Bonita Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in La Habra, California.
- Location
- 1233 West La Habra Boulevard, La Habra, California 90631
- CMS Provider Number
- 055622
- Inspections on file
- 27
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Bonita Hills Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its own policies for documenting and accounting for a resident's personal belongings at discharge. A cognitively intact resident’s clothing and possessions form included an itemized list on admission but the discharge section was left incomplete, marked only with "discharge AMA" and no detailed inventory. During interviews, a CNA and an RN confirmed that staff should have counted, sorted, and documented the resident’s belongings, placed them in a labeled bag, and routed them appropriately, but this was not done. The DON acknowledged that whoever packed the belongings should have specified the items on the form to maintain an accurate account of the resident’s possessions.
A cognitively intact resident arranged a podiatry appointment and left the facility by bus for that visit, but staff failed to obtain and document a physician’s order for the appointment in the EMR. Facility policies required that social services assist with transportation and that licensed staff document all services and appointments in the medical record. An RN, the Social Services Assistant, and the DON all confirmed that no physician order existed for the podiatry appointment, despite knowledge of the scheduled visit and usual practice that such appointments be entered as physician orders so all departments could coordinate care and transportation.
A resident experienced a change in urine color from yellow to dark amber, which was documented by an LVN but not reported to the physician as required by facility policy. Interviews with the LVN, PA, and DON confirmed that the physician was not notified, and there was no documentation of such notification in the medical record.
A licensed nurse administered Tylenol to a resident for a temperature of 99°F, despite a physician's order specifying the medication should only be given if the temperature exceeded 100.5°F. The QA Nurse and DON confirmed that the medication was given outside the ordered parameters.
A resident with suspected financial abuse did not receive the required care plan interventions, as staff failed to implement or communicate protective measures such as increased monitoring and supervision during visits from the alleged perpetrator. Key assessments and documentation were not completed, and staff were not informed of the situation, leaving the resident without appropriate safeguards.
Licensed staff failed to complete required sections of the Dialysis Communication Forms for two residents undergoing hemodialysis, omitting documentation of access site status and general condition before and after treatments, despite physician orders and facility policy. Both the RN and DON acknowledged the importance of these assessments and the incomplete records.
A facility failed to provide a resident with a bed hold for up to seven days upon readmission, placing them in a different room despite available beds in the original room. Additionally, the facility did not provide the resident or their representative with a written bed hold policy upon transfer to a hospital, as required by facility policy. The DON and RN Consultant confirmed the lack of notification, and the Administrator acknowledged the findings.
A long-term care facility failed to implement effective infection control practices, leading to a deficiency. A resident with salmonella was improperly cohorted with another resident, increasing the risk of contamination. Staff, including an RN and a caregiver, did not adhere to PPE protocols, such as hand hygiene and wearing gowns, while providing care. Additionally, a visitor was observed without proper PPE. The facility's policies for transmission-based and standard precautions were not effectively followed, compromising the safety and sanitary environment.
A resident experienced a failure in care when the facility did not monitor their forehead wound and arm skin breakdown every shift as ordered. The resident had a fall resulting in a forehead laceration, and the TAR showed missed assessments. Additionally, the facility did not notify the physician of documented skin breakdowns, as confirmed by interviews with the LVN and DON.
A facility failed to ensure a resident with an order for thickened liquids was evaluated by a speech therapist (ST) as per policy. The resident, unable to make decisions, had orders for nectar consistency liquids, but the care plan lacked this detail. Interviews revealed the RD expected the ST to evaluate liquid consistency, but the ST confirmed no evaluation was done.
The facility failed to assess five residents' ability to handle hot liquids, leading to incidents where two residents with severe cognitive impairment were injured by hot beverages. The facility's policy required such assessments, but they were not conducted, as confirmed by staff interviews and medical record reviews.
A resident requiring nectar-thick liquids was served regular consistency coffee, revealing a lack of staff training and knowledge in preparing thickened beverages. Despite facility policies, CNAs and nurses were responsible for preparation without adequate guidance, leading to potential aspiration risks.
A resident's family reported that the resident felt intimidated by a CNA's care, which was not reported or investigated by the facility as required by their Abuse, Neglect, and Exploitation P&P. The DON and Administrator were aware of the allegation but failed to notify the State Agency or conduct an investigation, posing a risk to resident safety.
A resident was improperly transferred/discharged from a facility after exceeding her out-on-pass time and missing medications. Upon her return, the facility did not allow re-entry, failed to notify her physician, and did not conduct an assessment. The resident was taken to an emergency department, where she experienced elevated blood pressure and low oxygen saturation. The facility did not provide necessary documentation or coordinate a safe transition of care.
A facility failed to provide a required transfer/discharge notice to a resident and their representative before initiating a discharge against medical advice. The resident, who had decision-making capacity, was not informed of their appeal rights or the specific location for transfer. The facility's administrator confirmed the failure to adhere to policies requiring such notice.
A resident in an LTC facility did not receive adequate care for pain and skin conditions. The resident's pain was not fully assessed, and non-pharmacological interventions were not offered before administering medication for severe pain, despite the resident reporting moderate pain. The physician was not informed, and documentation was lacking. Additionally, the resident's skin issues were not comprehensively assessed, and there was no care plan in place. Interviews with staff confirmed these deficiencies.
A resident with impaired cognition and a history of falls was left unattended after requesting assistance to use the bathroom. Despite informing a CNA, the resident did not receive help due to a lack of communication and follow-up among staff. The resident attempted to transfer herself to the toilet, resulting in a fall and a fractured right humerus, requiring hospitalization.
A facility failed to document necessary indwelling urinary catheter care for a resident, as required by their policy. The medical record review showed missing documentation for catheter care on multiple occasions, despite the facility's policy mandating care every shift. Interviews with an LVN and the Infection Preventionist confirmed the lack of documentation and assessment, with the LVN admitting to performing care without documenting it. The Infection Preventionist was also unable to provide the required care plan documentation.
The facility did not follow its policy regarding the management of a resident's personal belongings after the resident's death. The inventory list was not provided to the family, and there was no documented communication about the belongings' disposition. Interviews with staff confirmed the oversight, as the Social Worker did not follow up with the family, and the Director of Medical Record acknowledged the failure to provide the inventory list.
A resident's bedside commode was found rusty and corrosive, and despite the resident informing staff, it was not replaced promptly. The DON was aware and intended to inform maintenance, but the issue persisted, as confirmed by the DSD.
The facility did not meet room size requirements, lacking waivers for rooms under the required 80 square feet per resident. Although a waiver was approved in 2019, none were obtained for 2023 and 2024. The Administrator was unaware of the waiver requirement due to a lack of transition from the previous administrator, and the Maintenance Director confirmed the non-compliance of 16 rooms.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses for 75 residents. Observations revealed wet-stored kitchen equipment, unsanitary cutting boards, undocumented thawing of bacon, and an unclean ice machine. These issues were confirmed by the Dietary Supervisor and other staff.
The facility failed to assess three residents for safe self-administration of medications, as required by policy. A resident with Lung Cleansing Spray, another with hydrocortisone and pain relief creams, and a third with antifungal powder were found with medications at their bedsides without physician's orders, assessments, or care plans. Staff confirmed the lack of necessary documentation and evaluations.
The facility failed to assist two residents in formulating advance directives (ADs). One resident, who was cognitively able, had an AD but the facility did not follow up to obtain a copy. Another resident, with impaired cognitive skills, had a family member interested in creating an AD, but the facility did not assist in this process. These oversights were confirmed by the QA Nurse and SSD.
A facility failed to document a resident's transfer/discharge notice and notify the Ombudsman, as required by policy. The deficiency was identified during a review of the resident's closed medical record, which lacked the necessary documentation. This was confirmed by the SSD and Medical Records Director.
The facility failed to coordinate PASRR assessments for two residents, leading to deficiencies in their care. One resident, initially admitted without a mental health diagnosis, was later diagnosed with schizophrenia and other disorders, but the PASRR was not updated for a Level II review. Another resident had a positive Level I PASRR screening for mental illness, but the required Level II evaluation was not conducted. These failures risked the residents not receiving necessary specialized services.
A facility failed to follow a physician's order for a resident with Alzheimer's disease by not providing a winged low air loss mattress (LALM) as required. The resident was observed on a LALM without the necessary wing, which is crucial for skin management and preventing the resident from rolling out of bed. Both the Treatment Nurse and QA nurse confirmed the absence of the winged LALM, despite the order for its use.
The facility failed to provide necessary respiratory care for three residents. A resident with COPD and acute respiratory failure had a disconnected nasal cannula, leading to low oxygen saturation. Another resident received oxygen at a higher rate than prescribed. A third resident's incentive spirometer was not stored properly and lacked a physician's order and care plan.
A facility failed to accurately assess a resident with a permacath requiring dialysis. The facility's policy required ongoing assessment before, during, and after dialysis, but documentation inaccurately marked the presence of bruit and thrill, which are not applicable for permacath access. Interviews confirmed the inaccuracies, and the facility's leadership acknowledged the findings.
The facility failed to properly store and dispose of medications, including expired Bisacodyl suppositories and a wasted oxycodone tablet. Expired medications were found stored with oral medications, and a wasted narcotic was not disposed of as per policy. The DON confirmed that wasted controlled medications should be immediately disposed of.
The facility failed to ensure safe food handling for food brought by visitors, lacking a designated refrigerator for residents' perishable items. Staff confirmed that such food was improperly stored in the employee refrigerator, contrary to facility policy. The DON stated that leftovers were discarded, and family members were advised to bring food within two hours of consumption. The RD, Dietary Supervisor, Administrator, and DON acknowledged these findings.
The facility failed to adhere to its infection control program, with a CNA not wearing proper PPE for a resident on Enhanced Barrier Precautions and another CNA neglecting hand hygiene protocols while caring for two residents. Additionally, a soiled cloth pad was improperly stored in a shared bathroom, violating facility policy.
The facility failed to maintain the ice machine in safe operating condition by not cleaning and sanitizing it according to the manufacturer's instructions. The Maintenance Supervisor only cleaned the bin and exterior weekly with bleach spray, contrary to the facility's policy and manufacturer's guidelines, which require monthly cleaning with Scotsman Clear 1 solution. The internal parts were cleaned by an outside company every three months. These findings were confirmed by the RD, Dietary Supervisor, Administrator, and DON.
The facility failed to complete entrapment assessments for bed systems, specifically missing documentation for Zones 6 and 7 for three residents using side rails. Observations and interviews confirmed the oversight, with the Maintenance Supervisor acknowledging incomplete assessments. The facility's policy emphasized the importance of assessing entrapment risks, but documentation was lacking, as confirmed by the Administrator and DON.
A facility failed to update a resident's care plan to reflect their DNR status as indicated in the POLST form. The care plan inaccurately documented the resident as a full code, leading to a potential mismatch in care. Both an RN and the DON confirmed the discrepancy and the importance of aligning the care plan with the resident's wishes.
The facility failed to manage two compost bins properly, which were overflowing with trash and not fully covered by lids, attracting insects. The Maintenance Supervisor confirmed the bins were for kitchen food scraps. Facility policy and USDA Food Code require covered containers for food waste. The Administrator and DON acknowledged the deficiency.
The facility failed to maintain complete medical records for two residents, as identified through interviews and record reviews. One resident's MAR lacked documentation for monitoring bleeding, bipolar disorder, and pain levels, while another resident's MAR was incomplete for monitoring body temperature, oxygen saturation, and pain evaluation. These deficiencies were confirmed by the Medical Records Director and the IP.
Failure to Document Resident Belongings at Discharge
Penalty
Summary
The facility failed to follow its discharge process for resident personal belongings for one of five sampled residents. Facility policy on Resident Personal Belongings required the protection of residents' rights to possess personal items and to ensure those belongings were rightfully returned to the resident or representative upon death or discharge. A separate policy on Documentation in Medical Record required that licensed staff and the interdisciplinary team document all assessments, observations, and services in the medical record to provide a clear picture of the resident’s experiences and progress. For Resident 1, who was cognitively intact per the MDS assessment, the Resident's Clothing and Possessions form dated 12/12/25 contained two sections: "On Admission" and "On Discharge." The "On Admission" section listed items brought in at admission, while the "On Discharge" section had only a slash across it with the notation "discharge AMA," and no itemized listing of belongings. During interviews and concurrent closed medical record reviews, staff confirmed that the discharge section of the belongings form for this resident was incomplete. CNA 5 verified that the "On Discharge" section was not filled out and stated that the resident’s belongings should have been counted and sorted by a licensed nurse or CNA, placed in a bag labeled with the resident’s name, and then given to social services. RN 2 also confirmed the form was incomplete and stated that the licensed nurse or CNA team lead should have completed the form to ensure no items were missing. The DON acknowledged these findings and stated that the form should have been completed when staff packed the resident’s belongings, with the person packing the items specifying them on the form so the facility would have an accurate account of the resident’s belongings.
Failure to Obtain and Document Physician Order for Podiatry Appointment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order for a resident’s podiatry appointment, as required by facility policy and practice. The facility’s Transportation policy stated that social services would assist residents with arranging transportation as needed, and the Documentation in Medical Record policy required that licensed staff and the interdisciplinary team document all services provided in the medical record. The resident in question was cognitively intact, had been admitted and later discharged from the facility, and on the day of discharge walked out of the facility to a bus stop stating she had an appointment and was leaving. A progress note documented that the bus picked up the resident and that the physician was made aware. During closed record review, the resident’s order summary failed to show any physician’s order for the podiatry appointment on that date. RN 2 stated that licensed nurses typically enter appointment orders on behalf of the physician and determine transportation and companion needs, and verified that no such order existed for this resident’s podiatry visit. The Social Services Assistant confirmed that the resident had scheduled a podiatry appointment and acknowledged that a physician’s order was needed for the resident to go to the appointment. The DON also verified there was no physician’s order for the podiatry appointment despite social services knowing about it, and stated there should have been an order so all departments would be aware of the appointment. RN 1 reported that, in usual practice, she would enter the physician’s order for any appointment into the EMR, print it, and provide it to social services, and that physicians usually write such appointments in their orders, but she could not recall being informed of this specific podiatry appointment.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services by not notifying a resident's physician when there was a significant change in the resident's condition, specifically a change in urine color from yellow to dark amber. According to the facility's policy and procedure on Notification of Changes, staff are required to inform the physician and the resident or their representative when there is a change that requires such notification. Review of the resident's closed medical record showed documentation by an LVN of the change in urine color, but there was no evidence that the physician was notified of this change. Interviews with the LVN, the physician assistant (PA), and the Director of Nursing (DON) confirmed that the physician was not notified about the resident's dark amber urine. The LVN acknowledged observing and documenting the change but did not report it to the physician, and both the PA and DON verified that there was no documentation of physician notification in the medical record. The failure to notify the physician occurred despite the facility's policy requiring such action when a resident experiences a change in condition.
Failure to Follow Physician's Order for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a licensed nurse administered two tablets of Tylenol (acetaminophen) 325 mg to a resident for a temperature of 99 degrees Fahrenheit. The physician's order specified that acetaminophen was to be given via gastrostomy tube (GT) every six hours as needed for fever, but only if the resident's temperature exceeded 100.5 degrees Fahrenheit. The medication administration record (MAR) confirmed that the medication was given outside the parameters of the physician's order. Interviews with the involved LVN and the facility's QA Nurse verified that the medication was administered contrary to the physician's instructions. The QA Nurse acknowledged that the nurse failed to follow the order, and the Director of Nursing (DON) was informed and acknowledged the findings. The resident in question had been readmitted to the facility and subsequently expired, but the report focuses on the medication administration event and the failure to adhere to the prescribed order.
Failure to Implement and Communicate Care Plan Interventions for Suspected Financial Abuse
Penalty
Summary
The facility failed to implement and communicate comprehensive care plan interventions for a resident with a suspected allegation of financial abuse. According to the facility's policies and procedures, the care plan should be reviewed and revised upon a resident's status change, including incidents of suspected abuse. The care plan for the resident included interventions such as assuring the resident's safety, providing emotional support, establishing visitation guidelines, and monitoring for signs of distress. However, these interventions were not effectively implemented or communicated to all staff involved in the resident's care. Interviews with facility staff revealed that the social services director (SSD) did not assess or monitor the resident regarding the suspected financial abuse, despite being aware of the situation. Certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) were not informed of the allegation or instructed to provide additional monitoring during visits from the alleged perpetrator. The visitor log confirmed that the family member accused of financial abuse continued to visit the resident multiple times after the allegation was reported, without increased supervision or monitoring as outlined in the care plan. Further review and interviews with the director of nursing (DON) and the administrator confirmed that required assessments, documentation of change in condition, post-incident monitoring, and social services assessments were not completed. The care plan interventions were not updated or implemented, and there was a lack of communication to staff regarding the necessary protective measures. This failure had the potential to leave the resident unprotected and without appropriate care and services to meet their needs following the suspected abuse.
Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Dialysis Communication Forms were properly completed for two residents receiving hemodialysis. For both residents, licensed staff did not document required pre- and post-dialysis information, including the status of dialysis access sites and the general condition of the residents upon return from the dialysis center. Medical record reviews showed multiple instances where sections of the Dialysis Communication Forms were left blank, such as shunt location/status, medications administered prior to dialysis, catheter status, and general condition post-dialysis. These omissions were in direct contradiction to the facility's own policies and procedures, which require thorough monitoring and documentation before and after dialysis treatments. Both residents had physician orders for regular hemodialysis and specific instructions to monitor their access sites every shift. Despite these orders, the required documentation was not completed on several dates. During interviews, both the RN and DON acknowledged the importance of conducting and documenting pre- and post-dialysis assessments to ensure appropriate care and timely interventions. The lack of completed documentation meant that the medical records for these residents were incomplete, as confirmed by the facility staff.
Failure to Provide Bed Hold and Notification
Penalty
Summary
The facility failed to ensure that a resident was provided a bed hold for up to seven days when the resident returned to a different room and bed upon readmission. The resident, who had severe cognitive impairment as indicated by a BIMS score of two, was initially admitted to the facility and later transferred to an acute care hospital. Upon readmission, the resident was placed in a different room despite the facility having available beds in the original room. The Director of Nursing (DON) and RN Consultant were unable to provide an explanation for this decision. Additionally, the facility did not provide the resident or the resident's representative with a written bed hold policy upon transfer to the hospital. The facility's policy requires that residents and their representatives be informed of the bed hold policy prior to transfer, but a review of the resident's medical record showed no evidence that this information was provided. The DON and RN Consultant confirmed that no bed hold information was given before the transfer, and the Administrator acknowledged these findings.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, resulting in a deficiency related to the improper cohorting of residents and inadequate use of personal protective equipment (PPE). Resident 2, who was diagnosed with salmonella and placed on contact isolation precautions, was inappropriately cohorted with Resident 1, who did not have salmonella. Both residents were dependent on staff for care and shared a bathroom, increasing the risk of contamination for Resident 1. Interviews with LVN 1, RN 1, and the Director of Nursing (DON) confirmed that Resident 1 should not have been cohorted with Resident 2 due to the high risk of contamination. Additionally, the facility's staff failed to adhere to standard precautions and PPE protocols. RN 1 was observed not performing hand hygiene and not wearing gloves or a gown while providing care to Resident 2, who was under contact isolation precautions. This was verified by RN 1, who acknowledged the importance of following proper infection control measures. Furthermore, a visitor was observed sitting on Resident 2's bed without wearing gloves or a gown, and Caregiver 1 was seen feeding Resident 1 without wearing a gown, despite being in a contact precaution room. Caregiver 1 admitted to not receiving training or education regarding contact precautions. The facility's policies and procedures for transmission-based and standard precautions were not effectively implemented, as evidenced by the observations and interviews conducted. The failure to follow these protocols compromised the safety and sanitary environment of the facility, increasing the risk of disease transmission among residents, staff, and visitors. The Administrator, DON, and RN Consultant were informed of these findings, acknowledging the lapses in infection control practices.
Failure to Monitor and Notify Physician of Resident's Wound and Skin Breakdown
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 3, by not monitoring the resident's wound separation on the forehead and skin breakdown on the left and right arms every shift as ordered by the physician. The resident had an unwitnessed fall resulting in a forehead laceration, and there were physician orders to monitor these areas every shift. However, the Treatment Administration Record (TAR) for November 2024 showed that several shifts left the monitoring sections blank, indicating that the assessments were not conducted as required. Additionally, the facility did not notify the physician of changes in the resident's condition, as indicated by the documentation of 'Y' in the TAR, which signified skin breakdown. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the physician should have been notified of the skin breakdown, but there was no documented evidence of such notifications. The DON also verified the failure to monitor the resident's condition on specific dates, and there was no documentation explaining why the monitoring was not performed.
Failure to Evaluate Resident for Thickened Liquids
Penalty
Summary
The facility failed to ensure that a speech therapist (ST) evaluated a resident who had an order for thickened liquids, as per the facility's policies and procedures (P&P). The resident, who lacked the capacity to understand and make decisions, was admitted with orders for a regular diet with nectar consistency liquids and aspiration precautions. However, the resident's plan of care did not include a care plan for nectar thick consistency beverages, and there was no documentation of an evaluation by the ST. Interviews with the registered dietitian (RD) and registered nurses (RNs) revealed that the RD did not perform a functional ability evaluation and expected the ST to follow up for evaluation of liquid consistency. The RNs confirmed that the need for modified thickened liquids was not addressed in the resident's plan of care. The ST acknowledged that she had not evaluated the resident's swallowing function or the appropriate liquid consistency, which was part of her assessment responsibilities.
Failure to Assess Residents' Ability to Handle Hot Liquids
Penalty
Summary
The facility failed to ensure that five sampled residents were free from accident hazards related to the consumption of hot beverages. The facility's policy and procedure (P&P) for hot liquid safety required an assessment of residents' ability to handle containers and consume hot liquids, with individualized interventions noted on the care plan. However, the facility did not conduct these assessments for the residents involved, leading to incidents where residents were injured by hot liquids. Resident 1, who had severe cognitive impairment and required assistance for eating, spilled hot chocolate on her chest, resulting in second-degree burns. The incident occurred because the resident was not assessed for her ability to handle hot liquids, and the staff member, CNA 5, provided the hot chocolate without consulting a nurse. Similarly, Resident 2, who also had severe cognitive impairment, spilled coffee on himself. The facility's records showed no evidence of an assessment for his ability to handle hot liquids, and staff interviews confirmed that such assessments were not routinely performed. Residents 3, 4, and 5, who had varying levels of cognitive function, were also not assessed for their ability to handle hot liquids, as required by the facility's P&P. Interviews with staff, including the Rehab Director and RN 2, revealed that the facility did not perform specific assessments for handling hot liquids, despite the policy's requirements. The Director of Nursing (DON) acknowledged the lack of assessments for these residents, indicating a systemic issue in adhering to the facility's safety protocols.
Failure to Provide Properly Thickened Liquids
Penalty
Summary
The facility failed to ensure that food and beverages were prepared in a form to meet the individual needs of Resident 2, who required thickened liquids to prevent aspiration. Despite having orders for nectar-thick consistency liquids, Resident 2 was observed consuming regular consistency coffee on multiple occasions. Interviews with various CNAs revealed a lack of knowledge and consistency in preparing thickened liquids, with some staff unsure of the correct amount of thickener to use or the proper method of preparation. The facility's policy and procedure for serving meals indicated that diets should be served according to physician orders, and thickened liquids should be provided by the dietary department. However, the Assistant Dietary Manager confirmed that the responsibility for preparing thickened beverages fell on the CNAs and nurses, who were not adequately trained. The CNAs and nurses expressed confusion about the correct measurements and methods for preparing nectar, honey, or pudding-thickened beverages, with some relying on estimations or incomplete instructions. Further investigation revealed that the facility's in-service training did not adequately cover the preparation of thickened liquids. The Director of Nursing acknowledged that the plan of care for Resident 2 did not reflect the need for thickened liquids, and the in-service training materials provided did not include instructions on the proper preparation of thickened beverages. This lack of training and oversight placed Resident 2 at risk for aspiration, as the staff was not equipped to meet the resident's dietary needs.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of staff-to-resident abuse involving a resident who felt intimidated by the care provided by a CNA. The resident's family informed the facility's Director of Nursing (DON) about the resident's feelings of intimidation, which should have been considered an allegation of abuse according to the facility's Abuse, Neglect, and Exploitation Policy and Procedure (P&P). Despite this, the DON did not recognize the situation as an abuse allegation and did not report it to the State Agency as required. The facility's Administrator was aware of the allegation but confirmed that the facility did not report the incident to the State Agency or conduct an investigation. The facility's P&P mandates that such allegations be reported immediately, but not later than two hours after the allegation is made, and that a thorough investigation be conducted with results reported to the State Agency within five working days. The failure to follow these procedures resulted in the State Agency not being notified, which posed a risk to resident safety.
Improper Transfer/Discharge of Resident
Penalty
Summary
The facility failed to ensure a resident's right to remain in the facility was upheld, resulting in an improper transfer/discharge process. The incident involved a resident who exceeded her out-on-pass time and missed scheduled medications. Upon her return, the facility did not allow her to re-enter, failed to notify her physician, and did not conduct an assessment. The facility also did not coordinate a transition of care with a receiving facility or provide necessary information to the resident or her family for a safe transition. The resident's family member had to transport her to an acute care hospital emergency department, where she waited for hours. During this time, the resident experienced elevated blood pressure and low oxygen saturation levels, along with mild abdominal pain. The facility's actions led to the resident being labeled as discharged against medical advice (AMA) without proper documentation or communication with the resident's physician. Interviews with facility staff, including the social worker and physician, revealed a lack of communication and adherence to the facility's policies and procedures regarding transfers and discharges. The facility did not provide the resident or her family with a written transfer/discharge notice, appeal rights, or information necessary for a safe transition. The facility's administrator acknowledged that the resident did not meet any exemptions for a facility-initiated transfer/discharge and that the physician should have been notified of the resident's return.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a notice of transfer or discharge to a resident and the resident's representative before initiating a transfer or discharge. This deficiency was identified during a review of the facility's policies and procedures (P&P) and the medical record of a resident who was discharged against medical advice (DC AMA). The facility's P&P, revised on 12/19/22, requires that a transfer/discharge notice be provided to the resident and their representative in a language and manner they can understand, including specific details such as the reason for the transfer, the effective date, the new location, and the resident's right to appeal. However, the facility did not provide this notice to the resident or their family member, which could have affected their ability to appeal the decision. The incident involved a resident who had the capacity to understand and make decisions, as noted in their history and physical examination. The resident had a physician's order allowing them to be out on pass for four hours, but upon returning late, the social worker informed the resident and their family member that the resident could not re-enter the facility due to a DC AMA order. The social worker did not provide the required written notice or coordinate the transfer with a receiving provider or transportation company. The facility administrator confirmed that the facility failed to adhere to its P&P by not providing the necessary transfer/discharge notice, which would have included information on appeal rights and contact details for the state ombudsman.
Inadequate Pain and Skin Care Assessment
Penalty
Summary
The facility failed to provide adequate care and services for a resident's pain and skin condition. The resident complained of pain, but the pain was not comprehensively assessed for key characteristics such as location, timing, frequency, and duration. Non-pharmacological interventions were not offered before administering pain medication, and the resident was given medication prescribed for severe pain despite reporting moderate pain. The physician was not informed of the resident's moderate pain level, and there was a lack of documentation regarding the pain assessment and interventions. The resident was admitted with multiple skin issues, but the skin was not comprehensively assessed. The assessment lacked documentation of the size, location, drainage, pain, odor, type of tissue in the wound bed, and extent of redness and skin discoloration. Despite having physician's orders for wound care, the skin assessment was incomplete, and there was no documentation of the resident's refusal to be assessed or the reason for refusal. The care plan to address the resident's skin issues was also missing. Interviews with facility staff revealed that the necessary documentation and communication regarding the resident's pain and skin condition were not completed. The Quality Assurance staff acknowledged the need for a physician's order for moderate pain medication, and the Infection Preventionist confirmed the lack of documentation for the care plan. The failure to document and communicate effectively had the potential to impact the resident's care needs.
Failure to Assist Resident with Toileting Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure that Resident 5 remained free from accident hazards, resulting in the resident sustaining a fracture to the right humerus and requiring hospitalization. Resident 5, who had impaired cognition and was at risk for falls due to gait and balance problems, informed a CNA that she needed to use the bathroom. However, the CNA did not assist her and instead notified the CNA Team Lead to inform the assigned CNA. The assigned CNA was not informed, and Resident 5 attempted to transfer herself to the toilet, leading to a fall. Resident 5 had a history of falls and required assistance with toileting due to impaired mobility and being chair-bound. The facility's policies required adequate supervision and assistance to prevent falls, but these were not followed. The CNA Team Lead used the facility's paging system to request assistance for Resident 5 but did not follow up to ensure the request was fulfilled. Consequently, Resident 5 was left unattended and attempted to use the bathroom on her own, resulting in a fall. Interviews with the CNAs and LVN involved revealed a lack of communication and follow-up regarding Resident 5's need for assistance. The CNAs were occupied with other tasks and did not ensure that Resident 5 received the necessary help. The facility's investigative report confirmed that Resident 5 attempted to use the restroom independently and lost balance, leading to the injury.
Failure to Document Indwelling Urinary Catheter Care
Penalty
Summary
The facility failed to provide necessary care and services for indwelling urinary catheter care for one resident, identified as Resident 4. The facility's policy and procedure (P&P) for catheter care, dated 12/19/22, required catheter care to be performed every shift and as needed. However, the medical record review revealed that the catheter care documentation was missing for Resident 4 on several occasions, specifically on 9/9, 9/10, and 9/14/24. The Treatment Administration Record (TAR) for September 2024 also lacked documented evidence that the indwelling urinary catheter care was performed every shift, despite the presence of other treatments being documented. Interviews with LVN 3 and the Infection Preventionist confirmed the lack of documentation and assessment for the indwelling urinary catheter care. LVN 3 admitted to performing the catheter care but failing to document it, and acknowledged that the care should be given every shift. Additionally, LVN 3 was unable to provide documentation for the care plan addressing the use of the indwelling urinary catheter. The Infection Preventionist also could not provide the necessary documentation for the care plan, verifying the findings of the deficiency.
Failure to Notify Family of Resident's Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the management of a resident's personal belongings, specifically for Resident 4. The policy required that an inventory of the resident's personal items be reviewed and examined by a social services designee and the resident's representative. Additionally, upon a resident's discharge or death, the recipient of the personal items should sign a legal acknowledgment of receipt. In the case of a deceased resident, the facility was to notify the family or responsible agent via certified letter, including a copy of the inventory and options for disposition of the belongings. However, the review of Resident 4's closed medical record revealed that the inventory list was still in the record, and there was no documented evidence that the family was informed about the belongings or offered methods for their disposition. Interviews with facility staff confirmed the oversight. The Social Worker admitted to not following up with Resident 4's family regarding the personal belongings. Furthermore, the Director of Medical Record acknowledged that a copy of the inventory list should have been provided to the resident's representative or family member. This lapse in communication and procedure had the potential to affect the ability of the resident's family to be informed about the resident's belongings, as the facility did not follow its established protocol.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for a resident, identified as Resident C. During an observation on 9/18/24, the frame of Resident C's bedside commode was found to be rusty and corrosive. Resident C expressed discomfort with the condition of the commode and mentioned having informed the staff about it, but it had not been replaced. An interview with the Director of Nursing (DON) confirmed awareness of the issue, and the DON stated that maintenance would be informed to replace the commode. However, by 9/23/24, the commode had still not been replaced, as verified by the Director of Staff Development (DSD) during an interview with Resident C.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to comply with the required room size standards, as it did not obtain the necessary waivers for rooms that did not meet the minimum square footage requirements. During an observation and document review, it was found that multiple rooms were below the required 80 square feet per resident in multi-patient rooms. Although a waiver for room variance was approved in 2019 for several rooms, no waivers were obtained for 2023 and 2024. The Administrator confirmed the lack of current waivers and acknowledged not being aware of the need for them, as there was no handover from the previous administrator. The Maintenance Director also verified the non-compliance of 16 rooms with the required square footage.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk of foodborne illnesses to 75 residents who consumed food prepared in the kitchen. During an inspection, it was observed that kitchen equipment was not air-dried before storage, as required by the facility's policy. Specifically, two clear containers and two metal pans were stored wet. Additionally, two white cutting boards were found to be heavily marred with knife marks and frayed laminate material, making them difficult to clean and sanitize, which is against USDA Food Code standards. Further deficiencies were noted in the thawing process for meats, where a container of completely thawed bacon was found in the walk-in refrigerator without being documented in the Thawing Log. This oversight was confirmed by the Dietary Supervisor. Additionally, the ice machine's splash guard and the outside left area were not clean, with black residue and white hard residue observed. These findings were verified by the Treatment Nurse and Maintenance Supervisor, indicating a lack of adherence to the facility's Ice Machine Cleaning Procedures.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that it was safe for three residents to self-administer medications, as required by their policy and procedure. Resident 59 was found with a bottle of Lung Cleansing Spray at her bedside without a physician's order, assessment, or care plan for self-administration. Despite being cognitively intact and having the capacity to make decisions, there was no documentation supporting her ability to self-administer the medication safely. The resident admitted to purchasing the medication online and using it independently. Resident 72, who had moderate cognitive impairment, was observed with hydrocortisone cream and Pain-A-[NAME] cream at her bedside. Similar to Resident 59, there were no physician's orders, assessments, or care plans in place for her self-administration of these medications. The resident stated that her family brought the medication, and she applied it herself. The lack of documentation and assessment raised concerns about her ability to manage her medications safely. Resident 9 was found with antifungal powder at her bedside, which she claimed to have purchased online and used independently. Although she had the capacity to understand and make decisions, there was no physician's order, assessment, or care plan for her self-administration of the medication. The facility's interdisciplinary team had not evaluated her ability to self-administer medications safely, as required by the facility's policy. Interviews with staff confirmed the absence of necessary documentation and assessments for all three residents.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to assist two residents in formulating advance directives (ADs), which are crucial for ensuring that residents' healthcare wishes are respected when they are unable to make decisions themselves. Resident 62, who was cognitively able to make decisions, had an advance healthcare directive in place, but the facility did not follow up to obtain a copy for their records. Despite a request being made on 8/28/23, no further action was taken to secure the document, leaving the resident's wishes undocumented in the facility's records. Resident 476, who had severely impaired cognitive skills, also lacked an AD. The resident's family member expressed interest in formulating an AD, but the facility did not assist or follow up with the family to complete this process. Interviews with the QA Nurse and SSD confirmed these oversights, acknowledging that the necessary follow-ups were not conducted to ensure the residents' healthcare wishes were documented and respected.
Failure to Document Transfer/Discharge and Notify Ombudsman
Penalty
Summary
The facility failed to ensure proper documentation and notification procedures were followed for the transfer or discharge of a resident. Specifically, the facility did not document the notice of transfer or discharge for a resident who was transferred to an acute care hospital. Additionally, there was no evidence that the Ombudsman was notified about the transfer or discharge, as required by the facility's policies and procedures. The deficiency was identified during a review of the closed medical record of a resident who had been admitted to the facility and later transferred to a hospital. The review revealed that the necessary documentation, including the notice of transfer/discharge and notification to the Ombudsman, was missing from both the paper and electronic medical records. This lack of documentation was confirmed by the Social Services Director and the Medical Records Director during interviews conducted as part of the review process.
Failure to Coordinate PASRR Assessments for Residents
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident 13, who was admitted without a mental health diagnosis, was later diagnosed with schizophrenia, psychosis, depression, and anxiety. Despite these new diagnoses, the facility did not update Resident 13's PASRR to reflect the need for a Level II review, which is necessary for residents with serious mental disorders to receive appropriate specialized services. Similarly, Resident 18 had a positive Level I PASRR screening indicating the presence of a mental illness, but the facility did not conduct the required Level II mental health evaluation. This oversight was confirmed during an interview with the QA Nurse, who acknowledged that the evaluation was not performed. These failures risked the residents not receiving the necessary specialized services for their mental health conditions and potentially being inappropriately placed in the facility.
Failure to Implement Physician's Order for Winged LALM
Penalty
Summary
The facility failed to provide the necessary care and services for a resident, identified as Resident 57, by not following the physician's order to use a winged low air loss mattress (LALM). This mattress is designed to distribute the resident's body weight to prevent skin breakdown and to prevent the resident from rolling out of bed. Resident 57, who has Alzheimer's disease and is unable to make medical decisions, was observed on a LALM without the required wing (bolster) as per the physician's order. The Treatment Nurse and QA nurse confirmed the absence of the winged LALM, despite the existing order for its use. The deficiency was identified during an observation conducted on 7/9/24, highlighting the facility's failure to implement the physician's order for skin management and safety.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents, leading to deficiencies in their care. Resident 57, who had chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and acute congestive heart failure, was observed with a nasal cannula on the floor, disconnected from both the resident and the oxygen concentrator machine. This was contrary to the physician's order for continuous oxygen at three liters per minute. The resident's oxygen saturation level was critically low at 59% until the nasal cannula was reattached, which then improved the saturation level to 94%. Resident 62, who was capable of understanding and making decisions, was observed receiving oxygen at a higher rate than prescribed. The oxygen concentrator was set at 3.5 liters per minute, despite the physician's order for continuous oxygen at 2 liters per minute. This discrepancy was confirmed by the Infection Preventionist (IP) during an observation and interview, who acknowledged that the physician's orders should be adhered to. Resident 726 was found with an incentive spirometer on the bedside table, not stored in a bag, and without a physician's order for its use. Additionally, there was no care plan addressing the use of the incentive spirometer for this resident. The lack of a physician's order and care plan was verified by an LVN, who confirmed that there should have been a physician's order and a developed care plan for the incentive spirometer use.
Inaccurate Dialysis Assessment for Resident with Permacath
Penalty
Summary
The facility failed to ensure accurate ongoing assessment for a resident requiring dialysis services, specifically for Resident 476. The facility's policy and procedure for hemodialysis, revised in September 2022, required ongoing assessment and oversight of residents before, during, and after dialysis treatments. This included monitoring the resident's condition, checking for complications, and using appropriate infection control practices. However, the medical record review for Resident 476 revealed inaccuracies in the documentation of the dialysis access site assessments. The assessments inaccurately marked the presence of bruit and thrill, which are checked for residents with an AV fistula, not for those with a permacath like Resident 476. Interviews with the QA Nurse and LVN 1 confirmed the inaccuracies in the assessments. The QA Nurse verified that Resident 476 had a permacath access site and that the presence of bruit and thrill was incorrectly documented. LVN 1 stated that the charge nurses were responsible for completing the pre and post dialysis assessments and emphasized the importance of accurate assessments for residents with a permacath. The Administrator and DON acknowledged these findings, indicating a lapse in the facility's adherence to its own policies and procedures for dialysis care.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure the proper storage and disposal of medications, as observed during an inspection of Medication Room A. Expired medications, specifically three pieces of Bisacodyl 10 mg suppositories with an expiration date of August 2022, were found stored together with Goodsense Clearlax Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative, an oral medication house supply. This improper storage was confirmed by the Infection Preventionist (IP) during a concurrent interview, who acknowledged that the expired medication should have been disposed of and that oral medications should not be stored with rectal medications. Additionally, the facility failed to properly dispose of wasted narcotic medication stored in Medication Cart A. A half tablet of oxycodone, labeled with a resident's name and dated July 1, 2024, was found in a small plastic bag in the locked narcotic drawer. The Licensed Vocational Nurse (LVN) present during the inspection stated she was unaware of its presence and confirmed it should have been given to the Director of Nursing (DON) for disposal. The DON later verified that wasted controlled medications should be immediately handed over for proper disposal. The resident associated with the medication was cognitively intact and had a physician's order for oxycodone for severe pain, but the wasted medication was not disposed of according to the facility's policy.
Improper Storage of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to ensure safe food handling practices for food brought in by family members or visitors for residents. The facility's policy required that foods be in sealed containers, labeled with the resident's name and date, and stored appropriately based on whether they were shelf-stable or required refrigeration. However, during an observation and interview, it was revealed that the facility did not have a designated refrigerator for storing residents' perishable food items. Instead, these items were improperly stored in the employee refrigerator, which had signage indicating that resident food should not be stored there. Staff members, including an LVN and the DON, confirmed that the facility could not store residents' food in the employee refrigerator, and any leftovers were discarded. Interviews with various staff members, including the RD, Dietary Supervisor, and CNA, further highlighted the lack of a designated storage area for residents' perishable food. The DON stated that family members were advised to bring food within two hours of consumption, but there was no system in place to store food safely if it was not consumed immediately. The facility's failure to provide proper storage for perishable food brought by visitors posed a risk of unsafe food handling, which could lead to foodborne illness. The RD, Dietary Supervisor, Administrator, and DON acknowledged these findings during a follow-up interview.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection control program in several instances. A CNA did not wear the appropriate personal protective equipment (PPE) while providing high-contact care to a resident on Enhanced Barrier Precautions due to dialysis. Despite the signage indicating the need for a gown and gloves, the CNA only wore gloves, which was confirmed by the Director of Nursing (DON). Additionally, a soiled cloth pad was found on top of a toilet tank in a shared bathroom, contrary to the facility's policy that soiled linens should not be kept in resident rooms or bathrooms. This was verified by another CNA who removed the pad and placed it in the dirty linen bin. Another incident involved a CNA who failed to sanitize her hands before and after providing care to two residents. The CNA admitted to forgetting to wash her hands and use gloves, which was against the facility's hand hygiene policy. The DON and the Infection Preventionist (IP) confirmed that staff are required to sanitize their hands before and after resident contact and when moving between residents. These lapses in infection control practices posed a risk for the transmission of communicable diseases within the facility.
Ice Machine Not Properly Cleaned and Sanitized
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine, which was not cleaned and sanitized according to the manufacturer's instructions. The USDA Food Code 2022 and the facility's own policies and procedures require that equipment be maintained in good repair and cleaned regularly. The facility's policy, dated 2020, mandates monthly cleaning and sanitization of the ice machine, including its internal components, as per the manufacturer's recommendations. However, the Maintenance Supervisor admitted to only cleaning the ice machine bin and the outside of the machine weekly, using bleach spray instead of the recommended Scotsman Clear 1 solution. During an interview, the Maintenance Supervisor revealed that an outside company was responsible for cleaning the internal parts of the ice machine every three months, which deviates from the facility's policy. The Maintenance Supervisor confirmed that he did not follow the manufacturer's instructions for cleaning the ice storage bin. The findings were verified and acknowledged by the RD, Dietary Supervisor, Administrator, and DON during a subsequent interview.
Incomplete Entrapment Assessments for Bed Systems
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were complete and that measurements were recorded during bed inspections for three residents. Specifically, the assessments for Zones 6 and 7 were not documented for Residents 17, 62, and 726, who were using side rails as enablers for assistance with bed mobility, transfers, repositioning, and ADL care. This oversight was identified through observations, interviews, and reviews of medical records and facility documents. Resident 726 was observed using bilateral side rails for repositioning, but the Bed System Measurement Device Test Results Worksheet did not show the assessment results for Zones 6 and 7. Similarly, for Residents 17 and 62, the facility's documentation lacked evidence of assessments for these zones, and there was no indication of whether the overall bed assessments passed or failed. Interviews with the Maintenance Supervisor confirmed these findings, acknowledging that the assessments were incomplete and should have included all relevant zones to prevent potential entrapment. The facility's policy on the proper use of bed rails emphasized the importance of assessing the risk of entrapment and ensuring the correct installation and maintenance of bed rails. However, the failure to document complete assessments for Zones 6 and 7 for the residents in question indicates a lapse in adhering to these guidelines. The Administrator and DON were informed of these deficiencies and acknowledged the findings during interviews.
Care Plan Discrepancy with POLST for a Resident
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to accurately reflect the resident's current care needs and interventions. Specifically, the care plan did not reflect the resident's Do Not Resuscitate (DNR) status as indicated in the Physician Orders for Life Sustaining Treatment (POLST) form. The POLST form, signed by both the physician and the resident, indicated DNR, permission for hospitalization, and no artificial means of nutrition. However, the care plan inaccurately documented the resident as a full code, which included instructions to attempt CPR. During an interview and medical record review, a registered nurse (RN) confirmed the discrepancy between the POLST form and the care plan. The Director of Nursing (DON) also verified the inconsistency and acknowledged the importance of aligning the care plan with the POLST to ensure accurate documentation and adherence to the resident's wishes. The failure to update the care plan to reflect the resident's DNR status had the potential to result in care that did not meet the resident's needs.
Improper Management of Compost Bins
Penalty
Summary
The facility failed to properly manage two compost bins, which were observed to be overflowing with trash and not fully covered by their lids. This situation was noted during an observation of the garbage disposal area, where multiple insects and flies were seen on and around the overflowing trash and compost lids. The Maintenance Supervisor confirmed that the compost bins were used for food scraps from the kitchen. The facility's policy and procedure on garbage and trashcans, revised on 5/20/20, requires that all food waste be placed in covered containers and that the dumpster area be free from debris with lids closed. The USDA Food Code 2022 also mandates that outside receptacles for refuse and recyclables containing food residue must have tight-fitting lids. The Administrator and DON were informed of these findings and acknowledged the deficiency.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure the completeness of medical records for two residents, which was identified through interviews, medical record reviews, and facility policy reviews. For Resident 18, the Medication Administration Record (MAR) was incomplete in several areas: monitoring for signs and symptoms of bleeding and bruising related to anticoagulant therapy, monitoring for bipolar disorder manifested by angry outbursts, and monitoring of pain levels. Specific instances of missing documentation included the absence of monitoring for bleeding and bruising on two occasions, lack of monitoring for bipolar disorder on one occasion, and missing pain level monitoring on another occasion. These omissions were verified by the Medical Records Director during a review. Similarly, for Resident 72, the MAR was found to be incomplete and inaccurate regarding the monitoring of body temperature and oxygen saturation levels every shift for suspected or confirmed COVID-19, as well as pain evaluation every shift. The documentation was missing for one shift, which was confirmed by the Medical Records Director. The Infection Preventionist (IP) also verified the missing documentation for both residents' MARs, indicating a failure to meet the residents' care needs as per the facility's policy and professional standards.
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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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