Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blythe Post Acute Llc during CMS and state inspections, most recent first.
Controlled substance waste was documented without required witness signatures for several residents, and MARs did not match CSRs for two residents, including missing Norco and lacosamide doses. Staff also used one resident’s lactulose for another resident when the cart ran out, despite the facility policy that medications ordered for one resident may not be given to another resident.
Medication administration errors exceeded the allowed rate when nurses gave medications that did not match physician orders, crushed EC aspirin, administered a multivitamin without an order, missed an ordered lacosamide dose, and substituted tablets for capsules or chewable forms. The errors involved several residents and included aspirin, docusate, multivitamin, and seizure medication, with staff acknowledging some of the mismatches and unavailable medication during the med pass.
Food items were found improperly stored in the kitchen, refrigerators, and freezers, including opened items with no opened date, frozen items with no use-by date, and sandwiches in a resident refrigerator that were beyond the use-by date. Kitchen staff confirmed the items needed to be labeled and dated, and facility policy required foods to be covered, labeled, and dated appropriately.
Arbitration agreements for four residents did not include a venue for resolving disputes, despite facility policy stating the venue should be convenient to both parties. The residents involved had varying cognitive status, including BIMS scores of 15/15 for three residents and 13/15 with fluctuating capacity for one resident, and the ADM confirmed the agreements lacked the venue and that an inconvenient location would be disadvantageous.
A resident with dementia and psychosis received a PRN haloperidol injection without documentation of the resident’s behavior before administration or any attempted non-pharmacological interventions. The same resident also had a scheduled quetiapine order for psychosis manifested by delusional behaviors, but the record did not show specific, measurable, observable behaviors supporting the indication, and the MAR showed no documented delusional episodes. The DON and consultant pharmacist confirmed the behavior documentation was non-specific or missing, despite the antipsychotic Black Box Warnings and the facility’s psychotropic medication policy.
Delayed Completion of Comprehensive Admission MDS Assessment: A resident’s Comprehensive admission MDS Assessment was not completed within the required 14-day timeframe after admission. The DON/MDSC acknowledged the assessment was late, stated it should have been completed within 14 days, and confirmed the facility did not follow its Resident Assessment policy or RAI guidelines, delaying identification of care areas for the care plan.
Failure to care plan for removal of oxygen cannula: A resident with COPD and an order for O2 via NC PRN for SOB was observed with the NC lying beside the face while the O2 concentrator was on, and later was seen gasping for breath with the NC again off. The DON stated the resident had a habitual behavior of removing the NC, that it was not addressed in the care plan, and that the facility did not follow its care planning policy requiring an individualized interdisciplinary care plan.
A resident with dementia had schizophrenia listed in the record, but the facility could not confirm clinical documentation supporting that diagnosis. The PASARR screening did not identify a serious mental disorder such as schizophrenia, the H&P listed dementia with psychosis instead, and the DON stated the schizophrenia diagnosis was added after a hospital discharge summary noted it in the past medical history. The facility also had no policy addressing documentation requirements for a schizophrenia diagnosis, despite a charting policy requiring objective, complete, and accurate documentation.
Oxygen Therapy Not Delivered as Ordered: A resident with COPD had an order for O2 at 2 L via NC PRN for SOB, but surveyors observed the NC tubing lying beside her face and later next to her in bed while the concentrator was on. The resident was observed asleep with audible wheezing and later gasping for breath while talking. An LVN stated the resident removed the NC at times and admitted she did not check whether it was properly positioned in the nares before leaving the room.
A resident with an order for lacosamide 50 mg BID for seizure prevention missed four doses because staff documented the medication as unavailable. During a med pass, an LVN said the dose could not be given because the facility was out of the medication, yet the next day multiple opened and unopened blister packs were found in the locked narcotic drawer of the med cart. The DON acknowledged the medication was available and that staff did not know where it was stored.
Improperly Closed Dumpster With Exposed Trash: A metal dumpster in the outside garbage area was observed partially open with trash piled above the top and exposed. Kitchen staff confirmed the dumpster was not completely closed and stated dumpsters must always be closed to prevent harboring rodents. The facility policy required food-related garbage to be stored in a manner inaccessible to pests and outside dumpsters to be kept closed and free of surrounding litter.
Insufficient Bedroom Space in Multiple Resident Rooms: The facility failed to ensure that multiple 3-bed resident rooms provided at least 80 sq. ft. of livable space per resident. An ADM confirmed that several rooms did not meet the accommodation requirement, and surveyors measured room sizes at about 79.33 to 79.66 sq. ft. per resident. Residents stated they were comfortable, and no space complaints or safety hazards were observed.
A resident with a history of marijuana use, heart failure, COPD, and nicotine dependence was re-admitted without a comprehensive care plan addressing tobacco or marijuana use, despite facility policy and previous positive THC tests. Both RN and DON confirmed the absence of a smoking care plan in the resident's records after re-admission.
A CNA provided direct care to residents while lacking an active State-approved CNA certification and a current CPR certificate. The CNA was scheduled and worked shifts despite these missing credentials, as confirmed by employee records and staffing schedules. Both the DSD and DON acknowledged the oversight, and facility policies required current certification and licensure for such positions.
The facility did not ensure the high temperature alarm for hot water was functioning and failed to monitor and record hot water temperatures on several days, resulting in a lack of safeguards against excessively hot water for residents. Interviews with the Maintenance Supervisor and Administrator confirmed these lapses, which were not in accordance with facility policy.
The facility did not assess or document vital signs before transferring two residents with significant medical conditions to a general acute care hospital for further evaluation. In both cases, the last recorded vital signs were from the previous day, and no updated assessments were documented prior to transfer, despite facility policy and DON expectations that vital signs be obtained and recorded before such transfers.
A resident with left-sided paralysis and intact cognition alleged that a CNA was rough during care, resulting in pain and a wrist bump. The incident was reported, the resident was assessed, and the CNA was sent home, but the Administrator allowed the CNA to return to work before completing required interviews with the resident and others. Facility policy required suspension and a thorough investigation, which was not completed prior to the CNA's return.
A dietary staff member in the facility was unable to accurately verbalize the proper cool down process for cooked foods, which is crucial to prevent foodborne illnesses. The staff member incorrectly stated the cooling times, which did not align with the facility's policy requiring cooling from 135°F to 70°F within 2 hours and then to 41°F or below within the next 4 hours. This misunderstanding had the potential to expose 44 residents to foodborne illnesses.
The facility failed to maintain safe food storage and preparation practices, with turkey and bologna stored at unsafe temperatures, a dietary aide not wearing a beard net, and a dirty air conditioning grill above the food prep area. Additionally, a cleaning agent was improperly stored near food, and an expired sanitizer test kit was used, risking foodborne illness.
A resident received an expired Atrovent inhaler due to an LVN not checking the expiration date during medication preparation. The resident had been receiving this medication for COPD treatment. Additionally, an inspection revealed expired carisoprodol tablets in an E-Kit. Facility policies require the removal of expired medications and monthly inspections of emergency kits, which were not adhered to.
The facility failed to provide the required minimum of 80 square feet per resident in seven multi-resident rooms, accommodating three residents each with only 79.6 square feet per resident. Despite this, no complaints or negative impacts on residents' comfort were observed, and residents reported being comfortable.
The facility failed to ensure a licensed pharmacist conducted thorough monthly drug regimen reviews, leading to inconsistent procedures by nursing staff for holding blood pressure medications without physician-ordered hold parameters. This affected three residents, with medications being held or administered based on nursing judgment rather than standardized guidelines.
A resident with dementia was given Seroquel without prior non-pharmacological interventions or a psychiatric consult. The facility did not document attempts to assess the resident's mental status or distress level, violating their policy on psychotropic drug use.
A medication error rate of 11.11% was identified in an LTC facility, involving two residents. Errors included improper administration of an Advair inhaler due to language barriers, use of an expired Atrovent inhaler, and incorrect dosing of acetaminophen. These actions were contrary to the facility's medication administration policies.
A resident with muscle weakness and failure to thrive was served fish despite a clear preference against it, as indicated on their meal ticket. This oversight was acknowledged by the dietary manager, who noted the potential for reduced food intake. The facility's policy stresses the importance of honoring food preferences.
The facility failed to post necessary signage for Enhanced Barrier Precautions (EBP) in rooms of residents with conditions requiring such precautions. Interviews with staff confirmed the absence of signage indicating required PPE for residents with wounds or indwelling devices, despite facility policy mandating these precautions to prevent the spread of multidrug-resistant organisms.
A resident experienced an unwitnessed fall and hit her head, but the facility failed to conduct timely neurological assessments as per protocol. Despite the resident's history of falls and being on blood-thinning medication, the required neuro checks were not performed. The responsibility for monitoring was inadequately transferred between staff, and the Director of Nursing confirmed the protocol was not followed.
The facility failed to develop care plans for two residents who used marijuana, despite incidents indicating the need for such plans. One resident, with a history of embolism and thrombosis, reported feeling unwell after marijuana use, but no care plan was initiated. Another resident, with asthma, was found unresponsive and later confirmed to have used marijuana, yet no care plan was developed. The facility's policy requires care plans to be updated as conditions change, which was not followed.
A resident reported feeling like having a stroke and using marijuana, but the facility failed to monitor her condition or update her care plan. Despite the resident's cognitive intactness and history of embolism and thrombosis, the RN did not assess her or notify the physician, and the DON was unaware of the incident, indicating a breach in the facility's Change of Condition policy.
The facility failed to ensure correct medication orders for two residents. One resident received an incorrect dosage of Sertraline, while another did not have orders for her asthma medications, Symbicort and albuterol, upon admission. The DON confirmed the errors, which were against the facility's medication therapy policy.
The facility failed to maintain an effective pest control program, leading to an increase in flies in common areas and resident bedrooms. Multiple residents, including those with cognitive impairments and serious medical conditions, were affected by the flies. The removal of fly traps and lack of a contracted pest control service since April 2024 contributed to the issue, despite the facility's policy requiring an ongoing pest control program.
The facility failed to report alleged abuse and unauthorized medication administration involving three residents to the CDPH within the required timeframe. A resident was verbally abused by a CNA, while two others were allegedly given sleeping medicine without authorization. The Administrator delayed reporting these incidents, waiting for a written statement, which resulted in a delayed investigation and risk to the residents.
A resident's electric wheelchair was improperly stored in the maintenance office without a protective cover, and facility belongings were placed on it. Interviews with the Maintenance Supervisor and DON confirmed the lack of adherence to the facility's policy on resident rights, which requires treating residents and their possessions with respect and dignity.
A resident with left-sided muscle weakness following a stroke was not accommodated in their preference for an electric Hoyer lift for transfers and a large Geri-chair for seating. Both electric lifts were unavailable due to dead batteries, and the Geri-chair was shared among multiple residents, limiting its availability. This led to the resident refusing showers and being observed in a disheveled state, highlighting a failure to meet the resident's needs and preferences.
A resident diagnosed with atrial fibrillation did not receive timely cardiology follow-up after returning to the facility. Despite requests, the resident was not informed of any cardiology appointments. The facility physician prescribed Eliquis but did not ensure cardiology follow-up, and the facility's policies on timely physician visits and condition changes were not followed.
Two residents in a long-term care facility did not receive their prescribed Augmentin due to medication unavailability. One resident, with COPD, missed three doses, while another, with diabetes and a UTI, missed two doses. The facility's policy requires medications to be administered within one hour of the prescribed time, and the staff should have used the emergency kit while waiting for delivery.
Two residents with type 2 diabetes mellitus were served incorrect desserts during a lunch meal service, contrary to their prescribed diets of low concentrated sweets and no added salt. The dietary supervisor and DON confirmed the errors, acknowledging that the dietary staff failed to follow the physician's orders, which specified lemon pound cake instead of cheesecake with cherry topping.
The facility did not meet the required 80 square feet per resident in multi-resident rooms for 8 out of 18 rooms. Observations and interviews revealed that rooms 5 through 12 provided only 79.6 square feet per resident. Some residents expressed concerns about room size, but staff did not report care provision issues. The Director of Nursing was unaware of the space requirements, and the facility's policy was not followed.
A resident was moved to a new room without receiving the required written notice, despite being cognitively intact and expressing dissatisfaction with the change. The facility's policy mandates advance written notice for room changes, but the DON confirmed that only verbal notifications were given, which was reflected in the resident's medical records.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, with some rooms reaching 84.7 degrees, causing discomfort for two residents. One resident with cellulitis and hemiplegia and another with ventricular tachycardia and COPD were affected. The Maintenance Supervisor confirmed the air conditioning was functioning, but the Administrator acknowledged the temperature issue.
Controlled Substance Documentation and Medication Sharing Failures
Penalty
Summary
Controlled substance waste procedures were not followed for multiple residents. Resident 50 had an order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed, and the CSR showed Norco was wasted on several occasions without any witness documented. Resident 2 had an order for lacosamide 50 mg twice daily, and the CSR showed a wasted dose with no witness documented. Resident 5 and Resident 29 also had Norco waste entries in their CSRs with no witness documented, and Resident 24 had a Norco waste entry with no witness documented. Facility staff stated that a witness was supposed to be present for controlled substance waste and that the waste and witness should be documented in the CSR, while the facility policy required a second licensed staff member to be physically present and both staff signatures to be recorded. The facility also failed to keep controlled substance records consistent with the MARs. For Resident 24, the MAR documented Norco administration, but the CSR did not account for two doses. For Resident 2, the MAR documented lacosamide administration on multiple dates and times, but the CSR did not reflect nine of those doses. During interview, the DON-MDSC confirmed the MAR and CSR did not match and stated that if they did not match, it meant the medication was not given. The facility policy required complete and accurate documentation of medications administered and stated that the DON Services would investigate narcotics reconciliation discrepancies. In addition, prescription medication for one resident was used for another resident. At Medication Cart 1, an empty box of lactulose labeled for Resident 10 was observed, and staff stated it had been given to Resident 16 because Resident 16 needed the medication. Resident 16’s MAR showed lactulose was administered after the facility ran out of the medication, while Resident 10 had an order for lactulose 30 ml four times daily and Resident 16 had an order for lactulose 30 ml twice daily. The DON-MDSC stated it was not facility practice to use one resident’s medications for another resident, and the facility policy stated medications ordered for a particular resident may not be administered to another resident.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a medication error rate of 11.67% when seven medication errors occurred out of 60 opportunities during medication administration observations for five residents. During the observed medication pass, a nurse administered enteric coated aspirin to one resident whose order was for aspirin 81 mg capsule, and later stated the facility did not have aspirin capsules available. The same nurse also gave enteric coated aspirin to another resident whose order was for chewable aspirin, and acknowledged the resident’s order was for chewable aspirin. During the same observation, a nurse crushed enteric coated aspirin before giving it to a resident whose order was for aspirin EC 81 mg tablet, and also gave docusate as a tablet instead of the ordered capsule. The nurse stated she was not supposed to crush enteric coated aspirin and that the resident needed chewable aspirin if the medication was to be crushed. The consultant pharmacist stated enteric coated aspirin needed to be swallowed whole and could not be crushed. Additional errors were observed with other residents. One resident received a daily multivitamin tablet even though there was no physician order for it, and the nurse stated the resident did not have an order for multivitamin tablets. Another resident did not receive the ordered lacosamide because staff said the facility was out of the medication and did not know where it was stored in the medication cart, although the DON-MDSC acknowledged the medication was available for the morning pass. The same resident also received docusate 100 mg tablet instead of the ordered docusate sodium 50 mg capsule. Facility policy required medications to be administered according to physician orders and for staff to verify the right resident, medication, dose, time, and route.
Food Storage Items Found Unlabeled and Beyond Use Date
Penalty
Summary
Food items were not stored in a sanitary manner in the kitchen, two refrigerators, three freezers, and on the kitchen counter. During an observation of the kitchen and utility room, surveyors found an opened whipped topping in Refrigerator 1 with no opened date, an opened container of canola oil on the kitchen counter with no opened date, and an opened can of thickener on the kitchen counter with no opened date. In Freezer 1, a box of French toast had no use-by date, and in Freezer 2, a plastic bag of hashbrowns had no date labeled. In Freezer 3, a plastic bag of chicken patties and two bags of chicken strips had no dates labeled. Surveyors also found three plastic bags of sandwiches in the resident refrigerator that were beyond the use-by date. The kitchen staff confirmed that all food in the kitchen needed to be labeled and that food in refrigerators and freezers needed an opened date and use-by date, and that unlabeled food and food beyond the use-by date or without an opened date needed to be discarded. The facility diet log showed 47 residents were receiving food from the kitchen, and facility policies required foods stored in refrigerators or freezers to be covered, labeled, and dated, with received dates and use-by dates documented as applicable.
Arbitration agreements lacked a convenient dispute venue
Penalty
Summary
The facility failed to provide a convenient venue to both parties in the Arbitration Agreement for four residents. Review of the arbitration contracts for Residents 16, 26, 41, and 55 showed that the venue for resolving disputes was not included in the agreement. The facility’s policy titled Arbitration Agreement, revised 4/2021, stated that the agreement would provide for the selection of a venue that is convenient to both parties. Resident 16 was admitted with diagnoses including major depressive disorder and anxiety, and records showed capacity to understand and make decisions, with a BIMS score of 15 out of 15. Resident 26 had a history of cerebral infarction, had capacity to understand and make decisions, and had a BIMS score of 15 out of 15. Resident 41 was admitted with major depressive disorder, had capacity to understand and make decisions, and had a BIMS score of 15 out of 15. Resident 55 had adult failure to thrive, fluctuating capacity to understand and make decisions, and a BIMS score of 13 out of 15. Each resident confirmed voluntarily signing the arbitration agreement, and the Administrator confirmed the agreements did not contain the venue and that it would be disadvantageous if a dispute were resolved in a place not convenient for the residents.
Unnecessary Psychotropic Medication Use Without Specific Behavior Documentation
Penalty
Summary
The facility failed to ensure Resident 2 was free from unnecessary psychotropic medication use when the resident received a PRN haloperidol injection without the required documentation of the resident’s behavior before administration or documentation of attempted non-pharmacological interventions. Resident 2 had diagnoses of dementia and psychosis, and the physician’s order dated 11/19/25 directed haloperidol lactate 5 mg IM every 24 hours as needed for angry outburst toward staff and other residents for 14 days. The MAR showed the resident received haloperidol 5 mg injection on 11/27/25 at 1:49 AM, but the licensed progress notes and PRN non-pharmacological intervention and medication flowsheet did not contain the required documentation, which the DON-MDSC confirmed during interview. Resident 2 also received quetiapine 50 mg by mouth twice daily for psychosis manifested by delusional behaviors, but the record did not contain specific targeted behaviors supporting that order. During interview, LVN 1 described the resident’s psychosis behaviors as acting out, sundowning, trying to get out of the wheelchair, falls, and talking to people who were not there. However, the Psychotropic Medication Assessment identified the behavior problem only as delusional behaviors, and the DON-MDSC stated that delusional behaviors were non-specific. The MAR also showed orders to monitor episodes of psychosis manifested by delusional behaviors every shift, but zero episodes were documented in November 2025. The consultant pharmacist stated that indications for antipsychotic medications needed to include specific, measurable, detectable, observable behaviors. The haloperidol and quetiapine prescribing information both included Black Box Warnings stating that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death, and the quetiapine information also listed falls, somnolence, and dizziness as adverse reactions. The facility policy on psychotropic drug treatment stated that PRN psychotropic medications should not be given unless necessary to treat a specific condition documented in the clinical record and that behavior episodes and non-pharmacological interventions should be documented.
Delayed Completion of Comprehensive Admission MDS Assessment
Penalty
Summary
The facility failed to ensure the Comprehensive admission MDS Assessment was completed within 14 days of admission for one resident. Resident 24 was admitted to the facility on the documented admission date, and the Comprehensive admission MDS Assessment had an ARD of 2/6/26. During a concurrent interview and record review on 2/9/26, the DON/MDSC reviewed the assessment and stated it should be completed and signed that day. The assessment showed the RN Assessment Coordinator signed it as complete on 2/9/26. During a later concurrent interview and record review on 2/12/26, the DON/MDSC acknowledged that the Comprehensive admission MDS Assessment was not completed timely. The DON/MDSC stated the assessment should have been completed within 14 days of admission and that the facility did not follow its Resident Assessment policy or the RAI guidelines. The DON/MDSC also stated the assessment was important to identify care areas that needed to be addressed in the care plan.
Failure to Care Plan for Removal of Oxygen Cannula
Penalty
Summary
The facility failed to develop an individualized care plan for Resident 50 to address the resident’s habitual behavior of removing the nasal cannula used for oxygen therapy. Resident 50 was admitted with diagnoses including COPD, Type 2 diabetes mellitus, and muscle weakness, and the order summary indicated oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During an observation, Resident 50 was found asleep in bed with audible wheezing, while the nasal cannula tubing was lying beside the resident’s face and not in the nares, and the oxygen concentrator was running at 2 LPM. During a later observation, Resident 50 was again seen gasping for breath while talking, with the nasal cannula next to the resident in the bed and the oxygen concentrator on. The DON-MDSC stated that Resident 50 had a habitual behavior of removing the nasal cannula, that this behavior was common for the resident, and that it was not addressed in the care plan. The DON-MDSC later stated that the behavior should have been addressed in the care plan to ensure effective oxygen therapy, and confirmed that the facility did not follow its care planning policy requiring an individualized comprehensive care plan developed by the interdisciplinary team.
Lack of Documentation Supporting Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure services met professional standards of quality when Resident 8 did not have documentation supporting a diagnosis of schizophrenia. Resident 8 was admitted and later readmitted to the facility with diagnoses of dementia and schizophrenia listed in the admission record, with schizophrenia shown as having an onset date of 9/21/24. However, the PASARR Level I Screening completed by the facility on 2/20/24 indicated Resident 8 did not have a serious diagnosed mental disorder such as schizophrenia. A review of Resident 8's history and physical examination dated 2/26/24 listed dementia with psychosis and did not include schizophrenia. The MDS dated 11/28/25 listed schizophrenia as an active diagnosis. During interview and record review, the DON-MDSC reviewed the hospital discharge summary dated 9/21/24, which listed dementia and schizophrenia in the resident's past medical history, but stated she was unable to confirm whether clinical documentation in the medical record supported the schizophrenia diagnosis on 9/21/24. The DON-MDSC also stated the facility did not have a policy addressing clinical or documentation requirements for a schizophrenia diagnosis. The facility's charting and documentation policy stated that changes in a resident's medical condition shall be documented in the medical record and that documentation must be objective, complete, and accurate.
Oxygen Therapy Not Delivered as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 50, who was admitted with diagnoses including COPD, Type 2 diabetes, and muscle weakness. Resident 50 had an order for oxygen at 2 L via nasal cannula as needed for shortness of breath. During an observation, Resident 50 was asleep in bed with audible wheezing, and the nasal cannula tubing was lying beside her face rather than in her nares while the oxygen concentrator was on at 2 LPM. On a follow-up observation, Resident 50 was again seen gasping for breath while talking, and the nasal cannula tubing was next to her in the bed while the oxygen concentrator remained on. The LVN stated that Resident 50 removed her nasal cannula at times and acknowledged that she did not check whether the tubing was in place and properly positioned in the nares before leaving the room. The DON stated the nasal cannula should be positioned in the resident's nares to ensure ordered oxygen therapy was received, and the facility policy stated oxygen therapy shall be administered as ordered and the licensed nurse should check that the correct oxygen flow rate is administered in accordance with the physician's order.
Missed anticonvulsant doses due to medication availability confusion
Penalty
Summary
Resident 2 had an active physician order for lacosamide 50 mg, 1 tablet by mouth twice daily for seizure prevention, but the facility did not administer the medication as ordered on four of 10 days. The January 2026 MAR showed the evening dose on 1/31/26 was not given because lacosamide was not available. The February 2026 MAR showed the morning doses on 2/3/26, 2/4/26, and 2/9/26 were also not given because the medication was documented as unavailable. During a medication pass observation, an LVN administered five medications to Resident 2 and stated lacosamide could not be given because the facility was out of the medication. However, on the next day, an opened blister pack of lacosamide with one tablet remaining, another opened blister pack with 14 tablets remaining, and two unopened blister packs each with 15 tablets were found in the locked narcotic drawer of Medication Cart 1. An LVN stated the facility had enough supply of Resident 2's lacosamide for at least the past two weeks, and the DON-MDSC acknowledged the medication was available in January and February 2026. The DON-MDSC also stated staff did not know where lacosamide was stored in the medication cart.
Improperly Closed Dumpster With Exposed Trash
Penalty
Summary
The facility failed to properly close one of four metal dumpsters in the outside garbage area, and the dumpster had trash piled above the top of the container with trash exposed. During a concurrent observation tour and interview with Kitchen Staff, the dumpster was observed partially open, and the staff member confirmed that it was not completely closed. The staff member also stated that the dumpsters must always be closed to prevent harboring rodents. Review of the facility policy titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated that garbage and refuse containing food wastes must be stored in a manner inaccessible to pests and that outside dumpsters provided by garbage pickup services must be kept closed and free of surrounding litter.
Insufficient Bedroom Space in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that multi-resident bedrooms provided the required minimum of 80 square feet of livable space per resident in eight of 18 rooms, identified as Rooms 5, 6, 7, 8, 9, 10, 11, and 12. During a concurrent interview and record review, the Administrator stated the facility had a room waiver approval letter dated 4/24/25 and had submitted a request on 1/5/26 for re-approval of the waiver for the 2026 waiver period. The room waiver approval letter dated 12/3/24 stated that Rooms 5, 6, 7, 8, 9, 10, 11, and 12 were less than 80 square feet per resident in a three-bed room and could be approved for the room waiver. During observations, three beds were seen in the rooms, with two residents occupying one of the rooms at the time of observation. An environmental tour with the Maintenance Supervisor found seven resident rooms with three beds each, and measurements showed room sizes of 238 to 239 square feet, which equaled 79.33 to 79.66 square feet per resident. The Administrator later confirmed that Rooms 5, 6, 8, 9, 10, 11, and 12 did not meet the accommodation requirement per room. Residents in Rooms 5 through 12 stated they were comfortable in their rooms, and no complaints about space or room issues were reported.
Failure to Develop Comprehensive Care Plan for Tobacco and Marijuana Use After Re-Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing tobacco and marijuana use for a resident who was re-admitted with a documented history of marijuana use and multiple medical diagnoses, including heart failure, COPD, and nicotine dependence. Despite the resident's intact cognitive status and previous positive test for THC, the care plan did not include interventions related to marijuana or smoking following re-admission. Both the RN and DON confirmed during interviews and record reviews that no smoking care plan was present in the resident's current records, even though the resident was known to be a smoker and had previously tested positive for THC. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the completion of the required assessment and to be updated upon re-admission from a hospital stay. However, this process was not followed for the resident in question, as no new care plan addressing the resident's tobacco or marijuana use was created after re-admission. This omission was verified by both nursing staff and leadership during the survey.
CNA Worked Without Active Certification and CPR Credentials
Penalty
Summary
A Certified Nursing Assistant (CNA) was found to have provided direct care to residents without maintaining an active State-approved CNA certification and a current CPR certification. Review of the CNA's employee file showed that the CNA's license had expired and there was no documentation of a current CPR certificate. Staffing schedules confirmed that the CNA was assigned and worked shifts on multiple dates while not meeting these requirements. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that both were aware of the requirement for CNAs to have active licenses and CPR certification before providing care. The DSD, responsible for verifying staff credentials, acknowledged that the CNA should not have been scheduled to work. The DON confirmed that the CNA was allowed to work despite the expired license and missing CPR certification, attributing the lapse to an oversight. Facility policies and job descriptions reviewed also specified the necessity of current certification and licensure for employment in these roles.
Failure to Maintain Safe Water Temperatures and Monitoring
Penalty
Summary
The facility failed to maintain a safe water system for 44 residents by not ensuring the proper functioning of the high temperature alarm, which is designed to alert staff when water temperatures exceed 120°F. During interviews, the Maintenance Supervisor confirmed that the high temperature alarm at the nurses station was not working, and the Administrator stated that the Maintenance Supervisor was responsible for daily hot water monitoring and ensuring the alarm was operational. This malfunction meant that staff were not alerted to potentially unsafe water temperatures, as required by facility procedures. Additionally, the facility did not monitor or record hot water temperatures on three separate days in June 2025, as evidenced by blank entries in the Daily Hot Water Temperature Record. The Maintenance Supervisor acknowledged that no checks were performed on those days, which was contrary to the facility's policy requiring daily monitoring to prevent scalding. The facility's policy specifies that water temperatures should be maintained between 105°F and 120°F, and that maintenance staff must conduct and log periodic checks, which was not consistently done.
Failure to Document Vital Signs Prior to Hospital Transfer
Penalty
Summary
The facility failed to assess and document vital signs prior to non-emergent transfers to a general acute care hospital for two residents. For the first resident, who had chronic obstructive pulmonary disease and intact cognition, there was no documentation of vital signs being taken before her transfer to the hospital for increased difficulty breathing and lower leg edema. The last recorded vital signs were from the previous day, and the transfer was conducted without updated assessment. The Director of Nursing (DON) confirmed that it is expected for staff to obtain and document vital signs prior to any transfer, and that unstable vital signs would require ambulance transport rather than the facility van. Similarly, for a second resident with heart failure and moderate cognitive impairment, no vital signs were documented prior to her transfer to the hospital for shortness of breath, increased weakness, and lethargy. The last set of vital signs was recorded the day before the transfer. The DON reiterated that nursing staff are expected to obtain and document vital signs at least one hour before hospital transfer. Facility policy also requires nurses to make detailed observations and record relevant information in the medical record when there is a change in a resident's condition or status, including prior to transfer.
Failure to Complete Abuse Investigation Before Allowing Staff to Return to Work
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse made by a resident against a CNA before allowing the alleged perpetrator to return to work. The resident, who was cognitively intact and had a history of left-sided paralysis following a stroke, reported that the CNA was rough while changing her brief, causing pain and a bump on her left wrist. The incident was reported to the LVN, who assessed the resident and notified the DON and Administrator. The police were also involved and interviewed the resident. The CNA was sent home the evening of the allegation but was allowed to return to work the following morning, before the investigation was completed. The Administrator, who was responsible for the abuse investigation, did not interview the resident or other residents assigned to the CNA prior to allowing the CNA to return to work. The Administrator relied on interviews with staff and the police report, believing there was enough information to permit the CNA's return. The facility's policy required immediate suspension of any employee accused of abuse pending the outcome of a thorough investigation, including interviews with the resident, staff, and other residents cared for by the accused employee. These steps were not completed before the CNA resumed work, resulting in a failure to follow the facility's abuse investigation and reporting procedures.
Improper Food Cooling Process Knowledge in Dietary Staff
Penalty
Summary
The facility failed to ensure that a dietary staff member could accurately verbalize the proper cool down process for cooked foods, which is essential to prevent foodborne illnesses. During an interview, the staff member incorrectly stated that the cooling process from a hot food temperature of 135 degrees Fahrenheit to an ambient temperature of 70 degrees Fahrenheit would take one hour, and from 70 degrees Fahrenheit to a cold temperature of 40 degrees Fahrenheit would take less than an hour. This understanding was inconsistent with the facility's policy, which requires potentially hazardous foods to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and then to 41 degrees Fahrenheit or below within the next 4 hours, not exceeding a total cooling time of 6 hours. This discrepancy in the staff member's knowledge had the potential to expose 44 residents to foodborne illnesses due to improper cooling of food. The staff member mentioned referring to the cool down log when she had questions about the process, indicating a reliance on documentation rather than a clear understanding of the procedure.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices, as observed during a survey. Turkey and bologna were stored at unsafe temperatures, with measurements showing 46.7 F and 46.9 F, respectively, which is above the safe storage temperature of 41 F. This was acknowledged by the Dietary Manager (DM), who stated that storing deli meats above 41 F could lead to foodborne illnesses. Additionally, a dietary aide was observed preparing milk for residents without wearing a beard net, which the DM confirmed was necessary to prevent cross-contamination. Further observations revealed that the air conditioning unit's air outlet grill above the food preparation table was dirty, with a black substance found on it. The DM stated it was the cook's responsibility to clean the unit daily. A lemon juice container intended for cleaning was stored near food items, which the DM acknowledged should be labeled and stored separately to prevent contamination. Lastly, a dietary aide used an expired quaternary sanitizer test kit, which could lead to inaccurate readings and ineffective sanitization, potentially causing foodborne illness.
Expired Medications Administered and Found in E-Kit
Penalty
Summary
The facility failed to ensure that expired medications were not available for use, resulting in a resident receiving an expired medication. During a medication pass observation, an LVN prepared morning doses for a resident, which included an Atrovent inhaler with an expiration date of December 2024. The LVN did not check the expiration date before administering the medication. The resident had been receiving this medication four times a day since February 11, 2025, as per the physician's order for COPD treatment. The LVN confirmed the expiration date and acknowledged that a new inhaler needed to be ordered from the pharmacy. Additionally, during an inspection of a medication cart, an E-Kit containing controlled substances was found to have expired medications, including carisoprodol tablets with an expiration date of December 30, 2024. The facility's policies on expired medications and emergency medications require that expired medications be identified and removed promptly, and that the consultant pharmacist inspects emergency kits monthly. However, these procedures were not followed, leading to the availability of expired medications in the facility.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that multi-resident bedrooms provided the required minimum of 80 square feet per resident in seven out of 17 rooms, specifically Rooms 5, 6, 8, 9, 10, 11, and 12. During an initial tour, it was observed that these rooms contained three beds each, accommodating three residents per room, but only provided approximately 79.6 square feet per resident. The Administrator confirmed that these rooms did not meet the required space per resident and acknowledged the deficiency. Despite the deficiency, there were no complaints from residents or staff regarding insufficient living space, and no negative impacts on the health, safety, and comfort of the residents were observed during the survey. Residents interviewed stated they were comfortable in their rooms. The facility's policy, revised in May 2017, requires that bedrooms measure at least 80 square feet per resident in double rooms, which was not adhered to in the mentioned rooms.
Inconsistent Blood Pressure Medication Management
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review for three residents, which included identifying and making recommendations on non-standardized and inconsistent procedures by nursing staff for holding blood pressure medications. The consultant pharmacist did not address the lack of hold parameters for blood pressure medications ordered by physicians, leading to nursing staff using their clinical judgment to decide when to hold medications. This practice was inconsistent with the facility's policy and procedure for medication regimen reviews. Resident 3 was admitted with diagnoses including hypertensive heart disease with heart failure. The resident had physician orders for lisinopril and carvedilol without hold parameters, and the medication administration record indicated that these medications were administered even when blood pressure readings were low. Similarly, Resident 18 had orders for Lotensin, and the medication was held based on low blood pressure readings without specific hold parameters. Resident 32 also had orders for lisinopril and carvedilol without hold parameters, and the medications were inconsistently held or administered based on nursing judgment. Interviews with nursing staff and the Director of Nursing revealed that the facility relied on nursing clinical judgment to determine whether to hold blood pressure medications, with no clear policies or procedures in place. The consultant pharmacist acknowledged not identifying or making recommendations on these inconsistencies. This lack of standardized procedures and oversight had the potential to affect the effective management of residents' hypertension.
Failure to Attempt Non-Pharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to ensure that antipsychotic medications were used only after non-pharmacological interventions were attempted and the resident was assessed to be in significant distress or a danger to themselves or others. This deficiency was identified in the case of a resident with dementia who was administered Seroquel, an antipsychotic medication, without prior attempts at non-pharmacological interventions. The resident's medical record did not show evidence of hallucinations or delusions, and the facility did not conduct a psychiatric consultation to assess the necessity of the medication. The resident was admitted with a diagnosis of unspecified dementia with psychotic disturbance, but there was no history of psychosis or prior use of antipsychotic medication. Despite this, the facility continued the use of Seroquel, which was initially administered as a one-time dose in the hospital for agitation. The Director of Nursing acknowledged that non-pharmacological interventions were not attempted because the resident had received Seroquel in the hospital. The facility's policy requires that psychotropic drugs be used only after alternative methods have been tried unsuccessfully, and informed consent is obtained, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.11% during a medication administration observation. Three medication errors were identified out of 27 opportunities, involving two residents. The first error involved a Licensed Vocational Nurse (LVN 1) who administered an Advair inhaler to a resident with chronic obstructive pulmonary disease (COPD). The resident, who preferred communication in Spanish, was instructed in English to spit out water after rinsing the mouth, but instead swallowed it. This was due to a communication barrier, as the resident did not understand English well and LVN 1 did not use a Spanish-speaking staff or interpreter. This error had the potential to increase the risk of oral fungal infection. The second error involved the administration of an expired Atrovent inhaler to the same resident. LVN 1 did not check the expiration date before administering the medication, which had expired in December 2024. The third error involved another resident who was given two tablets of acetaminophen instead of the prescribed one tablet. LVN 1 documented the administration of one tablet, but admitted to giving two tablets. These errors were contrary to the facility's policy and procedure for administering medications, which requires checking expiration dates and administering medications as prescribed.
Failure to Honor Resident's Dietary Preference
Penalty
Summary
The facility failed to honor a resident's dietary preference by serving fish during a meal, despite clear instructions to avoid fish. The resident, who was admitted with diagnoses including muscle weakness and failure to thrive, had a meal ticket indicating a preference for no fish at both lunch and dinner. On February 27, 2025, during a tray line observation, it was noted that a slice of fish was placed on the resident's tray, contrary to the stated preference. The dietary manager acknowledged that serving food against the resident's preferences could upset the resident and potentially lead to reduced food intake. The facility's policy on resident food preferences, dated July 2017, emphasizes the importance of assessing and communicating individual food preferences to ensure resident satisfaction.
Failure to Post EBP Signage for Residents
Penalty
Summary
The facility failed to ensure that the required Personal Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents on Enhanced Barrier Precautions (EBP). This deficiency was identified through observation, interview, and record review, revealing that rooms of residents on EBP did not have the necessary signage posted by the door. Specifically, residents with conditions such as wounds, indwelling devices, or those undergoing dialysis were placed on EBP, but there was no signage to inform staff and visitors of the necessary isolation precautions and protective equipment required to prevent the spread of infection. During interviews, a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) confirmed that Resident 7, who had a wound on the right foot, was on EBP, yet there was no signage indicating the required PPE or specific precautions. The Infection Preventionist (IP) also acknowledged that EBP signage should have been posted for the rooms of Residents 4, 6, 7, 8, 18, 21, and 37. The facility's policy and procedure on infection control, dated October 2022, indicated that Enhanced Barrier Precautions are designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes, but this protocol was not followed as required.
Failure to Conduct Timely Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to conduct and complete neurological assessments for a resident following an unwitnessed fall. On January 16, 2025, a resident was found lying face down on the floor next to her bed, with a small pinkish discolored area on her right forehead, and she complained of right shoulder discomfort and nausea. Despite the resident's history of muscle weakness and falling, and being on blood-thinning medication, the required neuro checks were not performed as per the facility's protocol. Licensed Vocational Nurse (LVN 1) initially stated that neuro checks would be initiated every 15 minutes for the first hour, every 30 minutes for the second hour, and then every four hours for 24 hours. However, the neurological assessment was not completed as required, with no assessment of the resident's pupil response and other neurological functions after 9:55 a.m. The LVN was observed attending to other duties and did not return to reassess the resident, and the responsibility was later transferred to Registered Nurse (RN 1), who also did not conduct the necessary assessments. The Director of Nursing (DON) confirmed that the facility's protocol for neuro checks was not followed, and there was no written policy specifically for neuro checks. The DON acknowledged the importance of these assessments to ensure residents do not experience an altered level of consciousness or sustain additional injuries after a fall. The failure to conduct timely and complete neuro checks for the resident, who was at increased risk due to blood-thinning medication, was a significant deficiency in the facility's care protocol.
Failure to Develop Care Plans for Marijuana Use
Penalty
Summary
The facility failed to develop care plans addressing the use of marijuana for two residents, which was identified during a survey. Resident 1, who was admitted with diagnoses including embolism and thrombosis, was found outside the facility feeling unwell and reported using marijuana. Despite this incident, no care plan was initiated to address the marijuana use or the resident's reported symptoms. The Director of Nursing confirmed that the charge nurse did not initiate a care plan for Resident 1's marijuana use, which should have included interventions for monitoring the resident's safety. Similarly, Resident 2, admitted with asthma, was found unresponsive in a wheelchair and later confirmed to have used marijuana. Despite a positive drug screen for marijuana at a general acute care hospital, no care plan was initiated to address this new condition. The Director of Nursing acknowledged that a care plan should have been developed to monitor for adverse effects. The facility's policy requires comprehensive, person-centered care plans to be developed and revised as residents' conditions change, which was not adhered to in these cases.
Failure to Monitor Change in Condition
Penalty
Summary
The facility failed to assess and monitor a change in condition for a resident, which had the potential to delay necessary treatment. On October 25, 2024, the Maintenance Supervisor heard the resident expressing feelings of having a stroke and assisted her into the facility, notifying the nursing staff. Despite the resident's cognitive intactness and her history of embolism and thrombosis, there was no follow-up or monitoring conducted by the nursing staff. The resident had also reported using marijuana, which was not documented or addressed in her care plan. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the RN did not assess the resident, notify the physician, or update the care plan as required by the facility's policy. The DON was unaware of the incident, indicating a lack of communication and adherence to the facility's Change of Condition policy. The policy mandates prompt notification of the physician and detailed documentation when there is a significant change in a resident's condition, which was not followed in this case.
Medication Order Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents' admission orders included all current medications and correct dosages for two residents. Resident 4's admission order for Sertraline, an anti-depressant medication, had an incorrect dosage. The resident was receiving 100 mg twice per day at the General Acute Care Hospital (GACH) but was ordered 100 mg once per day at the facility. This discrepancy led to Resident 4 receiving an incorrect dose of Sertraline on September 6, 2024. Additionally, Resident 5's admission orders did not include her asthma medications, specifically the Symbicort and albuterol inhalers, which were listed on her GACH Discharge Medications list. The facility's Director of Nursing (DON) confirmed that the admission nurse is responsible for reviewing the GACH discharge medication list and obtaining physician orders for the medications. However, Resident 5 did not receive physician orders for her asthma medications upon admission, which was a failure to adhere to the facility's policy and procedure for medication therapy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in common areas and resident bedrooms. During an unannounced visit, multiple residents reported and were observed to be affected by the flies. One resident, who had a diagnosis of cerebral infarction and was cognitively intact, mentioned an increase in flies and was seen swatting at them. Another resident, also cognitively intact, reported flies in his bedroom, stating they were everywhere. A third resident, with moderate cognitive impairment and a diagnosis of pituitary gland cancer, was observed with flies hovering around her face, which had a necrotic area. The facility's maintenance supervisor and director of staff development confirmed that fly traps had been removed from the facility approximately one month prior, leading to an increase in flies. The administrator revealed that the facility had not been contracted with a pest control company since April 2024 due to corporate confusion and non-payment. Although the corporate office sent a maintenance crew monthly to treat for other insects, no treatments for interior flies were provided. The facility's pest control policy, revised in May 2008, stated that the facility should maintain an ongoing pest control program to ensure the building is free of insects and rodents, which was not adhered to in this case.
Delayed Reporting of Alleged Abuse and Unauthorized Medication Administration
Penalty
Summary
The facility failed to report alleged abuse involving three residents to the California Department of Public Health (CDPH) immediately or within 24 hours, as required. The incidents involved verbal abuse and unauthorized administration of medication by Certified Nursing Assistants (CNAs). Resident 1 was allegedly verbally abused by a CNA, who shook the resident's bed, antagonized her, and told her to "shut your mouth." Residents 2 and 3 were allegedly given sleeping medicine by a CNA without proper authorization. These allegations were reported to the facility's Administrator, but not to the CDPH or other authorities within the required timeframe. The Administrator received a call on August 28, 2024, regarding the unauthorized administration of medication to Resident 3, but delayed reporting the incident while waiting for a written statement. The written statement, received on August 30, 2024, included allegations involving all three residents and two CNAs. Despite this, the Administrator did not report the allegations to the CDPH until September 4, 2024, believing more proof was needed. This delay in reporting resulted in a delayed investigation and implementation of corrective actions, placing the residents at risk for further abuse.
Improper Storage of Resident's Electric Wheelchair
Penalty
Summary
The facility failed to treat a resident's possessions with respect and dignity, specifically concerning the storage of the resident's electric wheelchair. During an unannounced visit, it was observed that the electric wheelchair was stored in the maintenance/supply office without any protective cover. Additionally, a large roll of silver window insulation, which belonged to the facility, was placed on top of the wheelchair. This improper storage method had the potential to damage the wheelchair. Interviews with the Maintenance Supervisor and the Director of Nursing confirmed the improper storage practices. The Maintenance Supervisor acknowledged that the wheelchair was not covered and that the insulation roll was not the resident's property. The Director of Nursing expressed that she would expect the wheelchair to be protected and free from facility belongings being placed on it, acknowledging that the current state was disrespectful. The facility's policy on resident rights, which emphasizes treating residents with respect and dignity, was not adhered to in this instance.
Failure to Accommodate Resident's Transfer and Seating Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident 2, who relies on staff for transfers using a Hoyer lift and prefers an electric Hoyer lift for safety and comfort. However, both electric Hoyer lifts in the facility were unavailable due to dead batteries, leaving only a manual lift for use. This situation led to Resident 2 refusing showers in the past when the electric lift was not available. Additionally, Resident 2 prefers to sit in a large Geri-chair when out of bed, but the facility only has one such chair, which is shared among multiple residents, making it unavailable for Resident 2's exclusive use. Resident 2, who was admitted with a diagnosis of left-sided muscle weakness following a cerebral infarction, was observed lying in bed with a disheveled appearance, indicating a lack of proper accommodation for his needs. Interviews with facility staff, including the Maintenance Supervisor, CNA, DON, and Administrator, confirmed the unavailability of the electric Hoyer lifts and the shared use of the Geri-chair. The facility's policy on resident rights emphasizes treating residents with dignity and supporting their care preferences, which was not upheld in this case.
Failure to Coordinate Cardiology Care for Resident with Atrial Fibrillation
Penalty
Summary
The facility failed to coordinate cardiology specialty care for a resident who was diagnosed with atrial fibrillation during a hospital admission. After returning to the facility, the resident requested the Director of Nursing (DON) to notify the physician about the need for a cardiology follow-up. Despite reminders, the resident was not informed of any cardiology appointments. A review of the resident's records from May 4, 2024, to July 1, 2024, showed no documentation of a cardiology consultation. Interviews with the DON and the facility physician (FP) revealed that the FP saw the resident two days after hospital discharge and prescribed Eliquis, but there was no follow-up care with cardiology ordered. The FP stated that the licensed nurses should have followed up with him and that the resident should have been seen by cardiology within a month of discharge. The facility's policies on physician visits and changes in a resident's condition emphasize timely physician visits and prompt notification of significant changes, which were not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when the prescribed antibiotic, Augmentin, was not administered as ordered. Resident 1, who was admitted with chronic obstructive pulmonary disease, did not receive her Augmentin on three occasions due to the medication being unavailable. The medication was supposed to be administered every 8 hours for 7 days, but it was not given on the night of June 6 and twice on June 7. The Licensed Vocational Nurse confirmed that the medication was not administered because it was not available, and the initials on the Medication Administration Record were circled to indicate this. Similarly, Resident 3, who was admitted with diabetes and a urinary tract infection, did not receive Augmentin on two occasions. The medication was ordered to be given three times a day for 10 days, but it was unavailable on June 6 at noon and 10 p.m. The Pharmacist and Registered Nurse indicated that the medication should have been retrieved from the emergency kit while waiting for delivery. The Director of Nursing stated that if the emergency kit does not contain the needed medication, the licensed nurse should notify the physician or obtain a new order. The facility's policy requires medications to be administered within one hour of their prescribed time, and any deviations should be documented in the Medication Administration Record.
Failure to Follow Prescribed Diet Orders for Diabetic Residents
Penalty
Summary
The facility failed to adhere to the prescribed diet orders for two residents, both diagnosed with type 2 diabetes mellitus, during a lunch meal service. On July 1, 2024, Resident 2 was served cheesecake with cherry topping instead of the lemon pound cake specified in their diet order. The resident's physician had ordered a diet of no added salt, low concentrated sweets, and pureed food. The dietary supervisor confirmed that the dessert served was incorrect and did not align with the carbohydrate-restricted diet ordered by the physician. Similarly, Resident 3, who was also on a low concentrated sweets, no added salt, and mechanical soft diet, received the same incorrect dessert of cheesecake with cherry topping. The resident expressed that they regularly received inappropriate desserts and had previously informed the staff. The dietary supervisor acknowledged the error, stating that the dietary staff should have followed the diet spreadsheet and physician's order, which specified lemon pound cake for the resident. Interviews with the Director of Nursing and a review of the facility's policies highlighted that the dietary department failed to follow the physician's orders as required. The facility's policy on therapeutic diets emphasizes the importance of adhering to physician-prescribed diets to support residents' treatment plans. The failure to provide the correct diet had the potential to compromise the nutritional and medical condition of the residents involved.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that the required 80 square feet per resident in multi-resident bedrooms was met for 8 out of 18 rooms. During an unannounced visit, it was observed that rooms 5 through 12 each measured 239 square feet and housed three residents, providing only 79.6 square feet per resident, which is below the required standard. Interviews with residents and staff revealed that while some residents expressed concerns about room size affecting their ability to navigate or store belongings, staff did not report difficulties in providing care due to room size. The Director of Nursing was unaware of the minimum square footage requirements, and the facility's policy stated that rooms should meet federal and state requirements for space per resident. The Administrator confirmed that the rooms in question did not meet the required square footage per resident, as outlined in the facility's policy. Despite this, there were no complaints from residents or staff about inadequate living space or care provision issues due to room size. The facility's policy, revised in May 2017, mandates that bedrooms measure at least 80 square feet per resident in double rooms and 100 square feet in single rooms, which was not adhered to in the identified rooms.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident regarding a pending room change, which is a violation of the resident's rights. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 15, was informed verbally about the room change to accommodate another admission. The resident expressed dissatisfaction with the change, stating a preference for the previous room and indicating that she does not 'react well' to such changes. The facility's policy requires advance notice and documentation of room changes, including written notice to the resident or their representative. However, the Director of Nursing (DON) confirmed that the facility's practice was to verbally notify residents without providing written notice. This lack of written communication was evident in the resident's medical records, which did not contain any documentation of a written notice for the room change.
Facility Fails to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit, resulting in discomfort for residents and potential health risks. During an unannounced visit, it was observed that three out of six sampled resident rooms had temperatures exceeding the maximum limit, with one room reaching 84.7 degrees Fahrenheit. This deficiency was confirmed through observations, interviews, and temperature checks conducted by the Maintenance Supervisor using a handheld laser thermometer. Two residents were directly affected by the excessive heat. One resident, who was cognitively intact and had a history of cellulitis, hemiplegia, and hemiparesis, was found perspiring in his room with a small fan running. He expressed discomfort due to the heat, particularly in the morning when the sun shone directly into his room. Another resident, also cognitively intact and with a history of ventricular tachycardia, COPD, and heart failure, reported feeling too hot and having difficulty sleeping due to the high temperatures. The facility's Maintenance Supervisor indicated that the air conditioning system was functioning properly and that additional measures, such as sprinklers on the roof and industrial fans in the hallways, were in place to manage the heat. However, the facility's Administrator acknowledged that the temperatures in some rooms and the main hallway exceeded the acceptable range. The facility's policies and procedures emphasized maintaining a homelike environment with comfortable and safe temperatures, but the observed conditions did not align with these standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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