Burbank Healthcare & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Burbank, California.
- Location
- 1041 S. Main St., Burbank, California 91506
- CMS Provider Number
- 056129
- Inspections on file
- 100
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 62 (1 serious)
Citation history
Health deficiencies cited at Burbank Healthcare & Rehab during CMS and state inspections, most recent first.
Staff failed to follow the facility’s hand hygiene policy after providing ADLs and incontinent care to a resident with dementia, generalized muscle weakness, and difficulty walking. Two CNAs provided perineal and incontinent care, dressing, and preparation for activities while wearing gloves, then removed and discarded their gloves at the doorway and did not perform hand hygiene with soap and water or ABHR before moving on to other tasks. Both CNAs later acknowledged they did not perform hand hygiene despite knowing it is required before and after resident contact, and the facility’s IP and Administrator confirmed that hand hygiene is required after direct care and glove removal per facility policy.
Kitchen staff failed to follow facility policies requiring daily calibration of food thermometers and routine monitoring and documentation of refrigerator and freezer temperatures. Logs reviewed with dietary leadership showed several days without recorded thermometer calibration and missing entries for multiple cold storage units on both morning and evening shifts. The DSS, ADS, and Administrator all acknowledged that without calibration and documented temperature checks, the accuracy of food temperature monitoring cannot be verified and food may spoil, creating a risk of foodborne illness for residents.
A resident with muscle weakness, prior falls, and a recent stroke was assessed as high fall risk and had physician orders and a care plan directing use of a low bed and floor mats to reduce injury. During observation, surveyors noted a fall-risk indicator at the bedside but no floor mats in place. The resident did not recall having a mat, and the IP, DSD, and Administrator each confirmed that floor mats were ordered, required per the care plan, and intended to prevent injury, yet were not present at the time of the survey, creating potential for injury or fracture if a fall occurred.
Staff failed to implement timely contact precautions and appropriate cohorting for a resident who developed diarrhea consistent with CDI and was later confirmed positive. Despite facility policy requiring contact precautions for suspected CDI and private room placement or cohorting only with low-risk roommates, the infected resident remained in a shared room with two roommates, including one who was immunocompromised and receiving chemotherapy. No infection risk assessments were completed for the roommates, they were not informed or educated about their potential CDI exposure or required precautions, and they were not monitored for CDI symptoms, even though an isolation cart and contact precaution signage were present outside the room.
A cognitively intact resident, admitted with muscle weakness and sepsis, reported that a family member visitor took his wallet, left the building, charged $500 to the resident’s credit card, and then returned the wallet. The resident stated he informed the SW of the incident, and the SW confirmed receiving this report. The Administrator acknowledged being aware that the resident had reported the alleged misappropriation but did not report the allegation to the SSA, despite a facility policy requiring immediate reporting of suspected theft or misappropriation of resident property to state authorities within two hours.
Surveyors found that the facility did not develop or implement a comprehensive, person-centered care plan for an immunocompromised resident with diffuse large B-cell lymphoma, undergoing antineoplastic chemotherapy and with an acquired absence of a kidney. Although the resident’s MDS showed intact cognition and a need for substantial/maximal assistance with ADLs such as toileting hygiene, bathing, lower body dressing, and footwear, staff did not initiate a care plan addressing the resident’s high infection risk. The DON confirmed that neither licensed staff nor the MDS Coordinator created a care plan to address the resident’s immunocompromised status, including the need to avoid cohorting with residents who had active infections, contrary to the facility’s policy requiring comprehensive care plans with measurable objectives and timetables based on a thorough assessment.
The facility failed to revise comprehensive, person-centered care plans for two residents after they were cohorted with a resident who developed CDI and was placed on contact isolation. The cohorted residents had multiple comorbidities, including lymphoma with chemotherapy and acquired absence of a kidney in one, and hypertrophic cardiomyopathy, CKD, type 2 DM, depression, and anxiety disorders in the other, and both required substantial/maximal assistance with ADLs such as toileting hygiene and lower body dressing. Despite the change in their situation when they were grouped with a CDI-positive resident, their care plans were not updated by licensed staff or the MDS coordinator, contrary to facility policy requiring ongoing assessment and revision of care plans when resident conditions change.
A resident with pneumonia and a history of acute kidney failure and UTI was started on levofloxacin 500 mg PO daily for seven days after an abnormal WBC and modest right lower lobe PNA were identified. The care plan directed staff to administer the antibiotic, monitor for adverse reactions, track progress, and monitor VS and infection-related symptoms. The DON reported that residents on antibiotics are to be monitored for adverse effects every shift and that nurses should document this monitoring in progress notes, but review of the record showed only one documented monitoring entry during the entire treatment period. The facility’s antibiotic stewardship policy described oversight of antibiotic use and education on related risks but did not specify monitoring frequency, and the DON acknowledged that monitoring and documentation of antibiotic adverse effects every shift did not occur for this resident.
A resident admitted with acute kidney failure, difficulty walking, and generalized weakness had intact decision-making capacity and required moderate assistance for ambulation. An order was in place for RNA ambulation with a FWW five times weekly, but on two consecutive days RNA staff documented the service as not applicable while another RNA later reported the resident had actually refused RNA multiple times on those days and remained in the facility. The refusals were not reported to the Charge Nurse as required, no RNA was provided on those days, and no person-centered care plan was developed to address the resident’s repeated refusal of RNA services, despite facility policy requiring comprehensive care plans that include services not provided due to a resident’s right to refuse treatment.
A resident with acute kidney failure, difficulty walking, and generalized weakness, who was cognitively intact and required moderate assistance for transfers and walking, had physician orders and a care plan for RNA ambulation with a FWW five times per week. On two consecutive days, RNA documentation was marked as “not applicable,” even though the resident remained in the facility for at least part of that time and no RNA ambulation was provided. An RNA reported the resident refused to walk while awaiting discharge but did not report these refusals to the charge nurse, and the DON stated that RNA ambulation is needed to help prevent decline in ROM and ambulation, contrary to the facility’s restorative nursing policy requiring implementation of individualized restorative interventions.
A resident with acute kidney failure, pneumonia, and intact decision-making capacity had abnormal lab results, including elevated WBC and low Hgb/Hct, for which a physician had been contacted and new orders were reportedly given. However, review of the chart with an RN and the DON showed that the progress notes did not include required documentation of the physician notification, including the time of contact, who called, or the physician’s response or orders. This lack of documentation conflicted with the facility’s charting policy, which requires complete, accurate, and detailed recording of changes in condition and physician notifications.
Two residents and their representatives were not properly notified in writing of transfers or discharges, nor were they informed of their appeal rights or provided with required information about bed-hold policies. In both cases, staff signed the notification forms instead of the residents or their representatives, and the facility failed to mail the notices as required by policy, resulting in incomplete communication of rights and procedures.
A resident with multiple diagnoses, including dementia and hypertension, experienced a 20 mmHg drop in systolic blood pressure between lying and sitting positions while on antipsychotic medication. Despite physician orders and facility policy requiring notification for such changes, the nurse did not notify the physician, and there was no documentation of physician contact regarding this event.
The facility did not ensure that the discharge portion of Inventory Lists was completed for two residents, resulting in incomplete documentation of personal belongings at discharge. Staff interviews revealed that Inventory Lists were not consistently filled out or verified, and belongings were picked up without proper listing or signatures, contrary to facility policy.
A nurse administered blood pressure medication to a resident without reassessing vital signs immediately prior to administration, as required by the physician's order. The nurse had checked the resident's blood pressure and heart rate about 30 minutes earlier, but after the resident initially refused the medication, the nurse later gave the previously prepared medication without a new assessment, resulting in a medication error.
A nurse failed to wear gown and gloves or perform hand hygiene when entering a resident's room under contact isolation precautions. Additionally, after the resident refused crushed medications, the nurse placed the labeled medicine cup inside a medication cart next to a glucometer used for multiple residents, contrary to infection control policy.
A resident with chronic kidney disease and other conditions was placed on contact isolation precautions, and housekeeping staff performed a deep cleaning of the room. However, the required Deep Clean Checkoff List was not completed, resulting in an incomplete medical record. Interviews confirmed the cleaning took place, but no documentation was made to verify the specific actions performed, contrary to facility policy.
A resident with an indwelling urinary catheter and a history of kidney and urinary conditions did not have physician orders for catheter care or monitoring after returning from the hospital. Nursing staff observed abnormal urine characteristics, including hematuria, but did not report these findings to the physician, considering them baseline. Catheter care and irrigation were performed without orders or proper documentation, and the resident was not monitored as required, resulting in undetected infection confirmed by laboratory results.
Two residents with indwelling urinary catheters did not receive proper care, including failure to anchor catheter tubing, monitor urine for hematuria and sediments, and apply wound dressings as required. Staff did not document or report abnormal urine findings, and catheter care orders were missing or not followed, resulting in abnormal urine characteristics and lab results indicating infection.
A resident with an indwelling urinary catheter and multiple urological conditions did not receive care in accordance with their comprehensive care plan. Nursing staff observed abnormal urine characteristics and improper catheter anchoring but did not report these findings to the physician. After a hospital stay, catheter care orders were not renewed, and there was no documentation of catheter care provided, contrary to facility policy and the resident's care plan.
A resident with high risk for pressure ulcers was found to have their low air-loss mattress set at 200 lbs, despite a documented weight of 116 lbs and care instructions to set the mattress based on weight. Nursing staff and the DON confirmed the setting was incorrect and not in line with care plan, physician orders, or manufacturer guidelines, placing the resident at risk for pressure ulcer development.
A CNA failed to accurately document a resident's meal intake percentages at the correct times, resulting in incomplete and inaccurate medical records. The issue was confirmed by both the DSD and DON, who stated that meal intake should be recorded after consumption and for each respective meal. The resident involved had multiple medical conditions and required moderate assistance with eating.
The facility failed to maintain accountability for controlled medications, resulting in missing doses for two residents. Licensed nurses did not document administration in the eMAR, and the DON did not investigate discrepancies or report missing medications to the Administrator. The DON collected medications without proper documentation, and a universal key bypassed the double-lock system, contributing to the deficiency.
The facility failed to document and assess the use of restraints for several residents, including pad alarms and beds placed against walls, without obtaining necessary physician's orders, informed consents, and care plans, as required by policy.
The facility's nursing staff failed to rotate insulin injection sites for four residents, leading to potential adverse effects. Despite physician orders and facility policies requiring site rotation, insulin was repeatedly administered in the same areas, risking tissue injury and affecting medication absorption. The ADON and DON confirmed these deficiencies, highlighting a lack of adherence to professional standards of care.
The facility failed to provide proper pressure ulcer care for four residents by inaccurately labeling and setting Low Air Loss Mattresses (LALM) according to residents' weights or physician orders. One resident's LALM was set at 160 pounds but labeled for 200 pounds, while another's was set at 200 pounds per a physician's order despite weighing 151 pounds. A third resident's LALM was set at 160 pounds, although the resident weighed 131 pounds, and the machine was labeled for 120 pounds. Additionally, a fourth resident used a LALM without a physician's order, set to 280 pounds, far above the resident's weight of 138 pounds.
The facility failed to maintain a safe environment for residents, with improper use of fall mats, a malfunctioning bed pad alarm, and inadequate assessment of bed placement as a restraint. These deficiencies increased the risk of injury for several residents.
The facility failed to properly dispose of medications in Medication Room Station 1, where the pharmaceutical waste bin contained intact loose medication tablets, capsules, and an albuterol inhaler. The DON acknowledged that the medications were not disposed of according to facility policy, which requires disintegration by liquid to prevent retrieval. The improper disposal practices did not align with EPA recommendations and facility policies, increasing the risk of medication diversion and accidental exposure.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications by not providing specific, measurable target behaviors for quetiapine use. The lack of specificity in monitoring led to inconsistent documentation by different nurses, hindering accurate assessment of the medication's effectiveness. Facility policies required specific target behaviors for behavioral symptoms, which were not followed.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. Two residents were affected: one did not receive a prescribed dose of oyster shell calcium due to unavailability, and another missed a dose of docusate due to oversight. The errors were acknowledged by the LVNs involved and confirmed by the DON, highlighting deviations from the facility's medication administration policies.
A LTC facility failed to ensure residents were free from significant medication errors, including improper administration of epoetin alfa and failure to rotate insulin injection sites. One resident received epoetin alfa against physician orders, while four others had insulin administered in the same areas, risking tissue injury. The facility's policies and guidelines were not followed, leading to these deficiencies.
The facility failed to manage medications properly, leading to deficiencies such as expired anastrazole for a resident with breast cancer, unlabeled budesonide and formoterol inhaler for a resident with COPD, and expired loperamide and improperly stored ipratropium with albuterol inhalation solution. These oversights were acknowledged by the DON and LVNs, highlighting the risk of administering ineffective medications.
The facility did not adhere to prescribed menu and portion sizes, affecting 123 residents on regular texture diets. A staff member failed to level off the scoop when serving rice and carrots, leading to larger portions than specified. This action was against facility policy, which requires correct portioning to prevent unintentional weight gain and complications for diabetic residents. The Dietary Supervisor confirmed the error, highlighting a lapse in following standardized recipes and portion sizes.
The facility failed to prepare puree foods according to IDDSI Level 4 standards, resulting in puree spinach that was too sticky and did not pass the spoon tilt test. This affected 24 residents on a puree diet, potentially due to excessive thickener use, and could lead to difficulties in swallowing or choking.
The facility failed to honor the food preferences of three residents, leading to dissatisfaction and potential nutritional issues. A resident was served green beans despite disliking them, another was incorrectly labeled as lactose intolerant, restricting their preferred dairy options, and a third resident was repeatedly given milkshakes despite disliking milk. These oversights in catering to resident preferences could lead to decreased food intake and weight loss.
The facility failed to maintain safe and sanitary food storage and preparation practices, with chipped racks, ice buildup, and dirty equipment observed in the kitchen. Dented cans were improperly stored, and staff did not fully cover their hair, risking contamination. These deficiencies could affect all 168 residents receiving food and ice.
The facility failed to update their medical director application with the State Agency, resulting in non-compliance with State and Federal regulations. Despite receiving a correction notice, the facility did not address the deficiencies, and the Administrator did not verify the facility's license status, relying on corporate notifications instead.
The facility failed to maintain effective infection control, with issues such as oxygen tubing touching the floor, lack of hand hygiene in the dining room, improper water temperature management, and inadequate use of Enhanced Barrier Precautions during enteral feeding. These deficiencies put residents at risk of infection.
A resident with impaired cognitive function and no representative was improperly given verbal consent for antipsychotic medication without convening the required Bioethics Committee. Facility staff acknowledged the oversight, which violated the policy for residents lacking decision-making capacity.
The facility failed to properly document and communicate discharge information for two residents, leading to potential discontinuity of care. A resident's discharge lacked documentation of vital signs, follow-up instructions, and accurate discharge location. Another resident was discharged without vital signs being documented. These deficiencies highlight lapses in the facility's discharge process.
The facility failed to ensure proper PASRR screening for two residents, leading to deficiencies in identifying necessary evaluations and services. One resident required a Level II evaluation due to a positive Level I screening but did not receive it timely. Another resident had discrepancies in their initial PASRR screening, which inaccurately reflected their mental health diagnoses. The ADON was unaware of her responsibilities regarding PASRR follow-up, contributing to these oversights.
A resident was discharged from an LTC facility without proper documentation and communication of follow-up care, specifically a GI consultation. Despite having the capacity to understand and make decisions, the resident's discharge process lacked necessary documentation, including a post-discharge plan of care and medication review. The facility's policies for discharge planning were not followed, leading to a deficiency in ensuring a safe discharge.
A resident with glaucoma and cerebral palsy did not have her prescription eyeglasses replaced after losing them, impacting her daily activities due to poor vision. Despite being prescribed eyeglasses to improve her quality of life, staff interviews revealed a lack of awareness and documentation regarding the resident's eyeglasses. The facility's policy required updating residents' personal property inventories, but this was not followed, leading to a deficiency.
A resident with a contracture of the left hand did not receive a prescribed ulnar splint, necessary for maintaining range of motion. Despite a physician's order and an occupational therapist's recommendation, the splint was not provided due to a failure in the ordering process. The Director of Rehabilitation acknowledged responsibility but could not confirm the order, and the facility's policy indicated therapists should order splints.
Three residents with urinary catheters were at risk for UTIs due to improper catheter care. Observations revealed that the catheter tubing had loops, obstructing urine flow. Despite facility policies requiring catheters to be secured and free of loops, staff failed to comply, increasing the risk of urinary retention and infection.
The facility failed to provide appropriate care for two residents receiving enteral feeding. One resident's enteral formula and water flush bags were not labeled with the administration rate and were not changed daily, posing infection risks. Another resident's feeding tube tip was left uncovered, exposing it to contaminants. These deficiencies risked dehydration, malnutrition, and infection.
A facility failed to obtain informed consent for an antipsychotic medication from a resident lacking decision-making capacity. The resident, with diagnoses including dementia and bipolar disorder, did not have a Resident Representative. Despite cognitive impairments noted in assessments, verbal consent was obtained without proper review. Staff interviews revealed the informed consent process was not followed, and the facility's policy was not adhered to.
Two residents were discharged without proper documentation and adherence to procedures. One resident was discharged to a lower level of care without vital signs or a complete post-discharge plan, while another was discharged home without documented vital signs. The facility's policies for discharge documentation were not followed, potentially delaying necessary care.
A resident with impaired cognition was physically abused by another resident with a history of anger outbursts in an LTC facility. The incident occurred when a CNA was assisting the resident in a wheelchair to the bathroom, and the other resident grabbed the wheelchair-bound resident's arm, causing both to fall. The facility was aware of the aggressive resident's behavior but failed to prevent the incident, resulting in a scratch on the abused resident's cheek.
A facility failed to thoroughly investigate a physical abuse incident between two residents, where one resident grabbed another, causing both to fall. The investigation omitted verbal altercations that preceded the incident, despite witness reports. The involved resident had a history of bipolar disorder, schizophrenia, and dementia. The facility's final report did not include these precipitating factors, contrary to their policy requirements.
Failure to Perform Hand Hygiene After Providing ADLs and Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices by CNAs following provision of ADLs. Resident 4, who had diagnoses including generalized muscle weakness, difficulty walking, and dementia, had documented self-care deficits and required assistance with ADLs, including incontinent care. The resident’s MDS indicated dependence for showering, substantial assistance with toileting, partial assistance with oral hygiene and dressing, and supervision with eating. During an observation, CNA 2 was seen at the doorway of the resident’s room wearing gloves after providing care, then removing and discarding the gloves in a trash receptacle near the doorway without performing hand hygiene with soap and water or alcohol-based hand rub (ABHR). Shortly afterward, CNA 1 was observed removing and discarding gloves in the same manner and then proceeding to a table to document, again without performing hand hygiene. In subsequent interviews, CNA 1 stated she had provided incontinent care and assisted the resident to activities, acknowledged she removed her gloves upon exiting the room, and confirmed she did not perform hand hygiene using ABHR, despite stating that hand hygiene should be performed after resident care due to the risk of contamination. CNA 2 reported she had provided perineal care with warm water and mild soap, assisted with dressing, and prepared the resident for activities, and confirmed she did not perform hand hygiene after providing care, while acknowledging that hand hygiene should be performed before and after resident contact. The Infection Preventionist stated staff are required to perform hand hygiene before entering and after exiting resident rooms and after providing direct care, and that CNA 1 and CNA 2 should have performed hand hygiene after removing gloves. The Administrator stated hand hygiene is required before and after resident care and after resident contact. Review of the facility’s Handwashing/Hand Hygiene policy showed that all personnel are required to perform hand hygiene before and after direct resident contact, after contact with bodily fluids, after removing gloves, and as the final step after removal of PPE, and that glove use does not replace the requirement for hand hygiene.
Failure to Calibrate Thermometers and Document Cold Storage Temperatures
Penalty
Summary
Surveyors identified a deficiency in safe and sanitary food preparation practices when kitchen staff failed to calibrate food thermometers and to monitor and document refrigerator and freezer temperatures as required. Review of the Thermometer Calibration Log with the Dietary Service Supervisor (DSS) showed that thermometer calibration had not been done or documented for multiple consecutive days, including 3/2, 3/3, and 3/4. Review of the Refrigerator & Freezer Temperature Log showed that the p.m. shift temperatures for multiple refrigerators and freezers on 3/3 were not documented, and the a.m. shift temperatures for 3/4 had not yet been logged. The DSS stated that if temperatures and calibrations are not logged, the facility cannot confirm they were done. During interviews, the Assistant Dietary Supervisor (ADS) explained that cooks are responsible for checking refrigerator and freezer temperatures at the start of the a.m. and p.m. shifts and that thermometers are to be calibrated before temperature checks and logged in the morning and monitored throughout the day. The ADS acknowledged that failure to calibrate thermometers and to record refrigerator and freezer temperatures could result in inaccurate readings and potential foodborne illness, and that undocumented temperatures cannot be verified. The Administrator confirmed that calibration is required daily to ensure accurate temperatures and that refrigerator and freezer temperatures must be taken to prevent food from spoiling or going bad, which could cause residents to become ill. Review of facility policies showed written requirements that thermometers be calibrated before each shift and that dietary staff check and record refrigerator and freezer temperatures at the beginning of each shift, with specified acceptable temperature ranges.
Failure to Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement ordered fall-prevention interventions for a resident assessed as high risk for falls. The resident was admitted with diagnoses including muscle weakness, history of falling, and cerebral infarction, and had a fall risk score of 11, indicating high fall risk. Physician orders dated 2/24/2026 directed the use of a low bed and floor mat to decrease potential injury, and the care plan for fall and injury risk instructed staff to utilize safety and supportive devices as ordered and provide adequate supervision and safety cues. The facility’s Falls and Fall Risk, Managing policy stated that staff will identify interventions based on evaluations and current data to prevent falls and minimize complications. On 3/4/2026, during observation of the resident’s room, surveyors noted a yellow star behind the bed indicating the resident was a fall risk and should have a low bed and floor mats in place, but no floor mats were present. The resident reported a history of falls but did not recall having a mat by the bed. The Infection Preventionist confirmed that the star signified the need for a low bed and floor mats and acknowledged that the absence of floor mats was not following the plan of care and could lead to a fall with possible injury. The Director of Staff Development stated the resident uses two landing mats and confirmed that at the time of observation the mats were not in the room and that the mats are intended to prevent injury when a resident falls. The Administrator also confirmed the resident had an order for floor mats, was a fall risk, and should have floor mats while in bed, and that without them there was potential for a fall resulting in injury or fracture.
Failure to Implement Contact Precautions and Risk Assessment for Suspected and Confirmed C. difficile
Penalty
Summary
The deficiency involves the facility’s failure to implement contact isolation precautions for a resident who developed signs and symptoms consistent with Clostridioides difficile infection (CDI) and was later confirmed positive. The resident was admitted with diagnoses including pulmonary embolism and sepsis and subsequently developed diarrhea meeting the facility’s criteria for suspected CDI on 1/18/2026. A physician ordered a stool test for CDI on that date, but the resident was not placed on contact precautions at the time of suspicion, despite facility policy requiring contact precautions for residents with diarrhea and suspected CDI while awaiting laboratory results. The resident’s change in condition evaluation on 1/20/2026 documented CDI with onset of symptoms on 1/18/2026, and the resident was not placed on contact isolation until 1/20/2026, after the physician ordered contact isolation for a positive CDI result. During this period, the CDI-positive resident continued to share a room with two roommates. One roommate had diffuse large B-cell lymphoma, was actively receiving antineoplastic chemotherapy, and was identified as immunocompromised and at high risk for infection. This roommate’s care plan, initiated later, identified her as at high risk for nosocomial infection and indicated staff should perform hand hygiene and wear gowns and gloves during high-contact activities, but there was no evidence that this high-risk status was used to prevent her from being cohorted with a resident with active CDI. The other roommate had multiple chronic conditions, including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety, and required substantial assistance with ADLs. Both roommates remained in the same room with the CDI-positive resident while an isolation cart and contact precaution sign were posted outside the room. The facility did not complete infection risk assessments for either roommate before or during their cohorting with the resident who had CDI. The DON confirmed there was no documented evidence of infection risk assessments for these roommates between 1/17/2026 and 1/30/2026, and stated that such assessments should have been completed by the Infection Preventionist or a licensed nurse to determine appropriate roommate placement when a resident had an infection. The Infection Preventionist Nurse and DON acknowledged that the immunocompromised roommate should not have been placed with the CDI-positive resident and that the facility failed to follow its own CDI and isolation policies, which required private rooms when possible or cohorting only with low-risk roommates. The facility also failed to inform and educate the two roommates about their potential risk of acquiring CDI and the infection control guidelines they should follow. One roommate reported not understanding why the room was on isolation and stated that staff did not provide any explanation when asked. The other roommate, aware of her compromised immune system and ongoing chemotherapy, stated she was not told why staff were wearing gowns when caring for her roommate and was reassured that it had nothing to do with her, despite her expressed concerns. The Infection Preventionist Nurse confirmed there was no documented evidence that staff notified or educated the roommates about their risk for CDI or appropriate precautions. Additionally, the facility did not monitor the two roommates for signs and symptoms of CDI after their exposure to the infected resident. The Infection Preventionist Nurse stated that no monitoring was conducted for these roommates for CDI-related symptoms such as fever, abdominal pain or spasms, diarrhea, nausea, or vomiting. The Medical Director stated that staff were aware of appropriate infection control measures but failed to implement them, and that staff did not follow facility policy or CDC guidelines regarding cohorting and isolation for CDI. The DON described this as a failure in the facility’s system process, including lack of staff training on isolation precautions and infection risk assessments, which contributed to the deficient practice. The facility’s written policies required that residents with diarrhea and suspected CDI be placed on contact precautions while awaiting lab results, and that residents with diarrhea associated with CDI be placed on contact precautions. The isolation policy further required that residents on contact precautions be placed in a private room if possible, or, if not, that the Infection Preventionist assess risks and cohort only with low-risk roommates. Despite these written requirements, the resident with CDI remained in a shared room with an immunocompromised roommate and another medically complex roommate, without documented risk assessments, without timely initiation of contact precautions at the time of suspicion, without education of roommates about their risk and needed precautions, and without monitoring of the roommates for CDI symptoms. These actions and omissions formed the basis of the cited infection control deficiency under F880.
Removal Plan
- Moved Resident 2 to Room B with no roommates due to immunocompromised condition and initiated RN Supervisor monitoring every shift for 40 days for CDI signs/symptoms.
- Designated Room A as a single isolation room and assigned Resident 1 no roommates.
- Reviewed and revised Resident 2’s care plan to reflect immunocompromised status and that Resident 2 should not share a room with a resident who has an active infection.
- Conducted in-service training for all nursing staff on Infection Control policy, with written quizzes to validate understanding; provided phone/follow-up training for staff not present prior to next shift; removed from schedule any staff who did not complete training until completed.
- Provided one-on-one in-service to the Administrator and DON on the admission process for residents requiring isolation precautions and appropriate cohorting.
- Provided one-on-one in-service training to the Infection Preventionist Nurse on infection control practices, including proper PPE use and appropriate cohorting.
- Conducted record review of all residents with changes in condition to identify residents with signs/symptoms consistent with CDI; found no other affected residents.
- Assessed all residents for CDI signs/symptoms; found no additional affected residents.
- Implemented process for DON and Infection Preventionist Nurse to review all incoming admissions to determine need for isolation/precautions and arrange appropriate room placement/cohorting.
- Implemented Infection Preventionist Nurse tracking log for all residents with active infections, including CDI, to prevent spread.
- Established monthly infection control meetings led by Administrator and IDT to ensure adherence to infection control and PPE policies and to promptly identify/address room placement and cohorting issues.
- Developed a QAPI plan for Infection Control practices including root cause analysis to be reviewed and updated during monthly QAPI meetings for three months to ensure corrective actions are effective and sustained.
Failure to Report Allegation of Misappropriation of Resident Property to SSA
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Survey Agency (SSA) as required by regulation and facility policy. A resident admitted with muscle weakness and sepsis had documentation in the History and Physical and Minimum Data Set indicating intact cognitive function and capacity to understand and make decisions. During an interview, the resident reported that a family member visitor took his wallet, left the facility, charged $500 to his credit card, and then returned the wallet and card. The resident stated he had informed the Social Worker of this incident, though he could not recall the exact date and time of either the event or the report. The Social Worker confirmed that the resident had reported that the family member took the wallet and charged $500 to the resident’s credit card, without specifying the date and time. The Administrator acknowledged that the resident had informed the Social Worker of the allegation and that she did not report this allegation of misappropriation of property to the SSA. The facility’s abuse, neglect, exploitation, and misappropriation reporting policy, last reviewed on 8/15/2025, states that all reports of theft or misappropriation of resident property must be reported to local, state, and federal agencies as required, and that suspected misappropriation must be reported immediately to the Administrator and to the state licensing/certification agency, with “immediately” defined as within two hours for allegations involving abuse or misappropriation. Despite this policy, the allegation was not reported to the SSA.
Failure to Care Plan for Immunocompromised Resident at High Risk for Infection
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident who was immunocompromised and at high risk for infection. The resident’s face sheet showed an original admission with a readmission date and diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney. The resident’s MDS indicated intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Despite these documented conditions and functional needs, there was no care plan addressing the resident’s immunocompromised status. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator did not initiate a care plan upon admission to address the resident’s immunocompromised condition related to diffuse large B-cell lymphoma. The DON acknowledged that the care plan should have included interventions such as not cohorting the resident with others who had active infections and that the existing care plan was not comprehensive or person-centered. Review of the facility’s policy on comprehensive, person-centered care plans showed that care plans were required to include measurable objectives and timetables, be derived from a thorough assessment, describe needed services, and reflect recognized standards of practice, which was not done for this resident’s immunocompromised status.
Failure to Revise Care Plans After Cohorting with CDI-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans for two residents after they were cohorted with another resident who had a suspected and later confirmed Clostridium difficile (CDI) infection. Resident 1 was admitted with diagnoses including pulmonary embolism and sepsis, and later developed enterocolitis due to CDI, with symptom onset identified as occurring on 1/18/2026. A physician ordered stool collection for CDI testing on 1/18/2026, and a Change in Condition evaluation completed on 1/20/2026 documented CDI, diarrhea meeting CDI criteria, and placement of Resident 1 on contact isolation. Despite these developments and the infection-control implications, the care plans for the cohorted residents were not updated. Resident 2 had a history of diffuse large B-cell lymphoma, chemotherapy, and acquired absence of a kidney, with an MDS indicating intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Resident 3 had diagnoses including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety disorders, with an MDS showing moderately impaired cognition and a need for substantial/maximal assistance with toileting hygiene, lower body dressing, and footwear. Both residents were cohorted with Resident 1 when CDI was suspected and then confirmed, but their care plans were not revised to reflect this change in condition and exposure risk. During an interview and concurrent record review with the DON on 1/30/2026, it was confirmed that staff did not update the care plans for Residents 2 and 3 when they were cohorted with the CDI-positive resident. The DON stated that licensed staff and the MDS Coordinator were responsible for updating care plans and acknowledged that the existing care plans for these residents were not comprehensive or person-centered in light of the new circumstances. The facility’s own policy on comprehensive, person-centered care plans requires that care plans be derived from thorough assessment, describe services to meet residents’ highest practicable well-being, reflect current standards of practice, and be revised as residents’ conditions change. The failure to revise the care plans after the cohorting event constituted the cited deficiency.
Failure to Monitor Antibiotic Adverse Effects Under Stewardship Program
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship policy by not monitoring a resident for adverse effects of levofloxacin during a prescribed treatment period. The resident was admitted with diagnoses including unspecified acute kidney failure, UTI, and generalized weakness, and was documented as cognitively intact and able to make decisions. An Interact Assessment Form dated 12/23/2025 showed an abnormal WBC of 15.2 and modest right lower lobe pneumonia, after which the physician was notified and ordered levofloxacin 500 mg orally once daily for seven days. The resident’s MAR confirmed administration of levofloxacin from 12/23/2025 to 12/29/2025. The resident’s care plan for pneumonia, initiated on 12/24/2025, included interventions to administer levofloxacin as ordered, monitor for adverse reactions, monitor for progress of status, notify the physician if the intervention was not effective, and monitor vital signs and infection-related symptoms. During interviews and record review on 1/14/2026, the DON stated that residents receiving antibiotics are to be monitored for adverse effects every shift so that any adverse effects can be identified and the physician notified to change the antibiotic if needed. The DON acknowledged there was no documented monitoring for antibiotic adverse effects in the resident’s progress notes from 12/23/2025 to 12/29/2025, except for one entry on 12/26/2025 at 6:06 p.m., and stated that monitoring should have been done every shift. LVN 2 reported that nurses monitor residents on antibiotics for adverse reactions and document in the progress notes whether there was an adverse reaction or not. Review of the facility’s Antibiotic Stewardship policy, dated 12/2016 and last reviewed 8/15/2025, indicated that antibiotics will be prescribed and administered under the guidance of the facility’s antibiotic stewardship program and that training and education will emphasize the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, and medication interactions. The DON stated the policy did not specify the frequency of monitoring, but that nurses should monitor and document adverse effects of antibiotics every shift. The surveyors determined the facility failed to monitor this resident for adverse effects of levofloxacin from 12/23/2025 to 12/29/2025.
Failure to Care Plan Resident’s Refusal of Restorative Nursing Services
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to address a resident’s refusal of Restorative Nursing Assistance (RNA) services. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness. A History and Physical and a Minimum Data Set assessment documented that the resident had intact cognitive skills and the capacity to understand and make decisions, and required moderate assistance for transfers and walking. An order was in place for RNA ambulation with a front wheeled walker five times per week. Record review of the resident’s Documentation Survey Report for December showed that on two consecutive days, RNA for ambulation with a front wheeled walker was documented as “not applicable.” One RNA staff member stated that “NA” is used when a resident is in the hospital or not in the facility. However, another RNA staff member reported that on those same two days the resident was present, refused RNA while waiting to be discharged, and that the resident refused RNA three times on one of those days. This RNA staff member acknowledged that no RNA was provided on those days and that the refusals were not reported to the Charge Nurse as required. The DON stated that when a resident refuses RNA services three times, the RNA staff should report this to the Charge Nurse so the Charge Nurse can speak with the resident, determine the reason for refusal, and encourage participation. The DON further stated that a care plan should have been developed to address the resident’s refusal of RNA services, and acknowledged that nurses did not have a guide on how to proceed with the plan of care for this refusal. The facility’s policy on Comprehensive Person-Centered Care Plans requires development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, including services not provided due to the resident’s exercise of the right to refuse treatment, and specifies that assessments are ongoing and care plans are revised as residents’ conditions change. This was not done for the resident’s RNA refusals.
Failure to Provide Ordered Restorative Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered Restorative Nursing Assistance (RNA) ambulation services to a resident with mobility limitations and a physician’s order for RNA ambulation five times per week. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness, and was assessed as cognitively intact and able to make decisions. The Minimum Data Set indicated the resident required moderate assistance for transfers and walking. The physician’s order recap and the resident’s care plan both specified RNA ambulation with a front wheeled walker as tolerated, five times a week. However, documentation for two consecutive days showed RNA marked as “not applicable.” During interviews, the Director of Rehabilitation confirmed the resident had been on RNA ambulation since late in the month. RNA 1 explained that “not applicable” is used when a resident is not in the facility or is in a general acute care hospital, but the resident was in the facility on at least one of the days in question. RNA 2 stated that on one of those days the resident refused to walk while waiting to be discharged home and was not actually discharged until the following day. RNA 2 further stated that no RNA ambulation was provided on either of the two days, acknowledged that RNA ambulation should have been provided, and that refusals should have been reported to the charge nurse. The DON stated that providing RNA ambulation helps prevent decline in range of motion and ambulation, and that not providing it could result in weakness and possible falls. The facility’s restorative nursing policy required residents to receive restorative care as needed to promote optimal safety and independence, with goals and interventions outlined in the plan of care, which was not followed for this resident on the identified days.
Failure to Document Physician Notification and Response for Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident by not documenting physician notification and response after abnormal lab results were received. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness. A history and physical dated several days after admission indicated the resident had the capacity to understand and make decisions, and a subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for transfers and walking. An Interact Assessment Form dated 12/23/2025 showed the resident had an abnormal WBC of 15.2 and modest right lower lobe pneumonia. The form indicated that an LVN notified the physician, who ordered levofloxacin and additional blood tests including a CBC, CMP, and procalcitonin on 12/26/2025. A laboratory test result dated 12/26/2025 at 5:55 p.m. showed low hemoglobin and hematocrit, with a written note indicating the physician was notified on that date. However, when surveyors reviewed the resident’s laboratory results and progress notes with an RN on 1/14/2026, the RN confirmed that the progress notes did not document that the physician was notified of the abnormal blood test results. The RN stated there was no documentation of the time the physician was notified, who called the physician, or the physician’s response, including whether any new orders were given. In a separate concurrent review, the DON also confirmed that the progress notes lacked documentation of physician notification regarding the abnormal blood test result and acknowledged documentation issues in the resident’s medical record. The facility’s charting and documentation policy required that all services, changes in condition, and notifications, including date, time, name and title of the person providing care, assessment data, and notification of the physician, be documented in the medical record. The absence of this required documentation for the abnormal lab result rendered the resident’s medical record incomplete and inaccurate.
Failure to Notify Residents and Representatives of Transfer/Discharge and Appeal Rights
Penalty
Summary
The facility failed to properly notify residents and their representatives of transfers or discharges, as well as their rights to appeal and information regarding bed-hold policies, for two out of three sampled residents. In the case of the first resident, who had severe cognitive impairment and was unable to make decisions, the facility did not ensure that the resident's representative, who held power of attorney and was the legally recognized decision-maker, received the required Notice of Proposed Transfer/Discharge (NTD). Although the NTD was completed and included necessary information about the transfer and appeal rights, it was not signed by the representative, and the representative later confirmed she did not receive the notice. Staff signed the NTD instead of the resident or representative, contrary to facility policy. For the second resident, who was cognitively intact and able to make decisions, the facility also failed to ensure proper notification procedures were followed. The NTD for this resident was signed by a staff member rather than the resident or their representative. Interviews with staff revealed that if the resident or representative was not present at the time of transfer, the NTD was not mailed to the representative as required. The facility's own policy stated that the NTD should be mailed to the representative the next day if not signed in person, but there was no documentation that this occurred. Interviews with facility leadership, including the DON and Administrator, confirmed that the required notifications were not mailed to the residents' representatives and that the facility's policy and procedure for notification and documentation were not followed. The lack of proper notification meant that the residents' representatives were not informed of their right to appeal the transfer or discharge, nor were they provided with contact information for the Ombudsman or the Department, as required by regulation and facility policy.
Failure to Notify Physician of Significant Blood Pressure Drop
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care consistent with professional standards of practice by not notifying the physician after a significant change in blood pressure. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and essential hypertension, was admitted with orders to monitor for orthostatic hypotension and to notify the physician if there was a 20 mmHg drop in systolic blood pressure (SBP) or a 10 mmHg drop in diastolic blood pressure (DBP) between lying and sitting positions. On the specified date, the resident's SBP dropped by 20 mmHg from lying to sitting position, as documented in the Medication Administration Record (MAR). Despite this significant change, there was no documentation that the physician was notified as required by the physician's order and the facility's policy on changes in a resident's condition. The Director of Nursing confirmed that the nurse did not follow the physician's order to notify the physician of the blood pressure drop and acknowledged that the facility's policy mandates prompt notification of the physician for significant changes in a resident's condition.
Incomplete Documentation of Resident Inventory Lists at Discharge
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents when the discharge portion of their Inventory Lists was left blank. For one resident with severe cognitive impairment and another with intact cognitive skills, the Inventory Lists at discharge were not completed, and in one case, belongings were picked up without being listed or signed for. Interviews with staff revealed that Certified Nursing Assistants were responsible for filling out the Inventory List at discharge, while Social Services was tasked with verifying its completion the following day. However, audits by Medical Records indicated that Social Services was not consistently completing or verifying the Inventory Lists, and there was a lack of communication regarding incomplete documentation. The facility's policy required that residents' personal belongings be inventoried and documented upon admission and updated as necessary, but this was not followed at discharge for the two residents. Staff interviews confirmed that belongings were packed and held by Social Services until picked up by family, but without a completed and signed Inventory List, there was potential for items to be lost. The Administrator acknowledged that the Social Service Department failed to check and complete the inventory lists after discharge, and failed to obtain the necessary signatures when belongings were picked up.
Failure to Follow Medication Administration Parameters
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow a physician's ordered parameters for administering valsartan to a resident with diagnoses including essential hypertension, osteoarthritis, and hyperlipidemia. The physician's order specified that valsartan should be withheld if the resident's systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. The LVN initially checked the resident's blood pressure and heart rate approximately 30 minutes before attempting to administer the medication, but the resident refused the medication at that time. The LVN then labeled the prepared medication and stored it in the locked medication cart. Later, the LVN administered the previously prepared crushed medications mixed with applesauce to the resident without reassessing the resident's vital signs immediately prior to administration, as required by the physician's order. The facility's policies indicated that medications must be administered in accordance with prescriber orders and that a medication error includes any administration not in accordance with such orders. The Director of Nursing confirmed that parameters such as blood pressure and heart rate must be checked immediately before medication administration to avoid adverse effects.
Failure to Follow Contact Isolation and Infection Control Procedures
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's infection control policy for a resident who was on contact isolation precautions. The LVN entered the resident's room without wearing the required gown and gloves, despite a contact isolation sign being posted outside the room. The LVN also did not perform hand hygiene before or after entering the room. The resident had severe cognitive impairment and required significant assistance with daily activities, and the need for contact isolation was documented in the resident's records. During medication administration, the LVN prepared crushed medications mixed with applesauce for the resident. When the resident refused the medication, the LVN labeled the medicine cup and placed it inside the locked medication cart, specifically in a section next to a glucometer that is used for multiple residents. The facility's Director of Nursing confirmed that the safest practice would have been to discard the prepared medication to prevent confusion and potential cross-contamination, and acknowledged that placing the medicine cup next to a shared glucometer could contribute to the spread of infection. A review of the facility's policies confirmed that staff are required to wear gloves and gowns when entering rooms under contact precautions, and to perform hand hygiene before and after room entry. The infection control policy also emphasizes maintaining a safe and sanitary environment to prevent the transmission of disease and infections. The observed actions by the LVN did not align with these established procedures.
Incomplete Documentation of Deep Cleaning for Resident on Isolation Precautions
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented after performing a deep clean of the resident's room. The resident, who had diagnoses including chronic kidney disease, muscle weakness, and hyperlipidemia, was placed on contact isolation precautions. Housekeeping staff began deep cleaning rooms in response to rash incidents, with the process involving disinfecting hard-to-reach areas such as beds and curtains. Although a designated Deep Clean Checkoff List for isolation rooms existed, it was not completed for this resident's room. Interviews with housekeeping staff and the Housekeeping Supervisor confirmed that deep cleaning was performed, but no checklist or documentation was completed to verify the specific actions taken. The resident confirmed that her room had been deep cleaned while she was showering. The Director of Nursing stated that accurate and timely documentation is necessary to confirm completed actions and to inform subsequent shifts. Review of facility policy indicated that documentation in the medical record should be objective, complete, and accurate, but this was not followed in this instance.
Failure to Ensure Physician Orders and Monitoring for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with an indwelling urinary catheter by not ensuring there were physician orders for catheter care and monitoring. The resident, who had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, was admitted with an indwelling urinary catheter and was at risk for urinary tract infection (UTI) as documented in the care plan. Despite this, there were no documented physician orders for catheter care after the resident returned from a general acute care hospital, and the treatment administration records did not show evidence that catheter care was provided or monitored as required. Observations and interviews revealed that nursing staff observed abnormal urine characteristics, including dark yellow, blood-tinged, and cloudy urine with hematuria, but did not report these findings to the attending physician. Both LVNs involved stated that the urine appearance was considered the resident's baseline and therefore did not notify the physician, even though the care plan and facility policy required prompt reporting of such findings. Additionally, one LVN performed a urinary catheter irrigation without a physician order, and another provided catheter care and changed the drainage bag without proper documentation or orders. The facility's Director of Nursing confirmed that there were no urinary catheter care orders in place prior to the observed change in the resident's condition and that the resident's catheter was not being monitored as required. Laboratory results later confirmed the presence of infection, with elevated white blood cell count and bacteria in the urine. Facility policies reviewed indicated that catheter care, monitoring, and documentation were required, and that changes in condition should be promptly reported to the physician, but these procedures were not followed in this case.
Failure to Provide Proper Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper care and services for two residents with indwelling urinary catheters, resulting in multiple deficiencies. For one resident with a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, the facility did not monitor urine output for hematuria as required by the care plan and physician documentation. Observations revealed that the resident's catheter tubing was not anchored to the leg, and the urine in the drainage bag was dark yellow to dark red, cloudy, and contained visible sediments and blood. Staff interviews confirmed that the catheter was not secured, and abnormal urine characteristics were not reported to the physician. Additionally, there was no documentation of catheter care or monitoring after the resident returned from the hospital, and catheter care orders were not in place until after the deficiency was observed. Another resident with similar diagnoses and a suprapubic catheter also did not receive appropriate monitoring or care. The care plan required daily treatment of the catheter site and monitoring of urine for sediment, cloudiness, odor, blood, and output. However, observations showed that the resident's catheter was not anchored, there was no wound dressing at the stoma site, and the urine was yellow, cloudy, and contained sediments. Staff acknowledged that these findings indicated a potential infection and should have been reported to the physician, but there was no evidence that this was done. The facility's policy required securement of catheters and prompt reporting of unusual urine findings, but these procedures were not followed. Record reviews and staff interviews further confirmed that both residents' catheters were not properly anchored, and abnormal urine findings were not documented or reported as required. The Director of Nursing acknowledged the failures in monitoring, documentation, and adherence to physician orders and facility policy. These deficiencies resulted in the presence of abnormal urine characteristics and laboratory findings indicating infection or inflammation, without appropriate assessment or intervention by the facility staff.
Failure to Implement Comprehensive Care Plan for Resident with Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with an indwelling urinary catheter. The resident had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, and was at risk for urinary tract infection due to the catheter. The care plan noted the need to monitor the catheter and urine characteristics and to report findings to the attending physician, but these interventions were not fully carried out. Observations and interviews revealed that nursing staff noted dark yellow, blood-tinged, and cloudy urine in the resident's catheter, and the catheter tubing was not properly anchored. Despite these findings, the appearance of the urine was not reported to the physician as required. Additionally, after the resident returned from a hospital stay, catheter care orders were not reordered, and there was no documented evidence that catheter care was provided during this period. The Director of Nursing confirmed that the care plan was not followed, and the resident's catheter was not monitored or reported for visible hematuria. Facility policies required comprehensive care plans and complete documentation of services and changes in condition, but these were not adhered to in this case, resulting in a failure to address the resident's identified needs related to the indwelling urinary catheter.
Failure to Set Low Air-Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at high risk for pressure ulcers received care consistent with professional standards of practice. The resident, who had diagnoses including acute kidney failure, benign prostatic hyperplasia, and anemia, was assessed as having moderately impaired cognitive skills and required maximal assistance for mobility. The resident's care plan and physician orders specified the use of a low air-loss mattress (LALM) for wound care and management, with the mattress setting to be adjusted according to the resident's weight. The resident's most recent documented weight was 116 pounds, and the LALM was supposed to be set at 120 lbs as indicated by a label on the machine. However, during observation, the LALM was found set at 200 lbs, which did not correspond to the resident's actual weight. Both nursing staff and the Director of Nursing confirmed that the mattress should have been set based on the resident's weight and acknowledged that the incorrect setting was not in accordance with the care plan, physician orders, and manufacturer guidelines. This failure to maintain the correct LALM setting placed the resident at risk for the development of pressure ulcers, as the mattress was not providing the intended pressure relief.
Inaccurate Documentation of Resident Meal Intake
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that a CNA documented the resident's meal intake percentages at the correct times. Specifically, the CNA recorded the percentages for breakfast and lunch meals at times that did not correspond to when the meals were actually consumed, as evidenced by multiple entries where both breakfast and lunch intakes were documented at the same time in the afternoon. The CNA acknowledged that the documentation times were inaccurate and that meal intake should be recorded after the resident has eaten. The Director of Staff Development and the Director of Nursing both confirmed that the documentation was inaccurate and did not reflect the resident's actual meal intake for each respective meal. The facility's policy requires that all services and changes in a resident's condition be documented objectively, completely, and accurately to facilitate communication among the interdisciplinary team. The resident involved had multiple diagnoses, including a cervical vertebra fracture, epilepsy, and anemia in chronic kidney disease, and required moderate assistance with eating. The inaccurate documentation resulted in incomplete and inaccurate medical records for the resident.
Failure in Controlled Medication Accountability
Penalty
Summary
The facility failed to maintain a system-wide method of accountability for controlled medications, resulting in the inability to account for 43 doses of Norco 5-325 mg for one resident and an unspecified amount of Oxycodone-Acetaminophen 5-325 mg for another resident. Licensed nurses did not document the administration of controlled substances in the electronic Medication Administration Record (eMAR) for one resident, and there were no records maintained for the transfer of controlled medications from licensed nurses to the Director of Nursing (DON) after the resident was discharged. Additionally, the DON did not investigate discrepancies related to the controlled medication reconciliation for both residents. The report highlights that the DON failed to report the missing controlled medications to the Administrator. Interviews with licensed vocational nurses revealed that the DON would collect controlled medications without requiring signatures or documentation, leading to a lack of evidence that medications were turned over to the DON. The facility's contracted pharmacist confirmed the delivery of 112 tablets of Norco 5-325 mg for one resident, but only 59 tablets were recorded as administered, with 10 remaining in the medication cart, leaving 43 tablets unaccounted for. Furthermore, the report indicates that the DON had access to a universal key that could open all medication carts and controlled medication drawers, bypassing the double-lock system intended for controlled substances. This lack of secure storage and documentation contributed to the missing medications. The facility's policies and procedures for controlled substances, including storage, disposal, and recordkeeping, were not followed, leading to the deficiency.
Removal Plan
- Resident 1 left against medical advice (AMA).
- A complete search of all six medication carts, all two medication rooms, and the controlled medications for disposal inside the controlled medications drawer located in the DON's office for Resident 1's hydrocodone-acetaminophen 5-325 mg was conducted and confirmed a total of ten remaining hydrocodone-acetaminophen 5-325 mg tablets with the corresponding Controlled Medication Count Sheet. A total of 43 tablets of Hydrocodone Acetaminophen 5-325 mg were confirmed missing and unaccounted for.
- The DON was suspended pending completion of investigation.
- The Assistant Director of Nursing (ADON), who also had access to the DON's office where the controlled medications for disposal were stored, will be placed on suspension upon her return from her medical leave.
- In-services were provided to licensed nurses regarding the controlled medication policy, covering the following: All licensed nurses are responsible for maintaining accurate records of controlled medication receipts, medication administrations, disposal, loss of medications or possible drug diversion.
- Documentation of controlled medication disposal will be maintained accurately in a log, including the following endorsement information: Medication information, including name, strength and quantity, Releasing nurse signature, Receiving party (Acting DON) signature, Disposal information including the medication information, medication name, strength and quantity.
- Proper procedures for controlled medications when discharging a resident to a lower level of care, including residents who discharged AMA will be implemented. The discharging licensed nurse will be responsible for controlled medication(s) when discharging a resident to a lower level of care, including AMA. Obtain a physician's order specifying the controlled medications, including the name and quantity of medications to be provided to the resident or responsible party, if indicated. The discharging licensed nurse must document the released quantity of the controlled medication in the Controlled Medication Count Sheet with signatures from the licensed nurse and receiving party. For resident(s) who are discharging on weekends, the licensed nurse will continue to keep and account for the discharged controlled medications stored in the controlled medication drawer inside the medication cart until the Acting DON is back on duty to receive the controlled medications.
- During the in-services, the licensed nurses were observed for possible signs of being under the influence of using controlled medications. No staff were identified to be under the influence of using controlled medications.
- The local Police Narcotic Unit was notified and went onsite to obtain information regarding the missing controlled substances.
- The Maintenance Supervisor replaced the locks to the DON's office, the storage room inside the DON's office, and the controlled medications drawer inside the storage room of the DON's office.
- The universal key that accesses all medication carts, including controlled medications drawer, was discontinued and removed from the facility.
Failure to Document and Assess Use of Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints without proper documentation and procedures. For six of the eight sampled residents, the facility did not have the necessary physician's orders, restraint assessments, informed consents, and care plans in place for the use of various restraints. These included pad alarms, beds placed against walls, and pillows tucked under sheets, which were used without the required documentation and assessments to ensure their appropriateness and safety. For instance, Resident 31 was observed with a pad alarm used for fall prevention, but there was no physician's order, informed consent, or restraint assessment documented. Similarly, Resident 5 was also using a pad alarm without the necessary documentation. Resident 30 and Resident 33 had their beds placed against the wall, which was considered a restraint, yet lacked the required physician's orders, informed consents, and care plans. Resident 63 had a pillow tucked under the sheet, used as a restraint, without the necessary documentation. The facility's policy and procedure on the use of restraints require a thorough assessment, physician's order, informed consent, and a care plan before implementing any restraint. However, these steps were not followed for the residents involved, leading to the deficiency. The lack of proper documentation and adherence to the facility's policy potentially compromised the residents' rights and safety.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for four residents, leading to potential adverse effects. Resident 49, who was admitted with type 2 diabetes mellitus and other serious health conditions, received insulin injections repeatedly in the same area, contrary to physician orders and manufacturer's guidelines. The Assistant Director of Nursing (ADON) confirmed that the insulin administration sites were not rotated as required, which could lead to tissue injury and affect medication absorption. Similarly, Resident 159, with a history of diabetes and other health issues, also received insulin injections without proper site rotation. The ADON verified that the insulin administration sites were not rotated according to the physician's orders, increasing the risk of lipodystrophy and amyloidosis. The facility's policy and procedure on insulin administration, which mandates site rotation, was not followed, as confirmed by the ADON. Resident 73 and Resident 100 also experienced similar deficiencies in insulin administration. Both residents had orders for insulin injections with specific instructions to rotate injection sites, which were not adhered to. Interviews with nursing staff and the Director of Nursing (DON) confirmed the failure to rotate injection sites, which could lead to discomfort and malabsorption of medication. The facility's policy on insulin administration, which emphasizes the importance of site rotation, was not implemented effectively, as evidenced by the repeated use of the same injection sites for these residents.
Inaccurate LALM Settings and Labeling Lead to Pressure Ulcer Care Deficiencies
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for four residents by not accurately labeling and setting Low Air Loss Mattresses (LALM) according to the residents' weights or physician orders. For Resident 124, the LALM machine was set at 160 pounds, but it was incorrectly labeled to be set at 200 pounds, despite the resident's weight being 163 pounds. This discrepancy was acknowledged by the Licensed Vocational Nurse and the Director of Nursing (DON), who stated that the incorrect labeling could lead to improper settings and potential skin issues. Resident 100's LALM was set at 200 pounds per a physician's order, although the resident weighed 151 pounds. The machine was mislabeled with a setting of 160 pounds, which could confuse staff and result in incorrect settings. The DON confirmed that the LALM should be set according to the resident's weight unless otherwise specified by a physician, and the mislabeling was likely due to a previous resident's settings not being updated. Resident 30's LALM was set at 160 pounds, while the resident's weight was 131 pounds, and the machine was labeled for 120 pounds. The DON and staff confirmed that the LALM should be set closest to the resident's weight to maximize its pressure-reducing function. Additionally, Resident 110 was using a LALM without a physician's order, and the mattress was set to 280 pounds, far above the resident's weight of 138 pounds. The DON acknowledged that a physician's order is required for LALM use to ensure appropriate treatment, and the incorrect setting could lead to ineffective pressure injury prevention.
Deficiencies in Resident Safety and Equipment Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to increased risks of injury. For Residents 124, 2, and 174, fall mats intended to prevent injury during falls were improperly used, with furniture or equipment placed on top of them. This misuse was observed during room inspections, where a side table, an oxygen concentrator, and a folded metal chair were found on the mats, potentially compromising their effectiveness and increasing the risk of injury during falls. Staff interviews confirmed that such placements could depress the mats and reduce their ability to cushion falls, contrary to the facility's policy and manufacturer's guidelines. Resident 334's safety was compromised due to a malfunctioning bed pad alarm, which was found unplugged during an inspection. The alarm was intended to alert staff if the resident attempted to get out of bed unassisted, a critical safety measure given the resident's need for substantial assistance with mobility. Staff interviews revealed that the alarm's functionality was not checked as required every shift, leaving the resident at risk of falls and injury. For Resident 129, the facility failed to properly assess and document the risks associated with placing the resident's bed against the wall, a practice considered a restraint. Despite the resident's severe mobility limitations and the potential for entrapment, the bed was positioned against the wall without a current physician's order, risk assessment, or informed consent. This oversight was acknowledged by staff, who noted that the necessary procedures were not followed upon the resident's readmission, thus increasing the risk of injury due to improper restraint use.
Improper Medication Disposal in Medication Room
Penalty
Summary
The facility failed to properly dispose of medications in one of the two inspected medication rooms, specifically Medication Room Station 1. During an observation and interview with the Director of Nursing (DON), it was noted that the pharmaceutical waste bin contained a mixture of intact loose medication tablets and capsules, medications in manufacturer bottles, insulin pens, and an albuterol inhaler. The DON acknowledged that the medications were not disposed of according to facility policy, which requires medications to be disintegrated by pouring liquid over them to prevent retrieval. Additionally, aerosolized inhalers, which can explode, were improperly disposed of in the pharmaceutical waste bin. The facility's policy and procedures, as reviewed, indicated that medications should be disposed of in accordance with federal, state, and local regulations. The policy specified that medications should be taken out of their original containers and mixed with an undesirable substance to ensure they are not retrievable. However, the observation revealed that the pharmaceutical waste bin did not contain the required amount of liquid to disintegrate the medications, leaving them in their original form and easily accessible for potential misuse or diversion. The review of the facility's policies on medication destruction and hazardous waste pharmaceuticals highlighted that the facility did not adhere to the guidelines for managing non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The improper disposal practices observed in Medication Room Station 1 did not align with the Environmental Protection Agency's recommendations and the facility's own policies, increasing the risk of medication diversion and accidental exposure to harmful substances for residents and staff.
Failure to Monitor Specific Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of quetiapine, an antipsychotic medication. The resident, who was moderately impaired with cognitive skills for daily decision-making, was prescribed quetiapine to manage psychosis manifested by an inability to process internal stimuli causing anger or stress. However, the facility did not provide specific, measurable target behaviors related to the use of quetiapine, as required by their policy and procedures. Interviews with licensed vocational nurses and the Director of Nursing revealed that the quetiapine order lacked monitoring for specific types of internal stimuli causing anger or stress. This lack of specificity led to variations in behavior monitoring by different licensed nurses, resulting in inconsistent documentation. Consequently, the physician could not accurately assess the effectiveness of the medication therapy for the resident. The facility's policies and procedures, which were reviewed, indicated that when medications are prescribed for behavioral symptoms, documentation should include specific target behaviors. Additionally, psychotropic medications should only be used when clinically indicated to treat a specific condition. The facility's failure to adhere to these policies resulted in the potential use of unnecessary psychotropic medication for the resident.
Medication Errors Result in 6.9% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during a medication administration task. Two medication errors were identified involving two residents. Resident 28 did not receive a prescribed dose of oyster shell calcium, a dietary supplement for bone support, due to the medication not being available in the medication cart. This omission was observed during a medication administration round, and the Licensed Vocational Nurse (LVN) acknowledged the error, stating the importance of timely medication availability. Resident 39 was also affected by a medication error when a dose of docusate, prescribed for constipation, was not administered at the scheduled time. The LVN responsible for this resident's care admitted to overlooking the administration of the medication, which was due in the morning. The Director of Nursing (DON) confirmed these omissions as medication errors, emphasizing the facility's policy that medications should be administered within a 60-minute window of the scheduled time. The facility's policies and procedures, last reviewed in September 2024, outline the guidelines for medication administration, including the requirement to compare the medication and dosage schedule with the resident's Medication Administration Record (MAR) and to administer medications according to physician orders. The policy also defines a medication error as any deviation from physician orders or accepted professional standards, with omission being a specific example. These errors were acknowledged by the facility's staff and were considered deviations from the established protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of epoetin alfa and insulin. For one resident, epoetin alfa was administered despite physician orders to hold the medication if hemoglobin levels were greater than or equal to 10. This resident received two doses of epoetin alfa with documented hemoglobin levels of 10.1, contrary to the physician's instructions. The Director of Nursing confirmed that this constituted a significant medication error, as it could lead to adverse consequences such as increased hemoglobin levels and thickened blood. Additionally, the facility did not adhere to physician orders and standards of practice regarding the rotation of insulin injection sites for four residents. Insulin was repeatedly administered in the same areas, which could lead to tissue injury, lipodystrophy, and amyloidosis. The Assistant Director of Nursing verified that the insulin administration sites were not rotated as required, and this was considered a medication error due to non-compliance with physician orders and professional standards. The facility's policies and procedures, as well as manufacturer's guidelines, emphasize the importance of rotating injection sites to prevent adverse effects. However, the facility staff failed to follow these guidelines, resulting in medication errors for multiple residents. The Director of Nursing acknowledged that not rotating insulin administration sites could cause discomfort and malabsorption of the medication, further highlighting the significance of these deficiencies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in accordance with both facility and manufacturer guidelines, leading to several deficiencies. In one instance, an expired bottle of anastrazole, a medication used for breast cancer, was found in a medication room. The Director of Nursing (DON) acknowledged that the medication, which had an expiration date of November 2024, should have been removed and discarded by the end of that month. The failure to do so meant that the medication could potentially be used, despite having lost its potency, which is crucial for treating breast cancer effectively. Another deficiency was observed with a budesonide and formoterol inhalation aerosol for a resident with chronic obstructive pulmonary disease (COPD). The inhaler was not labeled with an open date, making it impossible to determine its expiration. According to the manufacturer's guidelines, the inhaler should be used or discarded within three months of opening. The Licensed Vocational Nurse (LVN) present during the inspection confirmed that the inhaler was not labeled as required, which could lead to the use of an expired and ineffective medication, potentially exacerbating the resident's COPD. Additionally, expired loperamide medication boxes were found in two medication carts, and an ipratropium with albuterol inhalation solution was improperly stored outside its protective foil pouch. The loperamide boxes, intended for facility stock, were not removed by their expiration date, and the inhalation solution, which should have been used or discarded within two weeks of opening, was found outside the foil pouch beyond this period. These oversights were acknowledged by the LVNs and the DON, who stated that such expired medications would not be effective in treating the residents' conditions, potentially leading to adverse health outcomes.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes, impacting the nutritional needs of 123 out of 168 residents on regular texture diets. During an observation, it was noted that a staff member did not level off the scoop when serving rice and carrots, resulting in larger portions being served to residents. This action was contrary to the facility's policy, which requires the use of proper utensils to ensure correct portion sizes as per the menu spreadsheet. The Dietary Supervisor confirmed that the staff member was not following the correct procedure, which could lead to unintentional weight gain and complications for diabetic residents due to excessive calorie and carbohydrate intake. The facility's policies and procedures, reviewed on 9/20/2024, emphasize the importance of following standardized recipes and portion sizes to meet the nutritional needs of residents. The menu, prepared by a dietitian, is designed to ensure nutritional adequacy and variety, with specific portion sizes indicated for each food item. The failure to follow these guidelines was observed during a meal service, where the staff did not adhere to the portion size of 1/3 cup for Cajun Country Rice as specified in the recipe. This oversight highlights a lapse in the facility's adherence to its own policies, potentially affecting the health and well-being of the residents.
Failure to Prepare Puree Foods to IDDSI Standards
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for residents on a puree diet, specifically IDDSI Level 4, which requires food to be smooth, moist, and not sticky. During an observation, it was noted that the puree spinach was too sticky and did not pass the spoon tilt test, a method used to assess the stickiness and consistency of pureed foods. The Dietary Supervisor and Registered Dietitian acknowledged that the puree spinach did not fall from the spoon as required, indicating it was too sticky, potentially due to excessive thickener use. This deficiency was observed during a review of the facility's daily menu and food preparation process. The facility's policies and procedures, as well as the IDDSI guidelines, require that pureed foods pass specific tests to ensure they are safe for residents with dysphagia. The failure to adhere to these guidelines and the facility's own policies could lead to residents rejecting the food, experiencing difficulty swallowing, or even choking. The issue was identified as affecting 24 out of 168 residents on a puree diet.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to meet the food preferences of three residents, leading to dissatisfaction and potential nutritional issues. Resident 34, who was cognitively intact and dependent on staff for eating, was served green beans despite having a documented dislike for them. The Registered Dietitian (RD) confirmed that the kitchen staff was aware of this preference but could not explain why the resident was served green beans. This oversight in catering to Resident 34's food preferences could lead to decreased food intake and weight loss. Resident 1, who had moderately impaired cognition and required assistance with eating, was incorrectly labeled as lactose intolerant on their meal ticket. This error restricted the resident from receiving dairy products they enjoyed, such as yogurt and cheese, except for milk, which they disliked. Despite informing the kitchen staff of the mistake, the issue persisted, causing the resident to feel deprived of certain foods. The Director of Nursing (DON) acknowledged the error and noted that it limited the resident's meal options, potentially leading to dissatisfaction and weight loss. Resident 20, who had intact cognitive function and specific dietary preferences, was repeatedly served milkshakes despite expressing a dislike for milk and milk alternatives. The resident's care plan emphasized adherence to food preferences, yet the dietary team failed to honor this, resulting in frustration and refusal to eat. The Social Services Assistant (SSA) noted the issue and planned to inform the dietary team to prevent further occurrences. The facility's policy required the Dietary Service Supervisor to update meal tickets according to resident preferences, but this was not effectively implemented, leading to the deficiencies observed.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Three out of five green racks in the walk-in refrigerator had chips with paint coming off, which could harbor dirt and bacteria, leading to cross-contamination of residents' food. Additionally, the walk-in freezer had ice crystal buildup on the roof and right-side wall, potentially indicating a malfunction that could prevent food from being stored at the correct temperatures. The reach-in refrigerator's bottom shelves had dirt and dust buildup, and the dry storage room floor had food debris, both of which could lead to contamination. Further observations revealed that the juice machine filter was dusty, and the racks were sticky and dusty to touch. The scoops and paper drawer contained food debris, and the ice container had white residue buildup. The coffee machine's hot waterspout had dried mineral water buildup. These conditions were not in compliance with the facility's policies and procedures, which required daily cleaning and sanitizing of equipment and surfaces to prevent cross-contamination and foodborne illnesses. Additionally, ten dented cans were stored with non-dented cans in the dry storage area, posing a potential hazard due to the risk of botulism. Two trayline staff members were observed with their hair not fully covered by hairnets while serving food, which could lead to physical contamination of the food. These deficiencies were identified as having the potential to result in harmful bacteria growth and cross-contamination, affecting all 168 medically compromised residents who received food and ice from the kitchen.
Failure to Update Medical Director Application
Penalty
Summary
The facility failed to follow through with their submitted application to the State Agency 1 (SA 1) for the change of medical director, which is a requirement for compliance with State and Federal regulations. The application was initially sent on 6/30/2022 and received by SA 1 on 7/7/2022, but it was found to be non-compliant due to missing information or needed corrections. Despite receiving a 30-Day Correction letter from SA 1 on 1/9/2023, the facility did not address the deficiencies, leading to a determination on 3/1/2023 that the application was still not in compliance. The Administrator (ADM) assumed her position on 3/21/2024 and admitted during interviews that she did not verify the facility's license status or the active medical director, relying instead on corporate notifications. The ADM acknowledged the importance of having a medical director listed on the facility's license to oversee physician and clinical services but was unaware of the potential implications of not having this information updated. The facility's policy and procedure indicate that the medical director is responsible for ensuring compliance with regulations, but the ADM did not have proof of mailing for the resubmitted corrections in March 2023.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. One significant issue involved the improper handling of oxygen nasal cannula tubing for a resident with acute respiratory failure. The tubing was observed touching the floor, which was confirmed by a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) as a contamination risk. The facility's policy required that the tubing be kept off the floor, but this was not adhered to, placing the resident at risk of infection. Another deficiency was noted in the dining room, where staff failed to perform hand hygiene before distributing food trays and assisting residents with eating. Additionally, residents were not offered the opportunity to sanitize their hands before meals. This lapse in protocol was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the importance of hand hygiene in preventing food-borne illnesses. The facility's policy clearly stated the need for handwashing before and after direct care and eating, but this was not followed. Further issues included the failure to maintain appropriate water temperatures to prevent Legionella growth, improper use of sit-to-stand slings, and inadequate hand hygiene by a Certified Nursing Assistant (CNA) when assisting multiple residents with feeding. Additionally, a Licensed Vocational Nurse (LVN) did not implement Enhanced Barrier Precautions (EBP) while administering enteral feeding to a resident with a gastrostomy tube, despite the facility's policy requiring gown and glove use for such procedures. These deficiencies collectively highlighted significant lapses in the facility's infection control practices, putting residents at risk of acquiring infections.
Failure to Obtain Proper Informed Consent for Resident Lacking Capacity
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the informed consent process for a resident who lacked the capacity to make medical decisions. Resident 37, who was diagnosed with dementia, bipolar disorder, and other mental health conditions, was admitted without a resident representative. Despite the resident's impaired cognitive function and lack of capacity to make medical decisions, as indicated in their medical records, the facility obtained verbal consent from the resident for the administration of an antipsychotic medication, Zyprexa. This action was contrary to the facility's policy, which requires the involvement of a Bioethics Committee when a resident lacks capacity and does not have a representative. Interviews with facility staff, including a Licensed Vocational Nurse, Registered Nurse, Social Services Director, and Director of Nursing, confirmed that the informed consent was not obtained correctly. The staff acknowledged that the Bioethics Committee should have been convened to address the resident's treatment plan. The facility's policy mandates that when a resident lacks capacity for informed consent, a Bioethics Committee meeting should be held, including the resident's primary physician and other interdisciplinary team members. However, this procedure was not followed, leading to the deficiency in the informed consent process for Resident 37.
Deficiencies in Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication of discharge information for two residents, leading to potential discontinuity of care. For Resident 54, the facility did not document vital signs prior to discharge, failed to provide special instructions for follow-up with a gastrointestinal physician, and did not accurately document the discharge location address and contact information. The discharge was facility-initiated due to the resident's health improvement, but the necessary documentation and communication were not completed as required. Resident 54's discharge process was marked by several lapses. The Licensed Vocational Nurse (LVN) responsible for the discharge did not document the resident's vital signs, did not complete the post-discharge plan of care, and failed to go over the medications with the resident. The LVN also did not document the discharge location address, relying instead on information relayed by a Registered Nurse (RN) supervisor. The Director of Nursing (DON) emphasized the importance of documenting vital signs and discharge information accurately to ensure a safe transition of care. For Resident 75, the facility also failed to document vital signs prior to discharge. The resident was discharged home with a family member, but there was no documentation of the vital signs at the time of discharge. The facility's policy and procedure require that details of the transfer or discharge be documented in the medical record, including the resident's new location and a summary of their medical condition. The lack of documentation and communication in these cases highlights deficiencies in the facility's discharge process.
Deficiencies in PASRR Screening for Mental Disorders and Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that residents were properly screened using the Preadmission Screening and Resident Review (PASRR) process for mental disorders or intellectual disabilities prior to admission. Specifically, the facility did not follow through with the PASRR recommendations for Resident 124, who required a Level II evaluation due to a positive Level I screening. Despite being admitted and readmitted with diagnoses including schizophrenia, dementia, and major depressive disorder, the necessary Level II evaluation was not conducted until much later. The Assistant Director of Nursing (ADON) only assumed responsibility for PASRR follow-up recently and was unaware of who was previously in charge, leading to a lapse in ensuring the resident received the required evaluation. Additionally, the facility failed to submit a new Level I PASRR for Resident 11, who had discrepancies in the initial screening. Resident 11 was admitted with diagnoses including dementia with agitation, anxiety disorder, and psychosis, and was prescribed psychotropic medications. However, the initial PASRR screening inaccurately indicated no serious mental illness diagnoses. The ADON later discovered the error and submitted a corrected PASRR Level I Screening. The ADON was not initially aware that reviewing PASRRs upon admission was part of her responsibilities, which contributed to the oversight. The facility's policy and procedure on PASRR, last reviewed in September 2024, indicated that the facility should assist with Level II evaluations when necessary and ensure accurate PASRR screenings. However, the lack of clarity in staff responsibilities and oversight led to deficiencies in the PASRR process for both residents, potentially resulting in inappropriate placement and unidentified specialized services for the residents involved.
Failure in Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, identified as Resident 54, who was discharged without documented evidence of follow-up arrangements for a gastrointestinal consultation. The resident, who had a history of traumatic subdural hemorrhage, schizoaffective disorder, epilepsy, and alcoholic cirrhosis of the liver, was assessed to have the capacity to understand and make decisions. Despite this, the discharge process lacked the necessary documentation and communication regarding the resident's follow-up care, specifically the scheduling of a GI appointment. Interviews and record reviews revealed that the discharge was initiated by the facility due to the resident's improved health, leading to a transfer to a lower level of care. However, there was a breakdown in communication and documentation among the staff involved in the discharge process. The Licensed Vocational Nurse (LVN) responsible for the discharge did not document the discharge location accurately and did not complete the post-discharge plan of care, including going over medications with the resident. The Registered Nurse (RN) supervisor and social services were involved in preparing the discharge paperwork, but the necessary follow-up arrangements were not made, and the resident did not sign the discharge documents. The facility's policies and procedures require that a discharge summary and post-discharge plan be developed with the resident's involvement, including arrangements for follow-up care. However, these procedures were not followed, as evidenced by the lack of documentation and communication regarding the resident's discharge and follow-up care. The Director of Nursing acknowledged the importance of accurate documentation and communication to ensure a safe discharge, but these standards were not met in this case.
Failure to Replace Resident's Prescription Eyeglasses
Penalty
Summary
The facility failed to replace the prescription eyeglasses for a resident, identified as Resident 20, which had the potential to impact her activities of daily living due to poor vision. Resident 20 was admitted with diagnoses including glaucoma and cerebral palsy, and her care plan highlighted the need for good eye care to minimize injury risks related to visual impairment. An optometry report from December 2023 indicated that Resident 20 was prescribed eyeglasses to improve her vision and quality of life. However, during an interview in December 2024, Resident 20 reported difficulty seeing objects at a distance and mentioned losing her eyeglasses several months prior. Interviews with facility staff revealed a lack of awareness and documentation regarding Resident 20's eyeglasses. A CNA did not recall if the resident had eyeglasses, and a Licensed Social Worker noted the importance of maintaining an accurate inventory of residents' possessions. The Social Services Assistant confirmed receiving and personally handing the eyeglasses to Resident 20 in April 2024 but failed to update the resident's inventory list. The Director of Nursing emphasized the importance of accounting for residents' possessions to prevent delays in replacing lost items, which could affect residents' quality of life. The facility's policy required updating residents' personal property inventories, but this was not adhered to in Resident 20's case.
Failure to Provide Ulnar Splint for Resident with Contracture
Penalty
Summary
The facility failed to provide an ulnar splint for a resident with a contracture of the left hand, which was necessary to maintain and improve the resident's range of motion. The resident, who was admitted with diagnoses including cerebral palsy, contracture of the left hand, and generalized muscle weakness, had a physician's order for a left ulnar splint dated 10/25/24. However, during an observation on 12/16/24, the resident was found lying in bed with her left hand clenched in a fist, indicating that the splint had not been provided. The resident confirmed that she had not received the new splint promised during an occupational therapy session. The occupational therapist had recommended the splint in an evaluation dated 9/10/24, but was unaware of who was responsible for ordering it. The Director of Rehabilitation acknowledged that it was their responsibility to order the device following the therapist's recommendation, but could not provide an order confirmation for the splint. The facility's policy indicated that therapists are responsible for ordering splints, highlighting a discrepancy in the process that led to the resident not receiving the necessary device to prevent worsening of her contracture.
Improper Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to a potential risk of urinary tract infections (UTIs) for three residents. The deficiency was identified during observations, interviews, and record reviews, where it was found that the urinary catheter tubing for Residents 49, 153, and 1 had loops while hanging on the side of their beds. This improper positioning of the catheter tubing could obstruct urine flow, potentially causing urine to back up and increasing the risk of UTIs. Resident 49, who was admitted with diagnoses including obstructive and reflux uropathy, was observed with a loop in the urinary catheter tubing, verified by LVN 7. The facility's policy requires that catheters be secured with an anchor or leg strap, placed below the bladder level, and free of loops to ensure unobstructed urine flow. However, the observation revealed non-compliance with these guidelines, as the tubing was not properly positioned, posing a risk for urinary retention and UTI development. Similarly, Resident 153, with a diagnosis of obstructive uropathy, and Resident 1, with obstructive uropathy and other conditions, were also found with loops in their catheter tubing. LVN 7 and LVN 13 confirmed the improper positioning during their respective observations. The Assistant Director of Nursing reiterated the facility's catheter care policy, emphasizing the importance of maintaining unobstructed urine flow to prevent UTIs. Despite these guidelines, the staff failed to ensure the catheter tubing was free of loops, placing the residents at risk for complications.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility failed to ensure proper care and services for residents receiving enteral feeding, leading to potential complications. For Resident 159, the facility did not label the enteral formula bag and water flush bag with the administration rate, nor did they change the EF formula bag, water flush bag, and medication syringe daily as required. These items were observed to have a start date and time that indicated they had not been changed for several days, which was confirmed by LVN 7. The lack of proper labeling and timely changes posed an infection control issue and risked dehydration and malnutrition for the resident. Resident 159 had been admitted with conditions including asthma, gastrostomy, and generalized muscle weakness, requiring total assistance with activities of daily living. Despite having the capacity to understand and make decisions, the resident's care was compromised by the facility's failure to adhere to its own policies regarding the maintenance and labeling of enteral feeding equipment. The Assistant Director of Nursing acknowledged the importance of changing and labeling the equipment daily to prevent complications from expired formula and ensure the resident received the correct amount of feeding and water. For Resident 141, the facility failed to cover the feeding tube tip with a cap when disconnected, exposing it to environmental contaminants. This resident, who had a history of gastrointestinal hemorrhage and dysphagia, was at risk of gastric infection due to the uncovered feeding tube tip. LVN 2 and RN 1 confirmed that the feeding tube tip should have been covered to prevent infection. The Director of Nursing stated that the feeding tube should not have been disconnected unless necessary, and if disconnected, it should have been covered with a cap to prevent contamination.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) obtained informed consent for an antipsychotic medication from a resident who lacked the capacity to make medical decisions. Resident 37, who was admitted with diagnoses including dementia, bipolar disorder, and degeneration of the nervous system due to alcohol, did not have a Resident Representative (RR) to act on their behalf. The Minimum Data Set (MDS) and History and Physical (H&P) records indicated that Resident 37's cognitive function was impaired, and they did not have the mental capacity to make decisions. Despite this, the NP obtained verbal consent from Resident 37 for the administration of Zyprexa, an antipsychotic medication, without reviewing the resident's H&P and MDS to verify their decision-making capacity. Interviews with facility staff revealed that the informed consent process was not conducted correctly. Licensed Vocational Nurse (LVN) 6 acknowledged that Resident 37 experienced episodes of confusion and that the informed consent was obtained without proper review of the resident's cognitive assessments. The NP admitted to not verifying the resident's capacity to consent before obtaining it. The Director of Nursing (DON) stated that in cases where residents lack decision-making capacity and do not have an RR, an Interdisciplinary Team (IDT) meeting should be held to discuss the proposed treatment. The facility's policy and procedure on informed consent, which requires the physician to determine the necessary information for obtaining consent when a psychotherapeutic drug is ordered, was not followed in this instance.
Inadequate Discharge Documentation and Procedures
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 4) was competent in implementing the facility's policy and procedure for transfers and discharges for two residents. For Resident 54, the discharge process was not properly documented or executed. The resident was discharged to a lower level of care without proper documentation of the discharge location, vital signs, or a post-discharge plan of care. LVN 11, who was responsible for the discharge, did not document the resident's vital signs or the address of the new facility. Additionally, the post-discharge plan of care was incomplete, missing a scheduled GI appointment, and lacked the resident's signature. Resident 75's discharge was also mishandled. The resident, who was discharged home with a family member, had no documentation of vital signs at the time of discharge. LVN 11 stated that vital signs are only taken at discharge depending on the resident's condition, which contradicts the facility's policy that requires vital signs to be checked to ensure the resident's stability. The Director of Nursing (DON) emphasized the importance of documenting vital signs and ensuring accurate and timely documentation for a safe discharge. The facility's policies and procedures for discharge documentation and planning were not followed, leading to incomplete and inaccurate records for both residents. The lack of proper documentation and adherence to procedures had the potential to delay necessary care and services for the residents. The facility's policies require detailed documentation of the discharge process, including the resident's new location, mode of transportation, and a summary of their condition, which were not adequately fulfilled in these cases.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the specified date, a Certified Nursing Assistant (CNA) was assisting a resident in a wheelchair to the bathroom when another resident, sitting on the edge of his bed, suddenly grabbed the arm of the resident in the wheelchair, causing both to fall to the floor. This incident resulted in the resident in the wheelchair sustaining a superficial scratch on his right cheek. The facility's failure to prevent this interaction led to the resident being subjected to physical abuse. The resident who was abused had been admitted to the facility with diagnoses including bipolar disorder, schizophrenia, and dementia, and was noted to have severely impaired cognition. The resident required substantial assistance with mobility and activities of daily living and used a wheelchair. The incident occurred without any precipitating factors, and the resident was assessed and treated for the scratch by the treatment nurse. The resident who initiated the physical contact had been admitted with major depressive disorder and anxiety disorder and had intact cognition. This resident had a history of anger outbursts and verbally aggressive behavior, as noted in his care plan. The facility was aware of the resident's tendency to become upset when certain CNAs were not present, and this behavior had been witnessed multiple times by another resident. Despite this knowledge, the facility did not prevent the incident, resulting in the physical abuse of the resident in the wheelchair.
Failure to Investigate Resident Altercation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents. The incident occurred when one resident, who was being assisted to the bathroom by a CNA, was grabbed by another resident, resulting in both residents falling to the floor. The investigation report did not include the precipitating factors that led to the incident, such as verbal altercations between the residents prior to the physical altercation. Resident 85, who was involved in the incident, had a history of bipolar disorder, schizophrenia, and dementia, with severely impaired cognition and dependency on assistance for mobility and activities of daily living. The resident sustained a superficial scratch on the right cheek as a result of the incident. The facility's investigation failed to document the verbal exchanges that occurred between Resident 85 and Resident 73, which were reported by witnesses and staff members as contributing factors to the altercation. The Director of Nursing and the Administrator acknowledged that the investigation process was not adequately collaborative, leading to the omission of critical information in the final report. The facility's policy requires thorough documentation and investigation of all abuse allegations, including reviewing all events leading up to the incident and interviewing witnesses. However, the final investigation report submitted to the Health Department did not reflect these requirements, as it stated the incident was unprovoked and without identifiable precedents.
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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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