Brighton Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1836 N. Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 555338
- Inspections on file
- 38
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Brighton Care Center during CMS and state inspections, most recent first.
A cognitively intact resident with psychiatric and medical diagnoses reported to a surveyor that someone had hit him hard on the ribs while he was sitting on his bed, stating he only saw a shadow and not the assailant. The allegation was documented in the resident’s care plan and SBAR, and nursing staff notified the DON, who acknowledged that such an allegation of striking constitutes physical abuse and should trigger completion of an SOC 341 and reporting to CDPH, the Ombudsman, and law enforcement. However, the DON and ADM did not report the allegation to external agencies within the two-hour timeframe required by the facility’s abuse reporting policy, instead attributing the report to the resident’s mentation and behavior, resulting in a failure to follow the facility’s abuse reporting procedures.
A resident with a documented gluten allergy, identified in the admission record, assessment, diet order, and care plan, was served a breakfast tray that included sourdough toast containing gluten. The care plan specified honoring food preferences and offering substitutes as needed, and the resident was cognitively intact and able to communicate needs. A CNA reported that the resident stated they were allergic to gluten and could not eat the toast, demonstrating that the meal service did not align with the documented allergy and dietary requirements.
A resident with moderate cognitive impairment and multiple chronic conditions was found to have her call light tied to a bed rail and hanging below the bed, making it inaccessible. The resident was unaware of the call device's location and expressed fear of falling if she tried to reach it. Staff interviews confirmed the call light should have been within easy reach, in accordance with facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with dementia, anxiety, depression, and peripheral vascular disease repeatedly wrapped a bed remote cord around his arms, resulting in skin discolorations. Despite staff observations and documentation of this behavior, no individualized care plan with measurable objectives or interventions was created to address the issue, contrary to facility policy.
A resident with a history of falls and moderate cognitive impairment experienced an unwitnessed fall resulting in a nasal fracture. Although internal notifications and medical care were provided, the facility failed to report the incident to state authorities as required by policy and regulations, leading to a delay in external investigation.
A resident with a colostomy did not have a care plan developed or implemented to address their specific needs, despite having physician orders for colostomy care and requiring moderate assistance with daily activities. Staff interviews confirmed the absence of a care plan, and facility policy requires comprehensive, person-centered care plans for all residents.
A resident with a colostomy did not receive physician-ordered colostomy care, as staff only emptied the colostomy bag without cleansing the site or changing the bag as required. The nurse did not document any refusal of care or notify the physician, despite instructions from the resident's family member, and the medical record lacked evidence of proper documentation or care as per facility policy.
A resident with a colostomy and cancer diagnosis did not receive or have accurately documented the ordered daily colostomy care. Nursing staff either failed to provide the required cleansing and bag change or documented the care as completed without actually performing it, contrary to facility policy requiring accurate and complete treatment records.
Two residents in an LTC facility experienced falls and injuries due to inadequate supervision. One resident, requiring increased assistance, was left unsupervised during breakfast, resulting in rib fractures. Another resident, with poor sitting balance, was left alone during dinner, leading to a femur fracture. The facility failed to update care plans and ensure staff followed supervision protocols, contributing to these incidents.
A resident at high risk for falls experienced multiple unwitnessed falls due to the facility's failure to revise the care plan to include increased assistance and supervision as recommended by a Physical Therapy Recertification note. Despite the resident's diagnoses of dizziness, muscle wasting, and difficulty walking, the care plan was not updated to address these needs, leading to continued fall risks.
A resident with severe cognitive impairment and multiple health issues was left unattended despite their call light being on and calls for help. An LVN did not respond, citing not being the charge nurse, contrary to facility policy requiring prompt response to call lights. This delay in addressing the resident's needs highlights a deficiency in the facility's care practices.
A resident dependent on assistance for ADLs was found with long, jagged, and dirty fingernails and toenails, despite facility policies requiring regular nail care. The resident's care plan indicated a need for assistance with personal hygiene, but this was not adequately provided, leading to the deficiency.
The facility failed to update the Direct Care Service Hours Per Patient Day (DHPPD) as per its policy, leading to potential misinformation about staffing levels. Observations revealed that the DHPPD had not been updated for several days, and interviews with staff confirmed the lapse. The facility's policy requires daily posting of staffing data, including the number of nursing personnel and resident census, which was not adhered to.
A resident's Santyl ointment was found unlabeled, lacking necessary information such as the resident's name and administration instructions, posing a risk of improper medication administration. Additionally, a medication cart was left unlocked and unattended, risking unauthorized access. The facility's policies require proper labeling and secure locking of medication carts.
The facility failed to maintain dignity and respect for two residents. One resident, with muscle wasting and dementia, was left with food-stained clothes and linens, despite needing assistance with daily activities. Another resident, with metabolic encephalopathy and multiple sclerosis, was fed by a CNA standing up, rather than at eye level, which the DON acknowledged could make the resident feel disrespected. The facility's policy on resident rights was not followed in these instances.
The facility failed to develop comprehensive care plans for several residents, leading to potential delays in necessary care. A resident with oxygen needs, another requiring RNA services, and a third refusing RNA services lacked appropriate care plans. Additionally, a resident using a Low Air Loss mattress and another with an indwelling catheter did not have care plans, which are crucial for guiding staff interventions and ensuring continuity of care.
Two residents in a facility were found to have their low air loss (LAL) mattresses set incorrectly, contrary to physician orders and facility policy. One resident, weighing 107 pounds, had a mattress set for 210 pounds, while another, weighing 93 pounds, had a mattress set for 130-180 pounds. This failure to adjust settings according to weight could lead to discomfort and ineffective pressure ulcer management.
A long-term care facility failed to provide appropriate catheter care for two residents, leading to deficiencies in monitoring and documenting signs of urinary tract infections (UTIs). One resident with a history of kidney issues had sediment in the catheter tubing, which was not documented or reported to a physician. Another resident with Parkinson's disease and schizophrenia had catheter tubing touching the floor, posing an infection risk, and sediment was observed but not documented. Staff interviews revealed non-adherence to facility policies, contributing to the deficiency.
The facility failed to provide necessary respiratory care services for four residents, leading to deficiencies in their care. A resident's nasal cannula was improperly placed, and nebulizer equipment was not changed or stored properly. Another resident was not provided with a new humidifier when needed. A third resident received oxygen therapy without a physician's order, and a fourth resident's oxygen tubing was not stored or changed as required, increasing the risk of infection.
Two residents in the facility experienced medication administration deficiencies. One resident did not receive aspirin with food as required, risking stomach irritation, while another received eye drops outside the prescribed time frame. The LVN acknowledged these errors, and the DON emphasized the importance of following physician orders and facility policy to prevent adverse reactions.
A long-term care facility was found to have a medication error rate of eight percent during a survey. Errors included administering aspirin without food and late administration of Simbrinza Ophthalmic Suspension. The LVN involved acknowledged the mistakes, and the DON emphasized the importance of following physician orders and facility policies to prevent adverse reactions.
The facility failed to follow proper food handling practices, as observed by surveyors. Food items in the kitchen were not labeled with names and 'use by' dates, and expired items were not discarded. The Dietary Supervisor confirmed these deficiencies, which violated the facility's policies and the FDA Food Code.
The facility failed to follow infection control protocols, including not changing N95 masks after leaving isolation rooms, allowing a resident to take linen from carts, and not wearing masks during a COVID outbreak. Additionally, a nasal cannula was reused after being on the floor, suction equipment was not cleaned, and PPE was not worn in a droplet isolation room, increasing the risk of infection spread.
The facility failed to provide accessible call light systems for two residents, leading to deficiencies in care. One resident with dementia and depression was unable to reach their call light, while another with functional quadriplegia was given an inappropriate call light for their condition. The facility's policy required alternative communication means for residents with disabilities, which was not followed.
A facility failed to coordinate hospice care for a resident with quadriplegia, metabolic encephalopathy, and multiple sclerosis. Despite the responsible party signing a hospice consent and the administrator signing an agreement, there was no physician order for hospice services, and the facility did not collaborate with Hospice 1. The DON acknowledged the lack of an IDT meeting and follow-up on the hospice request, resulting in a delay in hospice care delivery.
A resident with multiple diagnoses, including contracture of the right hand, did not receive physician-ordered Restorative Nursing Services for passive range of motion (PROM) on the upper extremities. Despite orders for PROM exercises five times per week, the facility's Restorative Orders for November and December 2024 did not include these services. Interviews and record reviews confirmed the absence of RNA services and documentation, leading to a deficiency in maintaining the resident's range of motion and preventing further decline.
A facility failed to ensure proper pharmaceutical services by not labeling an open Humalog insulin vial with an open date and improperly storing two unopened Humulin N KwikPens in a medication cart instead of a refrigerator. The resident involved had chronic kidney disease and type 2 diabetes mellitus. The RN acknowledged the oversight, and the DON explained the importance of dating opened insulin and refrigerating unopened insulin to maintain efficacy.
A resident with diabetes and GERD expressed dissatisfaction with the taste of meals provided, noting that the food was bland and unappealing. A test tray sampling confirmed that the mashed potatoes and carrots lacked flavor, which was acknowledged by the Dietary Supervisor. The facility's policy requires food to be palatable, which was not met in this case.
A resident and their responsible party were not informed of the resident's rights and services upon readmission to the facility. Despite the facility's policy requiring an admission packet to be signed within 48 to 72 hours, the packet was not provided until nearly three years later. Interviews with staff confirmed the oversight, indicating a deficiency in the facility's admission process.
A resident with a history of hemiplegia and alcohol abuse eloped from an LTC facility through a sliding door and an emergency exit with a malfunctioning alarm. The alarm had been non-functional for a year, and maintenance staff failed to report it. The resident was found the next day outside the facility, highlighting a breach in the supervision system.
The facility failed to post and maintain accurate NHPPD forms, omitting actual nursing hours and resident census data on multiple occasions. The forms were not displayed in accessible locations, and many were missing, violating the facility's policy. The DON confirmed the absence of a Director of Staff Development contributed to this issue.
A resident with dementia was transferred to another facility without completing necessary documentation, including a Transfer Assessment form, Discharge Summary, and Physician's order. The resident was not informed of the transfer destination, and the facility failed to follow its own transfer/discharge policy.
A resident with dementia and severe cognitive impairment eloped from the facility due to inadequate supervision and an inaccurate risk assessment. The resident left through an unlocked door during a fire drill when no staff were present to monitor them. The facility's assessment incorrectly identified the resident as low risk for elopement, and the care plan was not updated to include necessary interventions like a wander guard. The facility's policies on safety and supervision were not effectively implemented, leading to the resident's unsupervised departure.
The facility failed to ensure that a registered nurse and two LVNs were competent to provide necessary care, as required by policy. Competency evaluations were not completed for these nurses upon hire, potentially compromising resident safety. Interviews and record reviews revealed that the facility did not adhere to its policy of evaluating nursing skills upon hire and annually.
The facility failed to provide documented evidence of required HCAI permits for roofing work and the replacement of an HVAC unit. Despite the Facility Administrator's belief that the necessary permits were obtained, no documentation was available to confirm HCAI approval for these projects, indicating non-compliance with regulatory requirements.
A resident with dementia and diabetes was found unable to reach their call light, which was on the floor, leading to a potential safety issue. The resident required substantial assistance for daily activities and did not have intact cognition. An LVN confirmed the call light was out of reach, and the DON acknowledged the safety risk, referencing the facility's policy on call light accessibility.
A facility failed to create a care plan for a resident with a PICC line, despite the resident's need for specific care such as daily flushes and weekly dressing changes. The absence of a care plan was confirmed by an LVN and the DON, highlighting a deficiency in meeting the resident's care needs.
The facility failed to maintain proper infection control measures for two residents. A resident's isolation room had an overflowing trash can, posing an infection risk, while another resident's IV tubing was not labeled with the date and time, increasing the potential for infection. These practices were against the facility's infection prevention policies.
A resident with multiple health issues, including dementia and acute kidney failure, experienced swelling and pain in the left hand. Despite facility policies requiring care plans for changes in condition, no care plan was developed to address this issue. The DON confirmed the oversight, which was observed during a survey.
Failure to Timely Report Resident’s Allegation of Physical Abuse to Required Agencies
Penalty
Summary
The facility failed to follow its abuse reporting policy and regulatory requirements when an allegation of physical abuse was made by a resident and was not reported to the California Department of Public Health (CDPH), local law enforcement, or the Ombudsman within two hours. Resident 8, who had diagnoses including schizophrenia, bipolar disorder, and cellulitis of the left lower limb, was cognitively intact per the MDS dated 11/12/2025 and required only supervision or touching assistance for several ADLs. During an interview with a surveyor on 1/26/2026, the resident stated that about a month earlier, while sitting on his bed and reading, someone hit him very hard on his right ribs, cracking them, and that he did not see who hit him but only saw a shadow. The allegation was documented in the resident’s records. The care plan dated 1/27/2026 noted that the resident had alleged being struck by a shadow a month prior, and interventions included close monitoring of the resident’s whereabouts, room visits every two hours and as needed, and following the abuse prohibition protocol. An SBAR dated 1/26/2026 recorded that the resident told the surveyor that someone had struck him on his rib and that he only saw a shadow. Nursing staff, including a RN supervisor, reported that the DON was notified of the resident’s statement that he had been struck on his right side by a shadow. Despite this, the allegation was not reported to external agencies as required by facility policy. The DON acknowledged that an allegation of abuse involving a staff member hitting a resident should be reported to the Administrator, who serves as the abuse coordinator, and that an SOC 341 form should be completed and sent to CDPH, the Ombudsman, and the police. The DON and Administrator both confirmed that the allegation was not reported when they were informed, and the DON stated she did not report it because she attributed the resident’s statement to his mentation and behavior related to his mental illness. Review of the facility’s abuse reporting and investigating policy, revised September 2022, showed that all reports of resident abuse must be immediately reported—defined as within two hours—to the state licensing/certification agency, Ombudsman, and law enforcement, which did not occur in this case.
Failure to Provide Gluten-Free Meal to Resident With Documented Allergy
Penalty
Summary
The facility failed to ensure a resident with a documented gluten allergy received a breakfast tray free of gluten-containing food. The resident’s admission record, admission assessment, diet order and communication, and care plan all identified gluten as a food allergy. The care plan also included interventions to honor the resident’s reasonable food preferences and to offer substitutes for meals as needed. The resident’s MDS indicated the resident was cognitively intact and required only supervision, setup, or clean-up assistance for mobility, dressing, personal hygiene, and eating. Despite these documented allergies and care plan interventions, on 12/22/2025 the resident was served a breakfast tray that included sourdough toast, which contains gluten, along with eggs. A CNA reported that the resident informed him at that time that they were allergic to gluten and could not eat the sourdough toast on the tray. The facility’s failure to prevent the inclusion of gluten-containing food on the resident’s tray had the potential to result in an allergic reaction such as anaphylaxis, as noted in the report.
Call Light Inaccessibility for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when a resident's call light was not within easy reach, as observed during a survey. The call device was found tied to the right-side rail and hanging below the bed frame, making it inaccessible to the resident. During an interview, the resident stated she did not know where her call device was and preferred to stay in bed rather than attempt to reach for it, expressing fear of falling. The resident required partial to moderate assistance with several activities of daily living and had moderate cognitive impairment but was able to make her own decisions and follow commands. Her medical history included type II diabetes mellitus, rheumatoid arthritis, and lumbar spinal stenosis without neurogenic claudication. Staff interviews confirmed that the call light was supposed to be within the resident's reach to ensure timely care and safety. Both a CNA and the Registered Nurse Supervisor stated that the call device should be accessible near the resident's hands, and the Director of Nurses reiterated that the call light is intended to ensure timely responses to resident needs and for safety monitoring. A review of the facility's policy on answering call lights also indicated that the call light should be accessible to residents in various locations, including in bed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Individualized Care Plan for Resident's Harmful Behavior
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions for a resident who exhibited the behavior of wrapping the bed remote cord around his arms. Despite multiple observations and staff interviews confirming that the resident had been engaging in this behavior since early May, and that it resulted in skin discolorations on both arms, there was no care plan in place to address this specific issue. The resident had a history of dementia, anxiety, depression, and peripheral vascular disease, and required varying levels of assistance with daily activities. The absence of a care plan was confirmed during a review of the resident's records with the Director of Nursing, who acknowledged that a care plan should have been created when the behavior was first noted. Staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, reported observing the resident wrapping the cord around his arms, and a Treatment Nurse documented multiple areas of skin discoloration on both forearms. The facility's policy and procedure required that identified problem areas and risk factors be incorporated into the care planning process, but this was not done for the resident's cord-wrapping behavior. As a result, necessary care and services were delayed, leading to the development of skin discolorations on the resident's arms.
Failure to Report Resident Fall to State Authorities
Penalty
Summary
The facility failed to report a fall incident involving a resident in accordance with its own policy and regulatory requirements. The resident, who had a history of falls, chronic obstructive pulmonary disease (COPD), and type II diabetes, experienced an unwitnessed fall resulting in a nasal fracture. The resident required moderate assistance with daily activities and had moderate cognitive impairment. After the fall, the nurse on duty notified the physician, obtained an x-ray order, informed the conservator, and followed the internal chain of command by notifying the Director of Nursing (DON) and the administrator. The resident was subsequently transferred to the hospital for further care. Despite these internal notifications, the facility did not report the fall to the California Department of Public Health (CDPH) or other appropriate agencies as required by both facility policy and state regulations. Interviews with staff, including the Registered Nurse Supervisor, Director of Staff Development, and the administrator, revealed a lack of understanding or misinterpretation of the reporting requirements. The facility's policy clearly states that unusual occurrences affecting resident welfare must be reported to appropriate agencies within specified timeframes, but this protocol was not followed, resulting in a delay in external investigation and potential interventions.
Failure to Develop Colostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a colostomy, as required by facility policy. The resident was admitted and readmitted with diagnoses including colostomy status, malignant neoplasm of the colon, and intestinal abscess. Documentation showed the resident required partial to moderate assistance with activities such as toileting hygiene, bathing, and personal hygiene, and had a colostomy site on the abdomen. Physician orders were in place for colostomy care, including cleansing the site and applying a colostomy bag, but there was no corresponding care plan in the resident's medical record. Interviews with facility staff, including a treatment nurse, registered nurse supervisor, and the DON, confirmed that a care plan addressing the resident's colostomy was not developed. Staff acknowledged that a care plan should have been created to guide nursing interventions, monitor the stoma site, and ensure continuity of care. Review of facility policy indicated that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, but this was not followed for the resident in question.
Failure to Provide Ordered Colostomy Care and Document Refusal
Penalty
Summary
A deficiency occurred when a resident with a colostomy did not receive colostomy care as ordered by the physician. The resident's medical record indicated a diagnosis of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The physician's order required the colostomy site to be cleansed with normal saline, patted dry, and a colostomy bag applied every dayshift. However, during observation, the treatment nurse only emptied the colostomy bag and did not perform the required cleansing or bag change. The nurse stated that she followed instructions from the resident's family member to only empty the bag and admitted to not documenting any refusal of care or notifying the physician, as required. Further review of the resident's medical chart showed no documentation of refusal of colostomy care or physician notification regarding any treatment refusal. The Director of Nursing confirmed that the physician's order was not followed and emphasized the importance of providing treatments as ordered. The facility's policy also required proper colostomy care and documentation of any concerns or refusals, which was not adhered to in this case.
Failure to Accurately Document and Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to ensure accurate and complete documentation of colostomy care for one resident with a history of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The resident required partial to moderate assistance with toileting hygiene and had a physician's order for daily cleansing of the colostomy site with normal saline, patting dry, and applying a colostomy bag every dayshift. Review of the Treatment Administration Record (TAR) for the relevant period showed that the required colostomy care was documented as completed, but direct observation and staff interviews revealed that the care was not actually provided as ordered on at least one occasion. During observation, a nurse was seen only emptying the colostomy bag without performing the required cleansing or bag replacement. Interviews with two treatment nurses confirmed that one did not provide or document the care, while the other documented the care as completed despite not having performed or witnessed it. The Registered Nurse Supervisor and Director of Nursing both confirmed that facility policy requires accurate, complete, and timely documentation by the staff who actually provide the care. Review of the facility's documentation policy further emphasized the need for objective, complete, and accurate records of all treatments and services provided.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to falls and injuries. Resident 1, who was assessed to require increased assistance and supervision to prevent falls, was left unsupervised by CNA 2 while sitting in a wheelchair during breakfast. This lack of supervision resulted in Resident 1 falling and sustaining acute hairline fractures in the ribs. The care plan for Resident 1 was not updated to reflect the need for increased assistance and supervision, despite previous falls and recommendations from physical therapy. Similarly, Resident 2, who had poor static sitting balance and required supervision, was left unsupervised by LVN 1 while sitting on the side of the bed during dinner. This resulted in Resident 2 falling and suffering a mildly displaced fracture of the right femur. The care plan for Resident 2 was not resident-centered and did not include necessary interventions for supervision, despite the resident's cognitive impairments and recommendations from physical therapy. The facility's policies and procedures on safety and supervision were not adequately followed, as both residents were left without necessary supervision, leading to preventable accidents. The facility's failure to revise care plans and ensure staff adherence to supervision requirements contributed to the incidents, highlighting deficiencies in the facility's approach to resident safety and fall prevention.
Failure to Revise Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to revise the care plan for a resident at high risk for falls, which was not updated to reflect the recommendations from a Physical Therapy Recertification note. The resident, who was admitted with diagnoses of dizziness, muscle wasting, and difficulty walking, was assessed as being at high risk for falls. Despite having multiple falls, the care plan was not updated to include increased assistance and supervision as recommended by the Physical Therapy Recertification note dated 3/4/2025. The resident experienced three unwitnessed falls within the facility, with the second and third falls occurring after the Physical Therapy Recertification note was issued. The care plan, initiated on 2/28/2025, did not incorporate the necessary changes to address the resident's need for increased assistance and supervision to mitigate fall risks. The Director of Nursing acknowledged that the care plan should have been revised to reflect these needs, particularly after the third fall when the resident was left unsupervised during breakfast. The facility's policies and procedures for managing falls and developing comprehensive, person-centered care plans were not adhered to, as the care plan did not include measurable objectives and interventions based on the comprehensive assessment. The failure to revise the care plan as per the Physical Therapy Recertification note contributed to the resident's continued risk of falls.
Failure to Address Resident's Call Light Promptly
Penalty
Summary
The facility failed to ensure that a resident's call light was addressed in a timely manner, which is a critical communication tool linking nursing home staff to the needs of residents. This deficiency was observed in the case of a resident who was admitted with diagnoses including dysphagia, muscle weakness, and hypothyroidism, and who had severely impaired cognitive skills for daily decision-making. The resident was dependent on staff for various personal care activities. During an observation, the resident's call light was on, and the resident was heard calling for help, indicating a need for assistance. Despite the call light being on and the resident calling for help, a Licensed Vocational Nurse (LVN) present at the nursing station did not respond, stating that she was not the charge nurse for the resident. Interviews with other staff, including another LVN and the Director of Nursing (DON), highlighted the importance of addressing call lights promptly to prevent residents from feeling helpless and to avoid potential accidents. The facility's policy requires that calls for assistance be answered as soon as possible, but not later than five minutes, with urgent requests addressed immediately. This policy was not adhered to in this instance, leading to a delay in care and services for the resident.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services to a resident who was dependent on assistance for activities of daily living (ADLs). The resident, who was admitted with diagnoses including sepsis, dysphagia, and depression, was observed to have long, jagged, and dirty fingernails and toenails. This condition was noted during an observation and interview with a treatment nurse, who confirmed the poor state of the resident's nails. The resident's Minimum Data Set (MDS) indicated that their cognitive skills for daily decision-making were intact, but they were dependent on personal hygiene assistance. The facility's policies and procedures for ADLs and nail care, which were reviewed, stated that residents unable to perform ADLs independently should receive services to maintain grooming and personal hygiene. The policy specifically outlined the need for daily cleaning and regular maintenance of nails to prevent infections. Despite these guidelines, the resident's care plan, which required assistance with all ADLs, was not adequately followed, resulting in the resident's unkempt nails. This deficiency was identified as a failure to adhere to the facility's established procedures, potentially leading to skin injury, infection, and scarring.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the Direct Care Service Hours Per Patient Day (DHPPD) was updated in accordance with its policy and procedure titled Posting Direct Care Daily Staffing Numbers. During an observation and interview with a licensed vocational nurse (LVN 1), it was noted that the DHPPD had not been updated since 3/4/25, despite the observation taking place on 3/7/25. This lapse in updating the DHPPD was confirmed by LVN 2, who stated that the nursing hours should be posted in every station to reflect the number of Registered Nurses (RN), LVNs, and Certified Nursing Assistants on each shift, based on the resident census. The failure to update the DHPPD could lead to residents and staff receiving incorrect information. Further investigation with the Director of Nursing (DON) revealed that the facility's policy and procedure, dated 1/2021, required the posting of nurse staffing data on a daily basis for each shift. This data should include the number of nursing personnel responsible for providing direct care to residents and should be posted within two hours of the beginning of each shift in a prominent location. The information should also include the facility's name, the current date, the resident census at the beginning of the shift, and the 24-hour shift schedule. The DON acknowledged that the DHPPD was not updated as per the policy, which could potentially misinform residents and visitors about the facility's census and staffing.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that a resident's Santyl ointment was properly labeled according to the facility's policy and procedure. The ointment, used for treating pressure injuries, lacked a label indicating the resident's name, route of administration, medication dose, and frequency of administration. This was observed during a medication preparation by a treatment nurse, who acknowledged that the label had fallen off. The absence of a label posed a risk of the resident not receiving the medication as ordered or directed. Additionally, the facility did not secure medication cart 1, which was found unlocked and unattended. This was confirmed during an observation and interview with a licensed vocational nurse, who admitted the cart was supposed to be locked to prevent unauthorized access. The Director of Nursing reiterated the importance of keeping medication carts locked to prevent unauthorized individuals from accessing medications. The facility's policies and procedures clearly state that medication carts must be securely locked at all times when out of the nurse's view.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident 22, who has diagnoses of muscle wasting and dementia, was observed with food stains on his shirt and bed linens on two separate occasions. Despite being cognitively independent, Resident 22 required assistance with activities of daily living, including dressing and hygiene. Interviews with staff revealed that the resident was not offered a change of clothes or linens, which the Director of Nursing (DON) acknowledged as a dignity issue. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not adhered to in this case. Additionally, Resident 1, who has metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, was not assisted with feeding at eye level. The resident required partial assistance with eating, and during an observation, a Certified Nursing Assistant (CNA) was seen standing while feeding the resident, which the DON stated could make the resident feel disrespected and uncomfortable. The facility's policy also requires staff to treat residents with dignity, which was not followed in this instance, as feeding should be done at eye level to ensure comfort and respect for the resident.
Lack of Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, resident-centered care plans for five residents, leading to potential delays in necessary care and services. Resident 126, who was admitted with diagnoses of trigeminal neuralgia and repeated falls, did not have a care plan for the use of oxygen, despite a physician's order for oxygen administration. The MDS Nurse and the Director of Nursing acknowledged the absence of a care plan, emphasizing its importance for continuity of care and staff guidance. Resident 1, diagnosed with metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, did not have a care plan for Restorative Nursing Assistant (RNA) services for passive range of motion to the bilateral upper extremities, as indicated in the physician's orders. Interviews with the MDS Nurse and Physical Therapist confirmed the lack of a care plan, which is crucial for preventing functional decline and ensuring staff awareness of the resident's needs. Additionally, Resident 37, who had refused RNA services multiple times due to discomfort and pain, also lacked a care plan addressing these refusals, which could have provided interventions and goals to monitor and address the refusals more closely. Resident 59, admitted with contractures and Parkinson's disease, did not have a care plan for the use of a Low Air Loss mattress, which is essential for skin management and preventing pressure ulcers. The absence of a care plan was confirmed by both the Treatment Nurse and a Registered Nurse, who noted the importance of having specific goals and monitoring the effectiveness of the therapy. Similarly, Resident 2, with Parkinson's disease and schizophrenia, did not have a care plan for the use of an indwelling catheter, despite the presence of thick, cloudy sediment in the catheter tubing. The MDS Nurse and the Director of Nursing highlighted the necessity of a care plan to ensure staff are aware of the resident's needs and the interventions required for proper care.
Improper LAL Mattress Settings for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries for two residents, as observed during a survey. Resident 1, who was admitted with conditions including quadriplegia, a stage 4 pressure ulcer, and multiple sclerosis, was found to have an improperly set low air loss (LAL) mattress. Despite a physician's order to monitor the LAL mattress setting according to the resident's weight, the mattress was set at a level suitable for a person weighing 210 pounds, while Resident 1 weighed only 107 pounds. This discrepancy was noted during observations and interviews with the resident and staff, where it was confirmed that the incorrect setting could lead to discomfort and ineffective wound management. Similarly, Resident 59, who was admitted with contractures and Parkinson's disease, was also found to have an LAL mattress set incorrectly. The mattress was set for a weight range of 130 to 180 pounds, while the resident's actual weight was 93 pounds. Observations and interviews with nursing staff confirmed that the setting was inappropriate for the resident's weight, potentially leading to discomfort and ineffective prevention of pressure ulcers. The facility's policy and procedure for low air loss therapy, as well as the operation manual for the mattress system, were not adhered to, as they require the mattress setting to be adjusted according to the resident's weight. The facility's failure to ensure the correct settings of the LAL mattresses for both residents was a deviation from the physician's orders and the facility's own policies. This oversight had the potential to compromise the residents' skin integrity and hinder the healing process of existing pressure injuries. The observations and interviews highlighted a lack of adherence to the prescribed care plans and monitoring protocols, which are essential for effective pressure ulcer management and prevention.
Deficient Catheter Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, leading to a deficiency in monitoring and documenting signs and symptoms of urinary tract infections (UTIs). Resident 1, who had a history of benign prostatic hyperplasia, acute kidney failure, and kidney stones, was observed with sediment in the catheter tubing on multiple occasions. Despite the presence of sediment, which was a sign of potential infection, the facility staff did not document these findings or notify the physician as required by the care plan and physician orders. The facility's policy required staff to monitor for signs of infection and report any unusual findings immediately, but this was not adhered to, resulting in a delay in identifying and treating a possible UTI. Resident 2, diagnosed with Parkinson's disease and schizophrenia, also had an indwelling catheter with observed sediment in the tubing. The catheter tubing was noted to be touching the floor, which posed an infection control risk. Despite these observations, the facility staff failed to document the presence of sediment or notify the physician, as indicated in the treatment administration record. The facility's policy emphasized the importance of keeping catheter tubing off the floor and reporting any signs of infection, but these protocols were not followed, leading to a deficiency in care. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed a lack of adherence to the facility's catheter care policy. Staff acknowledged the presence of sediment and the need to notify the physician, but this was not reflected in the documentation or actions taken. The failure to monitor and document signs of infection, as well as maintain proper infection control practices, contributed to the deficiency in providing appropriate catheter care for the residents.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents, leading to deficiencies in their care. Resident 1's nasal cannula was improperly placed on the cheek instead of the nostrils, and the nebulizer face mask and tubing were not changed weekly or stored properly, increasing the risk of infection. Additionally, the nasal cannula tubing was not labeled or changed weekly as per facility policy. These lapses were confirmed by the Treatment Nurse and Director of Nursing, who acknowledged the potential for infection due to improper storage and labeling. Resident 16 was not provided with a new humidifier when the existing one was empty, contrary to the facility's policy that requires checking and replacing the humidifier to ensure the oxygen remains moist. This was observed by a Restorative Nursing Assistant and confirmed by a Licensed Vocational Nurse and the Director of Nursing. The facility's policy mandates that the humidifying jar should have enough water to bubble as oxygen flows through, and the water levels should be checked every 48 hours. Resident 231 received oxygen therapy without a physician's order, which is against the facility's policy that requires a physician's order for oxygen administration. This was confirmed by the Director of Nursing, who stated that oxygen is considered a medication and should not be administered without an order. Resident 279's oxygen nasal cannula tubing was not stored in a plastic bag when not in use, and the tubing connector was not changed weekly as required, posing a risk for infection. These deficiencies were observed by the Infection Preventionist and confirmed by the Director of Nursing, who emphasized the importance of proper storage and timely changes to prevent contamination.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications according to its policy for two residents, leading to potential adverse effects. For Resident 228, the facility did not administer aspirin with food as indicated in the physician's order. The resident, who was admitted with diagnoses including anemia and atherosclerosis, was observed receiving aspirin without food, despite the order specifying that it should be taken with food to prevent stomach irritation. The Licensed Vocational Nurse (LVN) acknowledged the oversight and the importance of following the order to prevent potential stomach irritation from the NSAID. For Resident 223, the facility did not administer Simbrinza Ophthalmic Suspension within the prescribed time frame. The resident, diagnosed with glaucoma and other conditions, was supposed to receive the eye drops between 8 AM and 10 AM, but the medication was administered late. The LVN admitted the error, noting that the facility's policy allows for medication administration within one hour before or after the prescribed time. The Director of Nursing confirmed that medications should be given as ordered to prevent adverse reactions, emphasizing the importance of adhering to the physician's orders and facility policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent. This was identified during a medication pass observation involving two residents. The first error involved the administration of aspirin to a resident without food, contrary to the physician's order which specified that the medication should be taken with food to prevent stomach irritation. The Licensed Vocational Nurse (LVN) responsible for administering the medication acknowledged the oversight and the importance of adhering to the order to avoid potential adverse effects. The second error involved the late administration of Simbrinza Ophthalmic Suspension to another resident. The medication was administered outside the prescribed time window of 8 AM to 10 AM, which is against the facility's policy that allows for administration within one hour before or after the scheduled time. The LVN admitted to administering the medication late and recognized the importance of timely administration to ensure the medication's effectiveness and to prevent adverse effects. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered as ordered and within the specified time frame. The DON emphasized the necessity of following the physician's orders and facility policies to prevent adverse reactions in residents. The facility's policy on medication administration also specifies that NSAIDs should be given with food or antacids and fluids, which was not followed in the case of the aspirin administration.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which was observed during a survey. The Dietary Supervisor (DS) acknowledged that food items in the kitchen were not labeled with the item name and 'use by' date, and expired food items were not discarded. Specific observations included a gallon bottle of teriyaki sauce with mold, a chunk of ham, a pitcher of dark juice, and several other food items such as peanut butter sandwiches, prepared Jello, and baking powder that were either expired or lacked proper labeling. The facility's policies, including 'Labeling and Dating of Foods' and 'Freezer Storage,' require all food items in storage to be labeled and dated. The DS confirmed that these practices were not followed, which could lead to serving expired or contaminated food to residents. The FDA Food Code also mandates that time/temperature control safety refrigerated foods must be consumed, sold, or discarded by the expiration date, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control measures, as outlined in its policies and procedures, resulting in several deficiencies. Staff members did not change their N95 respirators after leaving the room of a resident who was in respiratory isolation due to a positive COVID-19 test. This was observed on multiple occasions, and both the Infection Preventionist and the Director of Nursing confirmed that the expectation was for staff to change their masks to prevent the spread of infection. The facility's policy clearly stated that disposable respirators should be removed and discarded after exiting the resident's room. Additionally, a resident was observed taking linen from carts in the hallway, which could potentially contaminate the clean linen. Staff members acknowledged this behavior but did not intervene, and the Infection Preventionist was unaware of the issue. The facility's policy emphasized the importance of maintaining a safe and aseptic environment, which was not upheld in this instance. Other deficiencies included staff not wearing N95 masks in the hallways during a COVID outbreak, a resident's nasal cannula being placed on the floor and reused without being replaced, and suction equipment not being cleaned or replaced as per protocol. Furthermore, a staff member entered a droplet isolation room without wearing the required PPE, such as a face shield or goggles, which was necessary to prevent cross-contamination. These actions and inactions contributed to the potential spread of infections within the facility.
Failure to Provide Accessible Call Light Systems for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, leading to deficiencies in their care. Resident 39, who has dementia and depression, was observed on December 11, 2024, without access to a call light, which was placed behind the resident's bed. This resident, who requires assistance with most activities of daily living, was unable to call for help when needed, as confirmed by a Certified Nursing Assistant and the Director of Nursing. The care plan for Resident 39 indicated that the call light should be within reach, but this was not adhered to, resulting in the resident being unable to request assistance for water. Resident 29, diagnosed with functional quadriplegia and bullous pemphigoid, was provided with a call light that required pushing a button, which was inappropriate given the resident's contracted hands. The Director of Nursing acknowledged that the resident needed a touch pad call light, which would be more suitable for their condition. The facility's policy stated that residents should be provided with a means to call for assistance, and if a disability prevents use of the standard system, an alternative should be documented in the care plan. This was not done for Resident 29, leading to a deficiency in meeting the resident's needs.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate with the primary physician, the Interdisciplinary Team (IDT), and Hospice 1 regarding a request to place a resident under hospice care. This deficiency resulted in a delay or lack of coordination in the delivery of hospice care and services to the resident. The resident, who was diagnosed with quadriplegia, metabolic encephalopathy, and multiple sclerosis, had intact cognitive skills for daily decision-making but was dependent on assistance for various activities of daily living. Despite the responsible party signing a hospice consent and the facility administrator signing a hospice agreement, there was no physician order for hospice services, and the facility did not collaborate with Hospice 1. Interviews and record reviews revealed that the Director of Nursing (DON) acknowledged the lack of an IDT meeting to discuss the resident's condition and the failure to follow up on the hospice request. The DON admitted that there was no documented evidence of coordination with the IDT, the resident's primary physician, or collaboration with Hospice 1. The responsible party was under the impression that the hospice did not accept the contract, leading to a misunderstanding about the resident's hospice care status. The facility's policy indicated that staff should collaborate with hospice representatives and coordinate care planning, which was not adhered to in this case.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, who was admitted with diagnoses including metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, was supposed to receive passive range of motion (PROM) exercises for both upper extremities. However, the facility did not include these services in the resident's Restorative Orders for November and December 2024, despite the physician's order for PROM to be performed five times per week. Interviews and record reviews revealed that the resident did not receive the ordered RNA services for the upper extremities, which were crucial for preventing further decline in physical function and contractures. The resident confirmed not receiving these services since November, and the Restorative Nursing Assistant (RNA) stated that the resident's upper extremities were not included in the physician's orders, leading to a lack of PROM exercises for the arms. The Physical Therapist and Registered Nurse confirmed the absence of RNA services and documentation for the upper extremities, which were necessary to prevent worsening contractures and maintain mobility. The facility's policy on Restorative Nursing Services, revised in July 2022, emphasized the importance of supporting residents in maintaining their physiological and psychological resources. However, the failure to implement the physician's orders for PROM on the resident's upper extremities resulted in a deficiency, as the resident was at risk for further decline in physical function and contractures due to the lack of appropriate care and services.
Improper Insulin Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for one of its medication carts, specifically Medication Cart 2, as per the facility's policy. This deficiency was identified during an observation and interview with a registered nurse (RN 2) and involved the handling of insulin medications for a resident. The resident, who was cognitively intact and had a history of chronic kidney disease and type 2 diabetes mellitus, had an open vial of Humalog insulin that was not labeled with an open date, and two unopened Humulin N KwikPens that were improperly stored in the medication cart instead of the refrigerator. During the observation, RN 2 acknowledged that the Humalog vial was opened without an open date label, which she admitted to opening the previous day without documenting. She also confirmed that the Humulin N KwikPens were stored in the cart drawer, contrary to the requirement for refrigeration. The Director of Nursing (DON) further explained that opened insulin must be dated to ensure it is used within its effective period of 28 days, and unopened insulin should be refrigerated to maintain its efficacy. The facility's policy on drug storage and labeling mandates that all medications requiring an open date must be labeled immediately upon opening, and drugs stored under refrigeration must be kept between 36 and 46 degrees Fahrenheit. The failure to adhere to these guidelines for insulin storage and labeling could potentially lead to adverse reactions if the medications were administered to the resident beyond their effective period.
Failure to Provide Palatable Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, as evidenced by the experience of a resident who expressed dissatisfaction with the taste of the food. The resident, who has a history of type 2 diabetes mellitus with diabetic neuropathy and gastroesophageal reflux disease, was on a controlled carbohydrate diet with regular texture and thin liquids consistency. Despite the care plan indicating that the resident's reasonable food preferences should be honored, the resident reported that the food was unappealing and that the alternatives offered were not satisfactory. During a test tray sampling conducted with the Dietary Supervisor, it was found that the mashed potatoes served were bland and dehydrated, and the chopped carrots lacked flavor. The Dietary Supervisor acknowledged that the food lacked flavor and noted that the menu for the day was not satisfactory. The facility's policy and procedure on Food and Nutrition Services Staff, revised in October 2017, stated that food should be palatable, attractive, and served at the proper temperature, which was not adhered to in this instance.
Failure to Provide Admission Packet Upon Readmission
Penalty
Summary
The facility failed to inform a resident and their responsible party of the resident's rights and services upon admission. The resident was initially admitted to the facility and later readmitted after a hospital stay. Despite the readmission being considered a new admission, the facility did not provide the admission packet, which includes the resident's rights and responsibilities, until nearly three years later. This delay in providing the necessary documentation was identified during a review of the resident's records. The resident, who was diagnosed with dementia and depression, was admitted back to the facility from a general acute care hospital. The facility's policy required that an admission packet be signed within 48 to 72 hours of admission, but this was not adhered to. The admission packet, which should have been presented at the time of readmission, was only signed by the responsible party almost three years later, indicating a significant lapse in protocol. Interviews with facility staff, including the Admission Coordinator and Director of Nursing, confirmed that the resident's readmission should have been treated as a new admission, necessitating the completion of a new admission packet. However, due to incomplete and missing records, the packet was not presented to the responsible party until much later. This oversight was acknowledged by the facility's staff, highlighting a deficiency in the facility's admission process and record-keeping practices.
Resident Elopement Due to Malfunctioning Exit Door Alarm
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as Resident 1, who left the facility without staff knowledge or supervision. Resident 1, who had a history of hemiplegia, hemiparesis, alcohol abuse, and traumatic pneumothorax, was admitted with a low risk for elopement. Despite this, the resident managed to leave the facility through a sliding door in his room and an emergency exit door near the laundry room, which had a malfunctioning alarm that did not activate. The incident occurred between 1:38 AM and 1:48 AM, and the resident was not found until the following day, when he was located outside the facility, interacting with unknown individuals and refusing to return. Staff interviews revealed that the sliding door in the resident's room was left open, leading to an alleyway and the emergency exit door, which was unalarmed. The alarm on the exit door had been non-functional since the previous year, and the maintenance staff had not informed the administration about this issue. The facility's policies emphasized the importance of resident safety and supervision, yet the failure to maintain the alarm system compromised these priorities. The maintenance logs did not include checks for the alarm's functionality, and the lack of a working alarm allowed the resident to leave unnoticed, posing a significant safety risk. The facility's administration acknowledged the breach in the supervision system due to the malfunctioning alarm, which was the only tool in place to prevent such incidents.
Failure to Post and Maintain Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the posting of daily nurse staffing information, known as NHPPD (Nursing Hours Per Patient Day). Specifically, the facility did not indicate the actual hours worked by licensed and unlicensed nursing staff responsible for resident care on several dates, including 9/4/2024, 9/6/2024, 9/9/2024, and 9/11/2024. Additionally, the NHPPD forms were not posted in a prominent location accessible to residents and visitors, and forms for certain dates were missing entirely. This resulted in the inaccessibility of accurate daily staffing information, which is crucial for ensuring adequate care. Observations and interviews revealed that the NHPPD forms were incomplete, lacking actual nursing hours and resident census data. The Director of Nursing (DON) acknowledged the absence of a Director of Staff Development to manage the projected hours and the failure to compute and post actual hours. The facility's policy requires NHPPD forms to be posted daily at the beginning of each shift and maintained for 18 months, but this was not followed. The DON confirmed that the forms were not posted in areas easily viewable by residents and visitors, and many forms from previous months were missing, indicating they were not completed or retained as required.
Failure to Follow Transfer/Discharge Policy
Penalty
Summary
The facility failed to adhere to its Facility Initiated Transfer/Discharge policy for one of the three sampled residents, identified as Resident 1. The facility did not complete the necessary Transfer Assessment form before transferring Resident 1 to another facility, Facility 2. Additionally, a Discharge Summary was not completed, which should have included documentation of the basis for Resident 1's transfer. Furthermore, there was no Physician's order obtained for the transfer, and Resident 1 was not informed of the specific facility to which he was being transferred. Resident 1 had a history of fluctuating capacity to understand and make decisions due to dementia, as indicated in the History and Physical Examination. The Minimum Data Set assessment showed severe impairment in cognitive skills for daily decision-making. The Care Plan for Resident 1 included a goal for discharge to a different facility, Facility 3, once rehabilitation goals were met and the resident was medically stable. However, due to a recent elopement episode, the Interdisciplinary Team decided to transition Resident 1 to Facility 2's secured unit for safety reasons. Interviews with the Administrator and Director of Nursing revealed that the proper discharge process was not followed. The Administrator admitted to transferring Resident 1 directly to Facility 2 without following the discharge process or ensuring consent was obtained. The Director of Nursing confirmed the absence of a discharge summary and a physician's order, emphasizing the importance of these documents for ensuring coordinated care and safe transitions. The Medical Records department also noted that the wrong form was completed, further highlighting the lack of proper documentation and adherence to policy.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as Resident 1, due to inadequate supervision and inaccurate risk assessment. On the evening of 8/28/2024, Resident 1, who had a history of dementia and severe cognitive impairment, left the facility unsupervised through an unlocked front door. The resident was not monitored during a fire drill, which provided the opportunity for elopement. Interviews with staff revealed that Resident 1 was not visually checked as required, and the absence of supervision was a critical factor in the incident. The facility's assessment of Resident 1's risk for elopement was inaccurate, as the resident was scored as low risk despite having a history of wandering and exit-seeking behavior. The Minimum Data Set (MDS) and Elopement/Wandering Risk Assessment were not properly updated or completed, leading to a failure in identifying the resident's true risk level. The Director of Nursing acknowledged that the assessment was incorrect and should have indicated a higher risk score, which would have prompted more stringent preventive measures. Additionally, the resident's care plan was not adequately updated upon readmission to the facility. The care plan lacked specific interventions tailored to the resident's needs, such as the use of a wander guard, which was not provided despite being listed in the care plan. The facility's policies on safety and supervision, as well as wandering and elopement, were not effectively implemented, contributing to the resident's unsupervised departure and the subsequent risk to their safety.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that three out of four sampled licensed nursing staff were competent to provide necessary nursing services and care for residents according to the facility's policy and procedure. Specifically, the facility did not evaluate and ensure that a registered nurse and two licensed vocational nurses had the required competencies and skills before they began providing care to residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not complete the Competency Training Validation forms for these nurses upon hire, which is a process used to assess, verify, and document an individual's competencies in specific areas. Interviews with the Infection Preventionist Nurse, Administrator, and Director of Nursing highlighted that the facility's policy required licensed nurses to have their skills evaluated upon hire and annually. However, the records for the registered nurse and two licensed vocational nurses showed that these evaluations were not completed. The facility's policy, revised in May 2019, mandates that all nursing staff meet specific competency requirements and that evaluations be conducted upon hire, annually, and as necessary based on facility assessments. The lack of completed competency evaluations for these nurses had the potential to result in residents not receiving appropriate and safe nursing care, placing them at risk for injury or harm.
Lack of HCAI Permits for Roofing and HVAC Projects
Penalty
Summary
The facility failed to ensure a safe environment by not providing documented evidence of required permits and approvals from the California Department of Healthcare Access and Information (HCAI) for significant construction and equipment installation projects. Specifically, the facility did not have the necessary HCAI permits for roofing work that was conducted after a rainstorm in 2022, which affected three-quarters of the roof with leaks. Despite the Facility Administrator's belief that the facility went through HCAI for the roof replacement, no documentation was available to confirm this during the investigation. The invoices and payment records reviewed did not include any evidence of HCAI approval. Additionally, the facility replaced one of its six HVAC units, specifically HVAC unit #3, without documented evidence of HCAI permits and approvals. Although the Facility Administrator claimed that the replacement was fully documented with permits, the only documentation available was from the City of Pasadena Building & Safety and the State of California Energy Commission, which did not include HCAI approval. This lack of documentation for both the roofing and HVAC projects indicates a failure to comply with regulatory requirements for construction and equipment changes in the facility.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 3, while in bed. This deficiency was observed during a survey when Resident 3 was found yelling for help with the call light on the floor, out of reach. The resident had been admitted with diagnoses including type 2 diabetes and dementia, and required substantial assistance for daily activities such as toileting and dressing. The Minimum Data Set indicated that the resident did not have intact cognition, which further emphasized the need for accessible assistance. During an interview, LVN 5 confirmed that the call light was not within the resident's reach, acknowledging the potential danger as the resident might need medical assistance and be unable to summon help. The Director of Nursing reviewed the facility's policy on answering call lights, which mandates that call lights be accessible to residents when in bed. The DON acknowledged that failure to ensure this could lead to safety issues, including falls, and prevent residents from receiving necessary medical attention.
Failure to Develop Care Plan for PICC Line
Penalty
Summary
The facility failed to develop a comprehensive and resident-centered care plan for a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident was admitted with diagnoses including sepsis and COVID-19 and required specific care for the PICC line, such as daily flushes and weekly dressing changes. However, a review of the resident's Care Plan History revealed that there was no care plan addressing the PICC line care, which was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the absence of a care plan and the potential for inappropriate treatment due to staff being unaware of the PICC line. The Director of Nursing (DON) also confirmed that the facility's policy required care plans to incorporate goals and objectives based on comprehensive assessments, which was not done in this case. The DON emphasized the importance of having a care plan for the PICC line to prevent potential infections and complications that could lead to hospitalization. The lack of a care plan for the PICC line care was identified as a deficiency, as it could result in staff not being informed of the resident's specific care needs.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to observe infection control measures for two residents, leading to potential infection risks. For the first resident, who was admitted with sepsis and COVID-19, the trash can in their isolation room was found overflowing with used gowns, trash, and gloves. This was observed during a visit by a Licensed Vocational Nurse, who acknowledged that such a condition in a COVID-19 room poses an infection control problem and increases the risk of spreading infectious diseases. For the second resident, who was admitted with sepsis and a urinary tract infection, the facility failed to label and date the intravenous (IV) tubing used for administering medication. During an observation by a Registered Nurse, it was noted that the IV tubing lacked a label indicating the date and time it was started. The nurse confirmed that without proper labeling, the age of the IV tubing is unknown, which could lead to infection. The Director of Nursing also confirmed that these practices were against the facility's infection prevention and control policies, which aim to maintain a safe and sanitary environment.
Failure to Develop Care Plan for Resident's Swollen Hand
Penalty
Summary
The facility failed to develop a care plan for a resident who was readmitted with multiple diagnoses, including dementia, repeated falls, muscle wasting, atrophy, and acute kidney failure. The resident had moderately impaired cognitive skills and required maximal assistance with various daily activities. An X-ray conducted due to pain and swelling in the resident's left hand revealed the need for specific care interventions, which were not documented in a care plan. The Director of Nursing acknowledged the absence of a care plan for the resident's left hand swelling, which was contrary to the facility's policy requiring care plans for any change of condition. During an observation, the resident's left hand was visibly swollen, and the resident reported experiencing pain. The facility's policies emphasized the importance of comprehensive care plans to maintain the resident's highest practicable well-being and to prevent avoidable decline, yet these were not followed in this instance.
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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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