher during tube feeding. The facility's policy also required the HOB to be elevated at least 30 degrees during and after feedings. These observations demonstrated a failure to follow physician orders and facility policy for safe enteral feeding practices.
Failure to Maintain Resident Dignity by Labeling Residents Needing Feeding Assistance
Penalty
Summary
Facility staff failed to honor residents' rights to dignity and self-determination by referring to residents who required assistance with feeding as "feeders." This practice was observed for seven residents, all of whom required substantial or maximal assistance with activities of daily living (ADLs) due to various medical conditions such as muscle weakness, diabetes, COPD, hypertension, depression, and pressure ulcers. The residents' cognitive abilities ranged from moderately impaired to severely impaired, with one resident having intact cognition. During interviews, a CNA confirmed that staff maintained a list titled "Feeders" to identify residents needing feeding assistance, and routinely referred to these residents by this label. The Director of Staff Development also acknowledged that residents who needed help with feeding were called "feeders" by staff. The Interim Director of Nursing emphasized the importance of addressing residents by their names as a matter of respect and dignity, regardless of their cognitive status. A review of the facility's policy on "Assistance with Meals" indicated that staff should avoid using labels such as "feeders" when referring to residents. Despite this policy, the practice of labeling residents in this manner persisted, as evidenced by staff interviews and facility documentation. This failure to follow policy and maintain residents' dignity was identified through observation, interviews, and record review.
Failure to Ensure Staff Competency and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for residents, as evidenced by the lack of completed annual performance evaluations and skills competencies for all eight reviewed employees. Employee files revealed missing or outdated documentation, including annual physicals, tuberculosis (TB) skin tests, background checks, abuse training, and skills competencies. The Director of Staff Development confirmed that these requirements were not met and acknowledged that all necessary documents should be maintained in employee files and be readily accessible. Licensed nurses did not identify a discrepancy between the medication on hand and the medication ordered by the medical doctor for a resident. Specifically, the Medication Administration Record (MAR) indicated an order for Polyethylene Glycol 1450, while the medication available was Polyethylene Glycol 3350. Nurses failed to recognize and address this difference, and it was confirmed that the facility only stocked the 3350 formulation. The Interim Director of Nursing stated that nurses are expected to clarify such discrepancies with the physician but this was not done. Additionally, three sampled Licensed Vocational Nurses (LVNs) were unable to correctly perform basic nursing dosage calculation conversions, such as converting ounces to milliliters and tablespoons to milliliters. One nurse was observed administering medication to a resident without using proper measuring tools, instead using a plastic spoon and failing to measure the correct amounts as ordered by the physician. Both residents involved had severe cognitive impairment and were completely dependent on staff for care, with complex medical histories including neuromuscular dysfunction, tracheostomy, and atherosclerotic heart disease.
Significant Medication Errors Due to Improper Administration and Dosage Measurement
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration and preparation by licensed nursing staff. One resident with diabetes and moderate cognitive impairment did not receive their prescribed dose of Insulin Lispro before dinner, despite a blood sugar reading that required administration according to the physician's order. The nurse checked the resident's blood sugar but did not return to administer the insulin, and this omission was confirmed by both the resident and facility records. Facility policy required strict adherence to insulin administration protocols, including verification of the correct dose and type, which was not followed in this instance. Another resident, who was completely dependent on staff and had severely impaired cognition, was prescribed Polyethylene Glycol 1450 powder for administration via gastrostomy tube. However, the nurse failed to identify a discrepancy between the medication on hand (Polyethylene Glycol 3350) and the medication ordered by the physician (Polyethylene Glycol 1450). The nurse did not compare the medication label to the order and did not seek clarification from the physician, as required by facility policy. This discrepancy was observed during medication preparation and confirmed by interviews with nursing staff and the interim Director of Nursing. A third resident, also fully dependent and cognitively impaired, was prescribed Psyllium Husk Powder to be administered via gastrostomy tube. The nurse preparing the medication did not use proper measuring tools to ensure the correct dose of fiber powder and water, instead using a plastic spoon and an unmeasured amount of water. When questioned, the nurse was unable to provide correct dosage conversions or explain the importance of accurate measurement. Additional interviews revealed that three sampled nurses were unable to correctly identify basic dosage conversions, further contributing to the risk of medication errors.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored, labeled, and handled in a sanitary manner, as observed during multiple inspections of the kitchen and resident food storage areas. Kitchen staff did not appropriately label or date various food items, including corn tortillas, broccoli, bread, meat, and cooked turkey. Prepared leftover tuna was not stored in the refrigerator, and dietary staff did not follow proper cool down methods. Multiple food items lacked expiration dates, and the ice machine and kitchen stove were found dirty with old, dried food and debris. Clean water pitchers were stored on a cart above dirty dishes, and an employee water bottle was found next to clean cups on the counter. The walk-in freezer floor had brown/blackish stains, and the dishwashing sink had a leaking pipe with green corrosion. These conditions were confirmed through interviews with dietary and maintenance staff, who acknowledged the risks associated with improper food storage and handling. Resident food storage refrigerators on multiple floors contained numerous unlabeled or improperly labeled food items, including cooked food, cheese, milk, candies, juice, kombucha, yogurt, ice cream, and sour cream. Some items were expired, and several refrigerators lacked thermometers. Staff interviews confirmed that it was the responsibility of licensed nurses to label and store residents' food, and housekeepers were to discard expired or unlabeled items. However, these procedures were not consistently followed, increasing the risk of foodborne illness among residents. Maintenance staff also noted that leaking pipes and corrosion in the kitchen had not been promptly reported or repaired, contributing to unsanitary conditions. A specific incident involved a resident with multiple medical conditions, including heart failure, pneumonia, dysphagia, tracheostomy status, diabetes, and morbid obesity. This resident was observed with a container of strawberry yogurt and granola parfait at the bedside, despite instructions that such items should be kept refrigerated. Staff interviews confirmed that yogurt should not be left at bedside due to the risk of spoilage and contamination. Facility policies required all outside food to be labeled with the resident's name, date received, and use-by date, and to be stored in sealed containers and discarded after three days, but these policies were not adhered to during the survey.
Failure to Implement Standard Precautions and Safe Storage Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing standard precautions during the care of two residents. For one resident with chronic respiratory conditions, a partially used sterile saline solution vial for nebulizer inhalation was found at the bedside. Both a respiratory therapist and the lead respiratory therapist confirmed that any unused residual saline solution should be discarded after use to prevent contamination and infection, and that leaving such vials at the bedside is not permitted. For another resident with a history of cancer, gastrostomy tube, and chronic respiratory failure, several items were found improperly stored in the bedside drawer. These included an open water pitcher containing tube feeding formula, a piston syringe inside the pitcher, a urinal with urine, an open can of soft drink, a drinking cup with soft drink, and a bottle of sterile water. A licensed vocational nurse acknowledged that food and drink items should not be placed next to a urinal containing urine due to the risk of contamination and infection. Interviews with facility staff confirmed that the observed practices were not in accordance with facility policies on infection control and food storage. The facility's policies require standard precautions at all times and mandate that food and beverages be properly labeled, dated, sealed, and stored to prevent contamination. The failure to follow these procedures resulted in a deficient practice that increased the risk of infection transmission among residents, staff, and visitors.
Failure to Maintain Safe and Operable Shower Room Handrails
Penalty
Summary
The facility failed to maintain the shared shower room on the 5th floor east in a safe and operable condition, as evidenced by a broken safety handrail on the left side of the shower wall and a loose safety handrail on the right side. During an observation, it was noted that the left handrail was broken and the right handrail was loose. A certified nursing assistant (CNA) confirmed that the left handrail had been broken for about two months and that residents had complained about it being in the way, but primarily used the other handrails. The CNA was unsure how long the right handrail had been loose. The maintenance supervisor stated he was not aware of either the broken or loose handrails prior to being informed during the survey. The facility's policy and procedure for maintenance services requires that all equipment and building areas be kept in a safe and operable manner at all times, with maintenance staff responsible for identifying and prioritizing repairs. However, the broken and loose handrails in the shower room were not addressed in a timely manner, resulting in a deficiency related to the safe maintenance of essential equipment.
Delayed Response to Call Lights for Residents Needing ADL Assistance
Penalty
Summary
Facility staff failed to answer call lights in a timely manner for three residents who required assistance with activities of daily living, including personal hygiene and toileting. Resident interviews during a Resident Council Meeting revealed repeated delays, particularly during the 11PM to 7AM shift, with wait times reported as exceeding 30 minutes to over an hour. One resident reported having to get out of bed and go to the nurses' station for assistance due to unanswered call lights, resulting in missed colostomy care and leakage. Another resident described nearly urinating on himself because staff did not empty his urinal promptly. A third resident reported being left soiled for more than four hours on multiple occasions and stated that complaints to charge nurses did not result in improvement. Record reviews confirmed that all three residents had intact cognitive skills and required varying levels of assistance with ADLs due to conditions such as heart failure, muscle weakness, hemiplegia, and colostomy status. The facility's policy required call lights to be answered as soon as possible, and staff interviews confirmed the expectation that call lights should be answered within three minutes or immediately. Despite these policies and expectations, the documented delays in responding to residents' needs led to residents feeling upset, angry, and embarrassed.
Failure to Ensure Physician Order and Assessment for Self-Administration of G-Tube Feeding
Penalty
Summary
Facility staff failed to ensure that a resident who was self-administering a medical nutritional supplement via gastrostomy tube (g-tube) had a physician's order authorizing self-administration. The resident, who had a history of malignant neoplasms of the larynx and esophagus, gastrostomy status, pneumonitis due to inhalation of food and vomit, lack of coordination, and chronic respiratory failure, was observed with an open water pitcher containing a brown/tan liquid and a piston syringe at the bedside. The resident identified the liquid as Jevity, a tube feeding formula, and stated they self-administered the feeding. Nursing staff were unaware of the contents of the pitcher and could not confirm the presence of a physician's order for self-administration. Further review of the resident's records showed an order for Jevity bolus feedings but no specific order permitting the resident to self-administer the feeding. Additionally, there was no documented assessment or education to determine the resident's cognitive and physical ability to safely self-administer the g-tube feeding, as required by facility policy. The facility's policy mandates that residents must be assessed for mental and physical capability and have physician approval before being allowed to self-administer medications or nutritional supplements.
Failure to Document Indication for Physical Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints by not including a required indication for the use of bilateral hand mittens in the physician's order. The resident, who was admitted with diagnoses including encephalopathy, hypertension, and diabetes, was cognitively impaired and dependent on staff for activities of daily living. The physician's order for hand mittens specified their use and monitoring requirements but did not state the reason for their use, as required by the facility's policy. During interviews and record reviews, both the Registered Nurse Supervisor and the Interim Director of Nursing confirmed that the physician's order was incomplete due to the missing indication. They stated that the absence of a documented reason for the mittens could lead to inadequate communication among staff, the provider, and the resident's family, and could prevent staff from properly monitoring the resident's behavior and the need for the restraint. The facility's policy required that orders include the reason or problem for which they are given, which was not followed in this case.
Failure to Complete Required PASARR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to follow through with the federally required Preadmission Screening and Resident Review (PASARR) process for one resident. Specifically, after the resident was admitted and readmitted with diagnoses including schizophrenia, major depressive disorder, and diabetes, the PASARR Level I screening indicated a positive result for serious mental illness and required a Level II evaluation. However, the PASARR Level II evaluation was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. The Director of Nursing confirmed that the Level II evaluation was not completed and acknowledged that the facility did not follow up as required. The resident's records showed cognitive intactness and a need for supervision with activities of daily living. The facility's policy required all new admissions and readmissions to be screened for mental disorders and for the interdisciplinary team to determine if the facility could meet the resident's needs as outlined in the evaluation. The failure to complete the PASARR Level II evaluation meant that the facility did not fully assess whether it could meet the resident's mental health needs as required by regulation.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including COPD, heart failure, and diabetes mellitus, was not provided with podiatry services despite being at risk for skin breakdown and having a care plan intervention to refer to podiatry. The resident had not seen a podiatrist since admission over a year ago, and documentation showed that although a referral was made by social services, no podiatry visit was scheduled or attempted. The resident reported experiencing pain due to toenail growth, and interviews with staff confirmed that the referral process was not completed and there was no documentation of a podiatry visit request. The facility's policy required a review of ancillary service needs within 90 days of admission and indicated that residents should be offered such services as needed, with records maintained in the medical record. Despite these requirements, the resident's need for podiatry care was not met, and the lack of follow-through on the referral resulted in the resident not receiving necessary foot care. The deficiency was confirmed through observation, interviews, and record review.
Failure to Secure Indwelling Urinary Catheter per Physician Order and Policy
Penalty
Summary
A deficiency was identified when staff failed to secure a resident's indwelling urinary catheter as ordered by the physician and as required by facility policy. The resident, who had diagnoses including neuromuscular bladder dysfunction, heart failure, and dementia with severe cognitive impairment, was admitted with an order for the catheter to be anchored with a stabilization device to reduce pulling and friction. The care plan also specified the use of a Foley catheter strap to prevent catheter-related trauma. During observation, the resident was found with an unsecured catheter, and a nurse confirmed that the catheter was not anchored to the resident's leg or bed, despite the existing physician order and care plan instructions. Further review of facility policy indicated that staff were required to secure urinary catheters with a leg strap to minimize movement and friction at the insertion site, and to report unsecured catheters to a supervisor. The deficiency was confirmed through observation, staff interview, and record review, which all indicated that the required stabilization device was not in place, and the catheter was not properly secured as per physician orders and facility policy.
Medication Error Rate Exceeds 5% Due to Dosage Calculation and Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during the survey period. Licensed nurses did not identify a discrepancy between the medication on hand and the medication ordered by the physician for one resident. Specifically, the medication available was Polyethylene Glycol 3350, while the order was for Polyethylene Glycol 1450, and the nurses did not clarify this difference with the physician before preparing the medication. Additionally, three licensed vocational nurses were unable to correctly perform basic nursing dosage calculations, such as converting ounces to milliliters and tablespoons to milliliters. During medication administration, one nurse used a plastic spoon instead of a proper measuring tool to measure a powdered medication and did not use any measuring tools to accurately measure the prescribed amount of water. When questioned, the nurses were unable to provide correct answers for basic dosage conversions and did not demonstrate knowledge of proper measurement techniques. The residents involved had significant medical conditions and were completely dependent on staff for care, with documentation indicating severely impaired cognition and lack of capacity to make medical decisions. The facility's policy required medications to be administered as prescribed and in accordance with orders, but this was not followed during the observed medication passes.
Unopened Insulin Vials Improperly Stored Outside of Refrigerator
Penalty
Summary
Surveyors observed that unopened vials of insulin Lispro, a medication used to control blood sugar, were stored improperly in a medication cart on the 3rd Floor East, rather than in a refrigerator as required by the manufacturer's instructions. This was confirmed during an observation and interview with an LVN, who acknowledged that unopened insulin should be refrigerated to maintain its effectiveness. The LVN stated that nurses are responsible for ensuring unopened vials are stored in the medication refrigerator and confirmed that the observed vials would be relocated accordingly. Further interviews with the Interim Director of Nursing corroborated that facility policy requires unopened insulin vials to be refrigerated and that failure to do so could affect the medication's effectiveness. A review of the facility's policy and procedures indicated that medications requiring refrigeration must be stored in a designated refrigerator, separate from food, and properly labeled. The deficiency was identified through direct observation, staff interviews, and review of facility policy.
Failure to Provide Proper Notice of Medicare Non-Coverage to Resident's Representative
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to the representative of a resident with multiple medical conditions, including heart failure, dementia, edema, hypertension, dysphagia, generalized muscle weakness, unsteadiness, malaise, and disorientation. The resident was admitted with limited decision-making capacity and was dependent on staff for most activities of daily living. Upon review, it was found that the resident was discharged home with family, and the family member was informed of the discharge date and the start of financial responsibility if the resident remained in the facility. However, the required NOMNC, which informs beneficiaries of the end of Medicare-covered services and their appeal rights, was not properly delivered to the resident's representative. Specifically, the responsible nurse left only a single voicemail and did not attempt further contact or send the NOMNC by certified mail as required by the form's instructions. The Interim Director of Nursing confirmed that the NOMNC form was incomplete and not completed according to instructions, emphasizing the importance of timely and proper notification to allow the resident or their representative to make informed decisions and exercise appeal rights. Facility policy and job descriptions reviewed also indicated the responsibility to coordinate care and inform residents and their representatives of their rights, which was not fulfilled in this instance.
Failure to Provide Timely Assessment, Monitoring, and Physician Notification Following Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute respiratory failure, severe sepsis, pneumonia due to MRSA, UTI, diabetes, and pleural effusion, did not receive care and treatment according to physician orders and facility protocols. The resident was noted to have an elevated temperature and yellow emesis, prompting a physician order for transfer to a hospital, which was later canceled at the family's request. The physician then ordered vital sign monitoring every four hours, initiation of Augmentin, and a urinalysis with culture. However, vital signs were only recorded twice after the order and not every four hours as required, and there was no documentation of vital signs after the early afternoon. The resident's medication administration record did not indicate that Augmentin was administered, and staff interviews revealed confusion and lack of recall regarding the medication's administration and the monitoring of vital signs. Further deficiencies were identified when a nurse failed to notify the physician or hand over to another licensed nurse that the resident had not passed urine and that urine could not be collected for the ordered urinalysis. The nurse assumed someone else would report the lack of urine output and only endorsed the issue to the next shift. Additionally, when the resident developed difficulty breathing on two occasions in the evening, there was no evidence that a registered nurse or the assistant director of nursing assessed the resident, and 911 was not called immediately. Instead, the respiratory therapist was called, and oxygen was administered, but the resident's condition deteriorated further. Ultimately, the resident was found not breathing well later that night, and paramedics were called. Upon arrival, the paramedics found the resident in cardiac arrest and were unable to resuscitate, pronouncing the resident dead at the facility. The facility's own policies required prompt assessment, monitoring, and reporting of changes in condition, as well as timely administration of medications and vital sign monitoring, all of which were not followed in this case.
Failure to Administer Prescribed Antibiotic Due to Medication Unavailability and Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute respiratory failure, severe sepsis with septic shock, pneumonia due to MRSA, UTI, and pleural effusion, did not receive a prescribed antibiotic (Amoxicillin-Pot Clavulanate 875-125 mg) as ordered by the physician. The physician ordered the antibiotic to be administered twice daily for a possible UTI, but the medication was not available in the facility's emergency kit at the time it was needed. As a result, the nurse was unable to administer the medication and had to order it from the pharmacy, causing a delay. The medication was received from the pharmacy later that day, but documentation on the medication administration record (MAR) indicated that the resident was marked as 'unavailable' for the scheduled dose, and there was no evidence that the antibiotic was administered as ordered. Interviews with nursing staff revealed that the nurse on duty did not recall administering the medication and could not explain the documentation. Additionally, the nurse was unaware of the resident's change in condition and the need for vital sign monitoring every four hours, as ordered by the physician. Further review showed that the certified nursing assistant assigned to the resident was also unaware of the resident's earlier fever and did not take vital signs as required. Facility policies required medications to be administered safely, timely, and as prescribed, and for staff to prevent and manage medication errors. However, the failure to have the medication available, to administer it as ordered, and to notify the physician of the missed dose resulted in the resident not receiving the prescribed antibiotic for over 11 hours.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy and return form to a resident or the resident’s representative when the resident was transferred to an acute care hospital. The resident in question had diagnoses including multiple sclerosis, end stage renal disease, and heart failure, and was cognitively intact and able to make decisions at the time of transfer. The resident required maximal to total assistance with activities of daily living. Upon review of the resident’s records, there was no documentation of a physician order for bed-hold, nor was there any completed bed-hold notice after the resident was hospitalized. Interviews with the Assistant Director of Nursing revealed uncertainty about the facility’s policy and procedure regarding bed-hold notifications, but acknowledged that such notification and documentation should have occurred. The Administrator confirmed that the facility did not offer bed-hold notice or information to the resident because the resident did not have Medi-Cal insurance. The facility’s own policy stated that residents or their representatives should be notified of the option to hold a bed during a hospital transfer, with non-Medi-Cal residents having the option to pay for the bed-hold. Despite this, the required notification was not provided, and there was no documentation that the resident or their representative was informed of the bed-hold policy or given the opportunity to request a bed-hold during the hospital transfer.
Failure to Monitor and Document Resident After Change of Condition
Penalty
Summary
The facility failed to provide appropriate monitoring and documentation for a resident who experienced a change of condition (COC) involving nausea and vomiting. The resident, who had diagnoses of multiple sclerosis, end stage renal disease, and heart failure, was cognitively intact and required maximal to total assistance with activities of daily living. After the resident reported nausea and vomiting, including three episodes of emesis, an SBAR was completed to communicate the change in condition. Despite the facility's policy requiring 72-hour monitoring and documentation by charge nurses following a COC, there was no documented monitoring of the resident's status during the morning shifts on two consecutive days after the initial event. Progress notes for these shifts did not contain any assessment or follow-up information regarding the resident's condition. This lack of documentation was confirmed during interviews with both the assigned LVN and the Assistant Director of Nursing, who acknowledged the absence of required monitoring entries. The facility's policies on acute condition changes and documentation specify that all changes in a resident's condition and the care provided must be recorded in the medical record, including follow-up documentation as necessary. The failure to monitor and document the resident's status after the COC was not in accordance with these policies, as evidenced by the missing progress notes and staff interviews.
Failure to Provide Discharge Instructions
Penalty
Summary
The facility failed to provide and review discharge care instructions with the resident representative (RR) at the time of discharge for a resident with multiple medical conditions, including a stage II pressure ulcer on the sacrum. The resident was admitted with diagnoses such as central cord syndrome, fracture of the second vertebrae, Alzheimer's disease, essential hypertension, end-stage renal disease, type 2 diabetes mellitus, dementia, hyperlipidemia, and gout. The resident's Minimum Data Set indicated that their cognition was not intact, and they were dependent on assistance for daily activities. The physician's order indicated that the resident was to be discharged with home health and physical therapy, but the discharge instructions were not provided to the RR at the time of discharge. The California Department of Public Health received a complaint that the resident was discharged to dialysis without discharge instructions, and the RR was unsure of the follow-up care for the resident's pressure ulcer. The RR reported that the resident returned home without discharge instructions, and the niece had to visit the facility to obtain them. Interviews with the Registered Nurse and Case Manager revealed a lack of communication and coordination regarding the discharge process. The RN was unaware of the discharge plan, and the Case Manager placed the discharge instructions in the resident's bag but did not ensure they were reviewed with the RR. The facility's policy required that discharge instructions be provided to the resident or responsible party, which was not adhered to in this case.
Failure to Inform Resident of Financial Obligations and Rights
Penalty
Summary
The facility failed to ensure that a resident was properly notified and informed about their financial obligations and rights to dispute charges. The resident, who was admitted with conditions including metabolic encephalopathy, paraplegia, and a urinary tract infection, was not provided with monthly statements detailing the costs and charges for services received. Additionally, the facility did not provide information on how to dispute or appeal the resident's share of cost as outlined in the facility's policy. This lack of communication led to confusion for the resident, who received inconsistent statements showing increasing balances and was not informed about the process to appeal the denial of payment from secondary insurance. Interviews and record reviews revealed that the facility stopped providing monthly statements due to non-payment, and there was no documentation showing that the resident was informed in advance about the cessation of Medicare coverage or the initiation of Medi-Cal share of cost. The resident expressed confusion over the billing process and was threatened with eviction if the balance was not paid. The facility's policies indicated that residents have the right to be informed about their financial responsibilities and the ability to dispute charges, but these rights were not upheld in this case.
Failure to Properly Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was thoroughly assessed and monitored after being found lying on the floor, which was an alleged fall incident. The resident, who had a history of hemiplegia, hemiparesis, respiratory failure, and atrial fibrillation, was on anticoagulant medication. Despite being at moderate risk for falls, the resident was not reassessed after the fall incident, and necessary interventions such as laboratory or radiology tests were not immediately documented to ensure the resident's stability. The incident involved a lack of communication and documentation among the nursing staff. A registered nurse working the night shift was not informed of the fall by the nurse from the previous shift. Upon discovering the incident, the night shift nurse assessed the resident and found pain and a bump on the occipital area, leading to a physician's order for a CT scan. The nurse from the evening shift admitted to not completing the necessary documentation and was unaware of the resident's anticoagulant medication, which is crucial information for assessing potential internal bleeding after a fall. The facility's policy requires follow-up on falls with associated injuries until the resident is stable and complications are ruled out. However, the staff did not adhere to this protocol, as evidenced by the incomplete SBAR form and the lack of immediate testing to rule out injuries. The quality assurance nurse confirmed the need for documentation and testing in such cases, highlighting the deficiency in the facility's response to the fall incident.
Inadequate Incontinent Care Leads to UTI Risk
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for a resident who was incontinent of bowel and bladder. The resident, who was admitted with diagnoses including metabolic encephalopathy, paraplegia, and a history of UTI, required total dependence on staff for activities of daily living. The resident's care plan indicated a goal to keep the resident clean, dry, and odor-free, with interventions to monitor for signs and symptoms of infection. However, the resident reported that her incontinent brief was not being changed frequently, and on the day of observation, it had not been changed since early morning. During an observation, the resident was found with a soiled incontinent brief, indicating a bowel movement that had not been addressed. A CNA admitted to not changing the resident's brief on time due to a high workload, acknowledging that this could lead to a UTI. The facility's policy required residents to be changed at least twice per shift and as needed, but this was not adhered to, putting the resident at risk of infection. The Quality Assurance Nurse confirmed the importance of frequent changes to prevent infections like UTIs.
Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not following a physician's order to monitor the resident's vital signs every shift for the entire month of January 2025. The resident, a female with a history of vascular Parkinsonism, hemiplegia, osteoporosis, and major depressive disorder, was admitted to the facility with intact cognition but required assistance with daily activities. Despite the physician's order to monitor vital signs every shift for medical management, the Medication Administration Record (MAR) indicated that no vital signs were taken during the night shift from January 1 to January 28, 2025. During an interview and record review with the Quality Assurance Nurse, it was confirmed that the facility did not conduct a complete assessment and failed to follow the physician's order to check the resident's vital signs during the night shift. The facility's policy and procedures on comprehensive assessments and care delivery emphasize the importance of collecting and analyzing information, choosing and initiating interventions, and monitoring results. However, the facility did not adhere to these procedures, resulting in a failure to deliver necessary care and services to the resident.
Failure to Ensure Proper Post-Dialysis Monitoring and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services consistent with professional standards of practice for two residents requiring hemodialysis. Resident 1, who was admitted with diagnoses including End Stage Renal Disease (ESRD), respiratory failure, and type II diabetes mellitus, had a care plan that required immediate intervention for any signs and symptoms of complications from dialysis. However, the Post Dialysis Evaluation Forms for Resident 1 on two occasions were left blank, indicating no assessment or monitoring was documented post-dialysis. Similarly, Resident 2, also diagnosed with ESRD, respiratory failure, and diabetes, had a care plan to monitor for complications related to renal/urinary system issues. Despite this, there was no documentation of follow-up interventions after the dialysis nurse reported cloudy urine and requested the resident be cleaned before dialysis. Interviews with the RN and DON confirmed the lack of completed post-dialysis evaluations and follow-up documentation, which was contrary to the facility's policy requiring ongoing assessment and communication regarding dialysis care.
Failure to Inform Resident Representative of Hospital Return
Penalty
Summary
The facility failed to inform the Resident Representative (RR) of a resident's return from the general acute care hospital (GACH), which was a deficiency identified during a survey. The resident, a female with multiple diagnoses including vascular Parkinsonism, hemiplegia, osteoporosis, osteoarthritis, primary hypertension, hyperlipidemia, gastro-esophageal reflux disease, dysphagia, and major depressive disorder, was initially admitted to the facility on 10/21/2021 and most recently on 12/20/2024. The resident's Minimum Data Set (MDS) indicated intact cognition but dependency on assistance for daily activities. On 12/19/2024, the resident was transferred to the GACH due to a critically low hemoglobin level, and the family was notified of this transfer. However, upon the resident's return to the facility on 12/20/2024, the RR was not informed, despite the facility's policy requiring that residents and their representatives be informed of changes in condition. The Director of Nursing (DON) acknowledged that the RR frequently called the facility, which led to some staff reluctance to communicate with her. The RR reported making multiple calls over a 10-day period to get an update on the resident's condition, only to be informed by the Assistant Director of Nursing (ADON) after this delay. This failure to communicate promptly with the RR was a violation of the resident's rights as outlined in the facility's policy and procedures, which emphasize the importance of keeping residents and their representatives informed about their care and condition.
Failure to Supervise High Fall Risk Resident Leads to Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a high fall risk, resulting in an unwitnessed fall and injury. The resident, who was non-ambulatory and had severe cognitive impairment, was left unattended in a common area near the nursing station. This lapse in supervision occurred despite the resident's care plan indicating the need for close observation and specific interventions to prevent falls. The resident's medical history included dementia, osteoarthritis, diabetes mellitus type II, spinal stenosis, and gait abnormalities, all contributing to a high risk of falls. The resident required substantial assistance with daily activities and was dependent on staff for mobility. On the day of the incident, the resident was left alone by a companion hired by the family, who did not inform the staff before leaving the resident unattended. Interviews with staff revealed that the resident's companion was responsible for providing social stimulation and often transported the resident within the facility. However, the companion left the resident in a vulnerable position without notifying the staff, leading to the fall. The facility's policy emphasized the importance of resident supervision based on individual needs and environmental hazards, but this was not adhered to in this case.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to provide adequate skin and pressure ulcer prevention care for a resident, as outlined in the resident's care plan. The care plan, initiated and last revised in July 2024, required the resident to be on a turning and repositioning program every two hours. However, a review of the medication administration record (MAR) for August 2024 revealed a lack of documentation indicating that the resident was repositioned as required. The Director of Nursing (DON) confirmed that if repositioning was not documented, it was not performed, which was against the facility's policy. The resident, admitted in July 2024, had a stage 2 pressure ulcer on the left buttocks and required frequent turning due to various health conditions, including a left tibial fracture, peripheral vascular disease, dementia, and severe protein-calorie malnutrition. The resident's history and physical report indicated the need for frequent turning, as the resident lacked the capacity to make and understand decisions. The facility's policy on pressure ulcer prevention, dated January 2024, required a change in position at least every two hours, which was not adhered to, increasing the risk of the pressure ulcer worsening.
Medication Error Due to Incorrect Transcription and Administration
Penalty
Summary
The facility staff failed to ensure that a resident received appropriate treatment and services for spontaneous peritonitis by not clarifying the correct use of Ciprofloxacin. The resident was admitted with diagnoses including enterococcus, sepsis, and spontaneous bacterial peritonitis. However, the medication order for Ciprofloxacin was incorrectly transcribed and administered for a urinary tract infection (UTI) instead of its intended prophylactic use for spontaneous peritonitis. The Licensed Vocational Nurse (LVN) was unable to explain the lack of a urine culture or the delay in starting Ciprofloxacin. The Director of Nursing (DON) discovered that the medication list indicated Ciprofloxacin was to be given daily after dialysis, although the resident only underwent dialysis three times a week. The order was not uploaded into the facility's electronic medical record, and the DON could not identify the licensed nurse who verified the order. The facility's policies on antibiotic stewardship, medication administration, and physician orders were not followed, leading to a medication error. The DON acknowledged that medication errors could occur if orders are not verified and transcribed correctly.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate fall precautions for a resident identified as high risk for falls. The resident, who had a history of cerebral vascular accident, multiple fractures, and was dependent on a ventilator, required assistance with transfers and bed mobility. Despite these needs, the facility did not provide a two-person assist during care, as outlined in their in-service training, nor did they implement the use of fall mats as specified in the resident's care plan. On the morning of the incident, a CNA was providing care to the resident without the assistance of another staff member. During this time, the resident rolled over and fell from the bed, which was positioned above knee level. The fall resulted in the resident hitting their head on the floor, leading to a subdural hematoma and subsequent transfer to a general acute care hospital for intensive care. Interviews with facility staff revealed that the fall precautions, such as the use of fall mats, were not in place at the time of the incident. The Director of Nursing acknowledged that the resident was identified as high risk for falls and that the CNA did not follow the protocol of seeking assistance, which contributed to the fall. The facility's policy on fall risk management emphasizes the importance of implementing appropriate interventions to reduce fall risks, which were not adhered to in this case.
Medication Error: Incorrect Heparin Dosage Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a Licensed Vocational Nurse (LVN1) who administered an incorrect dose of Heparin Sodium Injection. The resident, a male with a complex medical history including non-traumatic intracerebral hemorrhage, epilepsy, and other serious conditions, was prescribed a 0.5ml dose of Heparin twice daily for DVT prophylaxis. However, on the specified date, LVN1 administered a 1ml dose instead, which was double the prescribed amount. This error was identified by the resident's representative, who questioned the dosage and subsequently informed the charge nurse, Director of Nursing (DON), and Administrator. Interviews conducted during the investigation revealed that LVN1 was not the regular medication nurse for the resident and had assumed the standard dose for DVT prevention was 1ml, without verifying the specific physician's order. The LVN admitted to not recognizing the 0.5ml as the correct dose despite checking the order before administration. The DON and Registered Nurse Supervisor (RNS) emphasized the importance of adhering to the facility's medication administration policy, which requires verifying the right patient, medication, dose, time, frequency, and route before administering any medication. The facility's policy also mandates checking the medication label three times to ensure accuracy, which was not followed in this instance.
Failure to Obtain Timely Physician Order for Urine Culture
Penalty
Summary
The facility failed to obtain a physician's order for a urine culture and sensitivity (C&S) test before collecting a urine sample using a straight catheter for a resident suspected of having a urinary tract infection (UTI). This oversight resulted in the urine specimen expiring, necessitating the resident to undergo the straight catheter procedure twice within a week. The resident, a male with multiple complex medical conditions including non-traumatic intracerebral hemorrhage, epilepsy, and diabetes, was admitted to the facility with severely impaired cognition and was totally dependent on staff for daily activities. On the first occasion, a staff member collected a urine sample from the resident after he had not urinated for over eight hours. However, the Registered Nurse Supervisor (RNS) was not aware of any orders for a urine C&S test and discovered the sample in the specimen refrigerator four days later. The RNS realized the sample was no longer viable and did not send it to the lab. Subsequently, the RNS notified the attending physician, obtained the necessary order, and collected a new sample for testing. The facility's policy requires that culture tests be performed only when ordered by a physician, and samples must be sent to the lab within 24 hours of collection. The failure to follow this protocol led to the delay in diagnosing the resident's UTI, as the initial sample was not processed in a timely manner. The deficiency was identified during an interview and record review, highlighting a lapse in communication and adherence to established procedures.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the state survey agency within the required two-hour timeframe. The resident, who had a history of spinal stenosis, post-laminectomy syndrome, and chronic pain, was dependent on staff for daily activities and reported being roughly handled by a certified nursing assistant (CNA) during morning care. The resident's cognition was intact, and they were able to articulate the incident, which involved a CNA allegedly placing a knee on the resident's back and causing discomfort during incontinence care. The incident was initially reported by the resident to a Licensed Vocational Nurse (LVN), who then removed the CNA from the situation and continued to assist the resident. The facility's abuse protocol required that such allegations be reported to the Director of Nursing and Administrator within two hours. However, the Social Services Director (SSD) reported the incident to the relevant authorities more than two hours after the allegation was made, citing a delay in the reporting process. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed the delay in reporting. The DON acknowledged that the abuse allegation was not reported within the required timeframe due to multiple changes in the resident's condition that morning. The facility's policy and procedures clearly stated that all suspected abuse must be reported within two hours to various authorities, including the state licensing agency, ombudsman, and law enforcement.
Delayed Administration of Bowel Medication
Penalty
Summary
The facility failed to administer bowel medication in a timely manner to a resident, leading to unnecessary pain and potential health risks. The resident, who had a history of chronic constipation due to a spinal cord injury, informed a Licensed Vocational Nurse (LVN) of severe constipation and requested Golytely, a medication he takes weekly. Despite notifying the doctor and obtaining an order for the medication, there was a delay in its administration. The resident reported experiencing significant discomfort and pain during this period. The delay was attributed to the pharmacy's delivery schedule, which was beyond the control of the Director of Nursing (DON). The facility's policy required medications to be administered safely and timely, but the Golytely was not available in the pharmacy when needed. The resident eventually received the medication three days later, which alleviated his symptoms. The facility's failure to adhere to its bowel management protocol and timely medication administration placed the resident at risk for serious complications.
Failure to Timely Administer Bowel Medication
Penalty
Summary
The facility failed to administer bowel medication in a timely manner to a resident, leading to unnecessary pain and potential health risks. The resident, who had a history of chronic constipation due to a spinal cord injury, was admitted with several diagnoses including osteomyelitis, neuromuscular bladder dysfunction, anxiety disorder, lumbar injury to the spinal cord, PTSD, and hypertension. Despite having intact cognition and the ability to make decisions, the resident experienced severe constipation exacerbated by narcotics taken for a bone infection. The resident informed a Licensed Vocational Nurse (LVN) of the need for Golytely, a medication taken weekly to stimulate bowel movement, but it took the facility three days to provide the medication, causing significant discomfort and pain. The delay in administering the medication was attributed to the facility's pharmacy delivery schedule and the unavailability of Golytely in the pharmacy. The Director of Nursing (DON) acknowledged that the delay placed the resident at risk for various complications, including nausea, vomiting, pain, bowel perforation, and unnecessary hospitalization. The facility's policy and procedures emphasized the importance of timely medication administration and bowel management to prevent complications from constipation. However, the failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe environment for Resident 108, who suffered a second-degree burn from a hot cup of coffee left unattended on their bedside table. The resident, who had hand tremors and required assistance with eating, requested a CNA to prepare coffee using their personal electric kettle. The CNA left the hot coffee within the resident's reach, resulting in the resident accidentally spilling it and sustaining a burn. The facility did not conduct an immediate assessment or measurement of the burn, nor did they document the degree of the injury. Resident 428 experienced a skin tear and a deviated nose due to inadequate accident prevention protocols. The resident, who lacked the capacity to make decisions and was dependent on staff for personal care, was injured when a clipboard fell on their head. The facility's staff failed to accurately report the incident to the resident's family, initially describing the injury as a burst water blister. This miscommunication led to the suspension of the nurse involved. The facility also failed to address environmental hazards for Residents 137 and 103. An oscillating fan was left in a high-traffic walkway in Resident 137's room, posing a tripping hazard. Additionally, CNA 2 left Resident 103 unattended in an unlocked wheelchair, increasing the risk of falls. These oversights highlight the facility's failure to adhere to its policies on safety and supervision, which emphasize the importance of preventing accidents and ensuring a hazard-free environment.
Failure to Report Missing Narcotics
Penalty
Summary
The facility failed to ensure that missing narcotics were documented and reported according to its policy, which could potentially lead to medication loss and diversion. During an observation and interview with an LVN, it was discovered that two tablets of hydrocodone were missing from the medication cart, and the LVN confirmed that she had received the cart with the tablets already missing from the previous shift. However, she did not report the missing narcotics to the DON or RN supervisor. The LVN acknowledged that failing to report missing narcotics could result in residents not receiving necessary pain medication. The DON was unaware of the missing narcotics until the interview and stated that an investigation would be conducted regarding the discrepancy. The facility's policy requires nursing staff to count controlled medications at the end of each shift and report any discrepancies immediately. An RN confirmed that any discrepancies should be reported to the RN supervisors if the DON is not available. The failure to follow this policy led to the deficiency noted in the report.
Expired Medications and Equipment Found in Storage
Penalty
Summary
The facility failed to ensure medications and medical equipment were discarded according to their policy and procedure titled 'Discarding and Destroying Medications' dated 2001. During an observation of the 4th floor medication storage area, a half-used box of BD Vacutainer Safety-Lok Blood Collection Sets with an expiration date of 4-30-2023 was found open and available for use. The Registered Nurse Supervisor was unaware of the expired vacutainers in the medication room and stated that expired equipment should not be used due to potential contamination or mechanical failure. The Director of Nursing confirmed that no expired medications or equipment should be kept in the medication storage area and that monthly inspections were conducted to check for expired items. Additionally, during a medication storage and labeling observation, a box of expired Bisacodyl 10 milligrams with an expiration date of 4-24 was found. A Licensed Vocational Nurse noted the expired medication and stated that administering expired medications could make residents sick. The Director of Nursing reiterated that licensed nurses were responsible for checking medication carts daily to ensure no expired medications were present. The facility's policy indicated that medications should be disposed of in accordance with federal, state, and local regulations.
Deficiencies in Food Storage and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and labeling practices in accordance with professional standards and facility policy. During an initial tour of the facility kitchen, several food items were found with expired labels, and some were not labeled at all. Specifically, blocks of cheese, a loaf of bread, and a container of ranch dressing were observed with expired dates, while a large plastic container of food and another labeled as jelly lacked proper labeling. Additionally, multiple food items in plastic containers across various floors were not labeled with expiration dates, posing a risk of foodborne illness. The facility also failed to maintain the kitchen environment in a safe and operable manner. Observations revealed a large amount of water on the floor under the sink, a greenish color on the pipes, and a significant amount of dust under the sink where dishes were washed. A leaking pipe under the sink was reported by the Dietary Supervisor to the Maintenance Supervisor a week prior, but no action had been taken. The Maintenance Supervisor admitted that the plumbing had not been serviced for approximately a year, and there were no records of recent repairs, which could lead to corrosion and safety hazards. Interviews with staff confirmed the lack of routine maintenance and cleaning in the kitchen area. The Dietary Supervisor acknowledged that the kitchen was not cleaned regularly, which could result in residents getting sick. The Maintenance Supervisor was unaware of how long the pipe had been leaking and recognized the potential for staff injuries due to water puddles on the floor. The facility's policies and procedures outlined the responsibilities for maintaining safe food storage and kitchen maintenance, but these were not adhered to, leading to the observed deficiencies.
Improper Handling of Resident's Personal Hygiene Items
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence and self-determination by improperly handling personal hygiene items. During a facility tour, it was observed that a wash basin containing a soiled washcloth and a toothbrush was placed on top of the toilet lid in the resident's bathroom. This practice was confirmed by an LVN, who acknowledged that such placement increased the risk of contamination with bacteria and was demeaning to the resident's dignity and self-worth. The Director of Nursing also stated that leaving a soiled towel and toothbrush in this manner compromised the resident's quality of life, dignity, respect, and individuality. The facility's policy on Quality of Life-Dignity emphasized that residents should always be treated with dignity and respect, and demeaning practices are prohibited.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for several residents, as evidenced by multiple deficiencies observed during a survey. Resident 328's room temperature was not maintained at the facility's standard of 74 degrees Fahrenheit, resulting in the room being at 68 degrees Fahrenheit. Despite the resident's complaints of feeling cold, the certified nursing assistant (CNA) did not take appropriate action to address the issue, leaving the resident shivering under multiple blankets. The licensed vocational nurse (LVN) later confirmed the room was too cold and adjusted the thermostat, but the Director of Nursing (DON) was unaware of the resident's ongoing discomfort. In another instance, Resident 71's room had multiple dark spots on the floor, which the resident had requested to be cleaned. The staff initially informed the resident that the marks were permanent, but the Maintenance Supervisor later confirmed that the spots could be removed easily. This oversight contributed to an unsanitary and unhomelike environment for the resident, who required maximum assistance from staff due to severely impaired cognition. Additionally, a soiled wash towel and toothbrush were found on top of a toilet lid in the bathroom of another resident's room, posing a risk of contamination. The LVN acknowledged that this placement was inappropriate and did not reflect good hygiene practices. The DON also recognized that such practices demean the resident's quality of life, dignity, and respect. These deficiencies highlight the facility's failure to adhere to its policy of providing a clean, safe, and homelike environment for its residents.
Failure to Provide Adequate Oral Care for Resident
Penalty
Summary
The facility failed to provide adequate oral care for Resident 4, who was unable to perform activities of daily living independently due to multiple medical conditions, including chronic respiratory failure, cerebral palsy, dementia, and candidiasis. Observations and interviews revealed that Resident 4's tongue was very dry and coated with a thick white substance, and their lips were chapped. The resident's care plan indicated a risk for dehydration, and interventions included monitoring for symptoms such as dry mucous membranes. However, the facility did not adhere to these interventions, as evidenced by the resident's condition. Interviews with staff, including a Licensed Vocational Nurse and a Respiratory Therapist, confirmed that Resident 4 had not received proper oral care for some time. The Director of Nursing stated that oral care for tracheostomy residents should be performed twice daily with chlorhexidine to prevent infections. The facility's policy on oral care for residents with tracheostomy tubes emphasized the importance of preventing infections by reducing the risk of pathogens entering the respiratory system. Despite these guidelines, the facility's failure to provide necessary oral care resulted in Resident 4 developing a very dry tongue and lips, with the potential for infection.
Failure to Reposition Residents Leads to Pressure Ulcer Risk
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the prevention of pressure ulcers by not turning and repositioning residents every two hours as required. This deficiency was observed in multiple residents, including Resident 30, who was admitted with a Stage IV pressure ulcer and other conditions such as cerebral infarction and hemiplegia. Despite the physician's order and care plan indicating the necessity for repositioning every two hours, Resident 30 was observed in the same position for extended periods, increasing the risk of worsening existing pressure ulcers. Similarly, Resident 103, who was at high risk for pressure sores due to conditions like chronic respiratory failure and osteomyelitis, was not repositioned as frequently as required. Observations revealed that Resident 103 remained in a supine position for several hours, contrary to the physician's orders and facility policies. Staff interviews confirmed the lack of adherence to the repositioning schedule, which is critical for preventing skin breakdown and promoting circulation. Resident 177 and Resident 105 also experienced similar neglect in repositioning, despite their high risk for pressure ulcers due to conditions like hemiplegia, dementia, and muscle weakness. Both residents were observed in the same positions for extended periods, and staff interviews corroborated the failure to reposition them every two hours as mandated by the facility's policies. This consistent failure across multiple residents highlights a significant deficiency in the facility's care practices regarding pressure ulcer prevention.
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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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