Cedar Pine Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1640 N. Fair Oaks Avenue, Pasadena, California 91103
- CMS Provider Number
- 555213
- Inspections on file
- 50
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cedar Pine Post Acute during CMS and state inspections, most recent first.
Two residents did not receive their scheduled morning medications within the required time frame, and one resident's medications were left unattended at the bedside. Nursing staff acknowledged that medications were overdue and that facility policy, which prohibits leaving medications unattended and requires administration within a specific window, was not followed. The DON confirmed that no residents were authorized for self-administration and that staff should observe medication intake.
Two residents engaged in non-consensual sexual activity in a hallway, witnessed by staff, due to inadequate supervision and insufficient care planning for one resident's disruptive behaviors. The facility lacked a policy on consensual sexual acts between residents and could not provide documentation of consent, resulting in a failure to prevent sexual abuse.
A resident with cognitive impairment and multiple diagnoses received PRN lorazepam for anxiety without a stop date or required physician reevaluation after 14 days, contrary to facility policy. Both the LVN and DON confirmed the absence of timely review and documentation for continued use of the medication.
A resident with severe cognitive impairment exhibited a behavioral change by screaming at another resident, which was not documented or addressed by staff. This lack of intervention led to a subsequent incident where another resident, who had moderate cognitive impairment and physical limitations, struck the first resident in the face, causing injury. Staff were aware of the behavioral issues but did not report or document them, and the DON confirmed that required procedures for change of condition and care planning were not followed.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The facility failed to provide adequate attention to continence needs, proper catheter care, and sufficient infection control measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited when a resident's care plan did not address all of their needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Two residents were not provided care in a manner that promoted dignity and respect, as required by facility policy. One resident, dependent on staff for daily activities, was dressed in a hospital gown instead of personal clothing without being given a choice. Another resident, also fully dependent, was observed with food debris around the mouth and a stained gown, with staff acknowledging the lack of cleanliness. These actions did not align with the facility's stated commitment to resident dignity and well-being.
Two residents with complex medical needs did not have accurate or comprehensive care plans addressing their specific medical devices. One resident's care plan incorrectly referenced a shunt instead of a central venous catheter for dialysis, while another resident with a heart monitor (Zio Patch) had no care plan interventions for device care or monitoring. Nursing staff and the MDS nurse confirmed these omissions, and the facility's policy requiring updated, individualized care plans was not followed.
Two residents were administered medications not in accordance with prescriber orders, resulting in a medication error rate above 5%. One resident received carvedilol without food, and another received sevelamer without a meal present, despite both medications being ordered to be given with food. Nursing staff confirmed the deviations from orders, and facility policy requires medications to be administered as prescribed.
Three unidentified loose pills were found on the floor of the medication storage room, and staff interviews confirmed that this was not in accordance with facility policy, which requires discontinued medications to be placed in a secure container for destruction. The pills were not identified, and staff acknowledged the risk of them being accessed outside the medication room.
Surveyors found that kitchen staff did not label food items in refrigerators and freezers with required information such as open dates and use by dates, and failed to discard expired pudding cups. Staff acknowledged these oversights, which were not in accordance with facility policy and could have led to unsafe food being served.
A resident with cancer and visual impairment, who was cognitively intact, repeatedly requested assistance to complete an Advance Directive but did not receive the necessary help from staff for seven years. The Social Services Worker failed to communicate with the Ombudsman and incorrectly believed the resident needed a designated decision-maker, resulting in the resident's wishes not being formally documented. Facility policy required staff to assist with advance directives, but this was not followed.
A resident with multiple complex medical conditions experienced eight episodes of low blood pressure while on antihypertensive medication. Despite reporting symptoms of syncope and having medication held due to low readings, the physician and responsible party were not notified, and no change of condition was documented by nursing staff, contrary to facility policy and standard practice.
A resident with a history of stroke and documented contractures in the left upper and both lower extremities was inaccurately assessed on the MDS, which failed to reflect any impairment in range of motion despite clear evidence from medical records and direct observation. The MDS nurse acknowledged the oversight, and the facility's policy requiring thorough assessments was not properly followed.
A resident with dementia and other medical conditions, who was dependent on staff for daily activities, did not receive regular oral care as required. Observations showed poor oral hygiene, and both the resident and a CNA confirmed that oral care was not provided consistently. Facility policy required staff to assist with oral hygiene, but this was not done.
Two residents did not receive their prescribed medications with food or meals as ordered by their physicians. One resident was given carvedilol without food, and another received sevelamer after eating, rather than with a meal. Nursing staff confirmed the medications were not administered according to orders, and facility policy requires medications to be given as prescribed.
A resident with chronic medical conditions and intact cognition experienced ongoing mouth pain and difficulty chewing due to the facility's failure to follow up on a dental consult and assist with obtaining dentures. Despite multiple requests and a care plan intervention for dental evaluation, the resident was overlooked for several months, leading to frustration and unmet dental needs.
A resident with multiple medical conditions and intact cognition repeatedly received meals that were unappetizing and did not align with his stated preferences, including overcooked vegetables and dry meats. Despite voicing his concerns to dietary staff, the facility did not consistently accommodate his food preferences, resulting in the resident refusing to eat and experiencing negative psychosocial effects.
A resident with multiple diagnoses and orders for adaptive feeding equipment was not allowed to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a staff member used the specialized utensils to feed the resident directly, contrary to physician orders and the care plan, which specified these devices to promote independence. Staff interviews confirmed the equipment was present but not used by the resident as intended.
Staff did not follow the facility's infection control policy when providing wound care to a resident on enhanced barrier precautions. During a wound dressing change, a RN and a CNA failed to wear required PPE, including gown, gloves, and mask, despite the resident's need for such precautions due to a wound. This lapse was confirmed by another RN and the DON, both of whom stated that EBP should have been implemented during direct care.
A resident with significant physical impairments and dependence on staff for daily activities was observed lying in bed with the call light on the floor and out of reach. Staff interviews and review of the care plan and facility policy confirmed that the call light should have been within the resident's reach, but this was not followed.
A resident assessed as high risk for elopement, with a history of substance abuse and mobility issues, was allowed to leave the facility on an unsupervised out on pass without a specific care plan or clear supervision guidelines. When the resident did not return as expected, staff failed to initiate a search or notify the DON, administrator, or authorities in a timely manner, and did not follow established elopement risk procedures, resulting in a prolonged period before the resident was reported missing.
A resident with alcohol use disorder and psychoactive substance abuse did not receive a person-centered care plan or behavioral health services, including counseling or referral to a psychologist. The facility allowed the resident to leave on pass without clear supervision guidelines, and staff confirmed that no care plan or interventions were developed to address the resident's substance use, contrary to facility policy.
A resident with severe cognitive impairment and a history of aggression was inadequately supervised while wandering the facility, resulting in the resident entering another's room and scratching a fellow resident's face. Staff interviews revealed that the incident occurred when the CNA briefly looked away, and that closer monitoring and redirection could have prevented the altercation. Facility policies require monitoring of residents with dementia and protection from abuse, but these were not effectively implemented, leading to a deficiency.
The facility did not follow its Enhanced Barrier Precaution policy, as a CNA failed to wear an isolation gown during high-contact care with a resident on EBP. Additionally, isolation gowns were unavailable in three EBP rooms, as confirmed by staff. This deficiency increased the risk of cross-contamination and infection spread.
A facility failed to document a resident-initiated discharge, leading to potential confusion among the healthcare team. The resident, with multiple medical conditions, was evacuated due to a fire and later expressed a desire to move closer to friends and doctors. Staff interviews revealed a lack of documentation regarding the discharge process, contrary to facility policy.
A resident with functional quadriplegia reported an alleged abuse incident involving aggressive handling by staff, resulting in pain in the resident's left hand. The facility failed to report the allegation within the required two-hour timeframe to the local police, state survey agency, and ombudsman. The charge nurse reported the incident to the Social Services Worker eight hours after it was initially reported by the resident, contrary to the facility's policy requiring immediate reporting.
A facility failed to accurately assess and document oxygen use for three residents, leading to omissions in the MDS and care plans. One resident with multiple diagnoses was observed using oxygen, but this was not reflected in the MDS. Another resident with acute respiratory failure was receiving oxygen at a higher rate than ordered, yet the MDS did not indicate oxygen use. A third resident with COPD was also receiving oxygen, but this was not documented in the MDS. The MDS Nurse acknowledged the oversight in each case.
The facility failed to administer oxygen according to physician's orders and did not label humidifiers for three residents. One resident received 1.5 LPM instead of the prescribed 2 LPM, another received 4 LPM instead of 2 LPM, and a third received 5 LPM instead of the ordered 2 LPM with a possible increase to 3 LPM. None of the humidifiers were labeled, and there was no documentation of changes or physician notification.
A facility failed to maintain accurate medical records by documenting vital signs for a resident who was hospitalized and not present in the facility. The resident, with conditions including epilepsy and HIV, was transferred to a hospital due to tachycardia. Despite this, vital signs were inaccurately recorded for several days. A nurse admitted to fabricating these records, which was confirmed by other staff. This failure to adhere to documentation policies could lead to incorrect treatment decisions.
The facility failed to follow infection control measures for two residents and four rooms under enhanced barrier precautions (EBP). A resident with MRSA bacteremia lacked isolation signage, and another with a gastrostomy tube did not receive care with appropriate PPE due to the absence of PPE carts. Staff admitted to not wearing gowns, increasing infection transmission risk. EBP signage was present, but PPE carts were missing, violating facility policies.
A facility failed to provide padded side rails for a resident with a seizure disorder, as ordered by a physician. Despite the resident's history of seizures and the facility's policy on side rails, observations revealed the absence of the required padding. Staff interviews confirmed the oversight, highlighting the potential risk of injury during seizure episodes.
A resident with muscle weakness and end-stage renal disease did not receive necessary OT and PT services due to pending insurance authorization, despite physician orders and care plan requirements. The facility's assessment tool confirmed these services should be provided based on resident needs, but the delay in authorization was not communicated to the rehabilitation department, leading to a lack of therapy provision.
Two residents in the facility requested female CNAs for personal care due to discomfort with male CNAs. Despite clear communication of their preferences, the facility continued to assign male CNAs, disregarding the residents' rights to self-determination. Staff interviews confirmed awareness of these preferences, yet the facility's policy on accommodating resident needs was not followed.
The facility failed to provide a safe and homelike environment for two residents. One resident experienced a loss of personal property due to incomplete documentation and verification of belongings upon admission. Another resident's bathroom had missing tiles, which were not promptly repaired, affecting the homelike atmosphere. Staff interviews revealed lapses in adherence to procedures for inventory management and maintenance reporting, impacting residents' quality of life.
The facility failed to update care plans for two residents, one with a diet change and another requiring dialysis monitoring. A resident's care plan was not revised to reflect a change from a regular diet to liquids, risking aspiration. Another resident's care plan lacked updated I&O monitoring for dialysis, risking fluid overload. These deficiencies were identified through interviews and record reviews, indicating a failure to adhere to physician orders and facility policies.
The facility failed to provide adequate pressure ulcer care for three residents. A resident's low air loss mattress was not set according to their weight, risking skin integrity. Another resident was not repositioned every two hours as required, and their refusal to be turned was not addressed in the care plan. A third resident with a stage 4 pressure ulcer did not have a low air loss mattress ordered since admission, delaying appropriate care.
The facility failed to provide safe and appropriate dialysis care for two residents. For one resident, the facility did not assess the dialysis catheter on two occasions and did not update the care plan when a new AV shunt was placed. For the other resident, the facility did not re-evaluate the intake and output order after 30 days, failed to contact the physician regarding fluid restriction, and did not conduct an Interdisciplinary Team meeting. These deficiencies indicate a lack of proper monitoring and communication regarding the residents' dialysis care needs.
The facility failed to assess and document the use of side rails for two residents, leading to potential safety risks. One resident, with conditions like seizures and hemiplegia, did not receive the required quarterly reassessments for side rail use. Another resident, with cognitive impairments, had a side rail up without any documented assessment or physician order. The facility's policy requires assessments and informed consent for side rail use, which were not followed, posing a risk of inappropriate use and potential harm.
A resident did not receive several prescribed medications, including Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch, at the scheduled time. Additionally, Dexamethasone was administered at the wrong time. This failure to follow physician orders was confirmed by both an LVN and an RN, potentially leading to medical complications.
The facility failed to report medication regimen irregularities for two residents to their primary physicians. A resident was prescribed both Vascazen and Vascepa, and another was prescribed Zyprexa without verifying the diagnosis and target behavior. The pharmacist's recommendations were not communicated in a timely manner, potentially leading to unnecessary medication use.
A resident in an LTC facility experienced a 28% medication error rate due to a nurse's failure to administer several prescribed medications, including Dexamethasone, Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch. The resident, with a history of angioneurotic edema, hypertension, and seizures, did not receive medications as ordered, potentially impacting their health. The facility's policies on timely and accurate medication administration were not adhered to.
The facility failed to remove expired eye medications and improperly stored Basaglar Kwik Pens and Trulicity pens at room temperature instead of in the refrigerator. Additionally, the medication refrigerator was not defrosted as required, potentially affecting medication efficacy. These deficiencies were confirmed through staff interviews and observations.
The facility failed to follow proper food handling practices, including labeling foods with 'use by' dates, discarding expired food, and maintaining sanitary storage conditions. Observations included a resident's personal container with a used napkin on food seasoning, undated opened items, and expired turkey in the refrigerator. Unsanitary conditions were noted, such as a bowl on the floor and a water line filter touching the drain, along with improper storage of a bathroom plunger. These practices were against the facility's policies, posing a risk of contamination.
The facility did not follow its policy to monitor refrigerator and freezer temperatures for resident food brought from home, affecting four residents. From June 1 to June 11, 2024, temperature logs were incomplete, and the refrigerator was found at 50°F, above the safe threshold. The Dietary Supervisor confirmed the lapse, acknowledging the risk of food poisoning due to unsafe storage temperatures.
The facility failed to include information about selecting a convenient venue for arbitration in agreements signed by two residents. The Admissions Coordinator confirmed that the agreements lacked this detail, resulting in residents not being informed of their right to a convenient arbitration location.
The facility failed to coordinate hospice care for three residents, resulting in undocumented and inconsistent hospice staff visits. Residents did not receive the required hospice services as per their care plans, with missing documentation from CHHA and other hospice staff. This lack of coordination and documentation raised concerns about the residents receiving necessary hospice care.
A resident with C. diff was not provided appropriate infection control measures in their isolation room. The facility used cleaning solutions not approved by the EPA for C. diff, contrary to their policy requiring EPA-registered disinfectants. Housekeeping staff were unaware of the effectiveness of the solutions used, leading to potential cross-contamination risks.
The facility staff failed to ensure a safe environment in the kitchen by improperly managing electrical connections. A portable air conditioner was incorrectly connected to an extension cord, and a wall outlet was covered with tape to secure a generator plug, posing a fire risk. The Maintenance Supervisor confirmed these practices violated safety protocols, as outlined in the facility's policies.
Failure to Administer and Monitor Medications According to Policy
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own policies and physician orders for two residents. For the first resident, who had multiple diagnoses including schizoaffective disorder, hyperlipidemia, major depressive disorder, and GERD, the facility did not administer eight scheduled morning medications within the required time frame. The medications, which included anticoagulants, antidepressants, antipsychotics, and other essential drugs, were due at 9AM but were not given until 11:03AM. The nurse confirmed that the medications were overdue and acknowledged that they should have been administered within one hour before or after the scheduled time. The resident also reported receiving medications late. For the second resident, who had diagnoses including benign prostatic hyperplasia, GERD, and chronic venous hypertension, the facility also failed to administer morning medications on time. The resident's 9AM medications were given at 10:30AM, and the nurse left the medications unattended on the resident's bedside table. The resident was observed taking the medications at 11:45AM, but the nurse admitted that the medications should not have been left unattended and that she did not observe the resident taking them. The DON confirmed that facility policy prohibits leaving medications unattended and requires nurses to observe residents taking their medications. The facility did not have any residents authorized to self-administer medications. The facility's policy and procedure on medication administration, last revised in July 2013, states that medications must not be prepared in advance or left unattended and must be administered within one hour before or after the scheduled administration time. Both the DON and the nurse involved acknowledged that these policies were not followed in the incidents involving the two residents.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to prevent sexual abuse between two residents in the hallway, as witnessed by staff on 12/18/2025. One resident, who had a history of cocaine dependence and moderate cognitive impairment, was observed pulling down his pants and exposing himself, while another resident, diagnosed with schizoaffective disorder and major depressive disorder, performed oral sex on him. Multiple staff members, including a dietary orientee and a CNA, witnessed the incident through a glass window and reported it to the charge nurse. The event was documented in the residents' records and confirmed through interviews with both residents and staff. Resident records indicated that one resident was considered self-responsible but had moderately impaired cognitive skills, while the other was not self-responsible and had a care plan for socially inappropriate and disruptive behaviors, including touching and kissing staff and residents. The care plan intervention was to observe the resident's behavior around others, but this was not specific enough to address the risk of sexual abuse. Prior to the incident, the resident with disruptive behaviors had also exhibited other inappropriate actions, such as throwing feces and attempting to touch or kiss others. Interviews with staff and residents revealed that the facility did not have a policy regarding consensual sexual relationships or acts between residents, nor could they provide documentation of consent for the sexual activity that occurred. The DON acknowledged that the care plan for the resident with disruptive behaviors was insufficient and not tailored to prevent sexual abuse. The facility's policy on abuse and neglect required prevention of all forms of abuse, including sexual abuse, but the measures in place were inadequate to prevent the incident between the two residents.
Failure to Review and Discontinue PRN Psychotropic Medication per Policy
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-anxiety medication, lorazepam, had a stop date and was reevaluated by a physician after 14 days as required by facility policy. The physician's order for lorazepam, initiated for anxiety, irritability, and restlessness, did not specify a stop date, and there was no documented evidence of a physician reevaluation for continued use after the initial 14-day period. Both the LVN and the DON confirmed that the medication order should have been reviewed and either renewed or discontinued within 14 days, in accordance with facility policy and procedure. The resident involved had a history of encephalopathy, type 2 diabetes mellitus without complications, and anxiety disorder. Assessment records indicated moderate cognitive impairment and significant dependence on staff for daily activities, including eating, hygiene, and dressing. Despite these needs and the facility's policy requiring timely review of PRN psychotropic medications, the required physician evaluation and documentation for continued use of lorazepam were not completed.
Failure to Address Behavioral Incident Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by not addressing a significant behavioral incident and not implementing appropriate interventions. One resident, with diagnoses including dementia, schizoaffective disorder, depression, and anxiety, exhibited a change in behavior by screaming at another resident. This behavioral change was not documented, monitored, or communicated to the physician as required by facility policy, nor was it incorporated into the resident's care plan. Staff separated the residents during the incident but did not report the event to a licensed nurse or take further action. Following the unaddressed behavioral incident, another resident subsequently hit the first resident in the face, resulting in a scratch under the eye and redness on the nose. The injured resident was severely cognitively impaired and dependent on staff for most activities of daily living. The resident who struck the other had moderate cognitive impairment and physical limitations. Interviews revealed that staff were aware of the first resident's tendency to invade others' personal space but did not report or document these behaviors, assuming it was common knowledge. The Director of Nursing acknowledged that the initial behavioral incident should have been treated as a change of condition, requiring immediate communication with the physician and care plan updates. Facility policies reviewed during the investigation emphasized the need to identify, document, and manage problematic behaviors and to intervene in situations likely to lead to abuse. The lack of documentation, monitoring, and intervention after the initial incident directly contributed to the subsequent physical altercation and injury.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Promote Resident Dignity and Respect in Personal Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not adhering to its own policies regarding resident choice and personal care. One resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, was observed wearing a hospital gown despite having personal clothing available in their closet. The resident reported that staff did not ask for their preference and dressed them in a hospital gown for staff convenience. A Certified Nursing Assistant confirmed the resident's dissatisfaction with wearing the gown, and the facility's administrator acknowledged that staff should offer residents a choice in what to wear. Another resident, who was severely cognitively impaired and dependent on staff for all personal care, was observed with food debris around their mouth and a brown stain on the shoulder of their gown. These observations were made during two separate visits, and both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed the presence of the food debris and the stained gown. The CNA stated that it is important to keep residents clean for their well-being and appearance, especially if family visits. The facility's policy on dignity and quality of life, revised in 2022, states that each resident should be cared for in a manner that promotes their sense of well-being, self-worth, and self-esteem. The observed actions and inactions by staff, including not offering clothing choices and not maintaining personal cleanliness, were inconsistent with this policy and resulted in a failure to uphold the residents' dignity and respect.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Medical Devices
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with specific medical devices and needs. For one resident with chronic kidney disease, anemia, and hypertension, the care plan inaccurately addressed a shunt for dialysis access, when the resident actually had a right upper chest tunneled central venous catheter. The care plan included interventions appropriate for a shunt, such as avoiding blood pressure measurements or blood draws in the shunt extremity and instructing the resident not to sleep on the side with the shunt, none of which were applicable. This inaccuracy was confirmed by both nursing staff and the MDS nurse, who acknowledged that the care plan did not reflect the correct dialysis access or the appropriate interventions required for a central venous catheter. Another resident, admitted with diagnoses including subdural hemorrhage, end stage renal disease, atherosclerotic heart disease, and atrial fibrillation, had a Zio Patch heart monitor placed by a cardiologist. Upon returning to the facility, the resident reported the presence of the device to nursing staff but did not receive any explanation or care instructions. The care plan was not updated to address the presence of the Zio Patch, and there were no interventions documented for monitoring the device, assessing skin integrity, or ensuring the device was returned as required. The MDS nurse and DON both confirmed that the care plan did not include the necessary information or interventions for the heart monitor. The facility's policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, and that care plans be revised as residents' conditions change. In both cases, the facility did not follow this policy, resulting in care plans that did not address the residents' actual needs or the specific care required for their medical devices.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 30 observed opportunities, resulting in a 6.67% error rate. The first error involved a resident with hypertension, osteoarthritis, and encephalopathy, who was ordered to receive carvedilol with food. During medication administration, the nurse gave the resident carvedilol without offering food, contrary to the prescriber's order. The nurse later confirmed that the medication was not administered with food, and the DON acknowledged the importance of following medication orders to ensure effectiveness and prevent complications. The second error involved a resident with end stage renal disease, anemia, and syncope, who was ordered to receive sevelamer with meals. During observation, the nurse administered sevelamer and other medications to the resident without a meal present at the bedside. The resident confirmed that medications were given after breakfast, but not with food. A registered nurse stated that medications ordered to be given with meals should be administered accordingly to avoid stomach upset or reduced effectiveness, and that food should be offered when administering sevelamer after breakfast is served. A review of the facility's medication administration policy indicated that drugs must be administered in accordance with the written orders of the attending physician and that all medications should be given following the scheduled administration times unless otherwise specified. The observed failures to administer medications as ordered, specifically regarding the requirement to give certain medications with food, directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Properly Dispose of Discontinued Medications
Penalty
Summary
Facility staff failed to follow established policy and procedure regarding the disposal of discontinued medications, as evidenced by the observation of three unidentified loose pills found on the floor of the medication storage room. During a survey, the Infection Preventionist Nurse (IPN) confirmed the presence of these pills, which included a light purple round pill, a yellow oblong pill, and a white round pill. The IPN was unable to identify the pills and acknowledged the risk that loose pills could be inadvertently moved out of the medication room and potentially accessed by residents. Further interview with a Registered Nurse (RN) confirmed that having loose pills on the floor was unacceptable and not in accordance with facility policy, which requires discontinued medications to be disposed of in a designated container for incineration. Review of the facility's policy indicated that all discontinued or outdated medications should be placed in a secure, designated location for destruction, which was not followed in this instance.
Failure to Label and Discard Expired Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to follow its own food handling policies and procedures by not labeling food items in the kitchen refrigerators and freezers with the required information, such as item name, date opened, and use by date. Specifically, a 1-gallon container of Thousand Island dressing in Refrigerator #2 was found without an open date, and the staff member acknowledged it had been opened the previous day but was not labeled as required. Additionally, three cups of vanilla pudding in the same refrigerator were found with a use by date that had already passed, and a dietary staff member confirmed these should have been discarded the previous day. Further observations revealed that a tray of ice cream cups in Freezer #2 lacked any labeling or use by dates, with staff confirming that dates should have been present to ensure safe service. Review of the facility's policy and procedure on labeling and dating of foods confirmed that all food items in storage, refrigerators, and freezers must be labeled and dated, and that prepared foods must be covered, labeled, and dated. These failures to adhere to policy had the potential to expose residents to pathogens due to improper food handling.
Failure to Assist Resident with Advance Directive Completion
Penalty
Summary
The facility failed to follow up on a resident's request to formulate an Advance Directive, resulting in a delay of seven years in addressing the resident's wishes. The resident, who had a diagnosis of malignant neoplasm of the right breast and blindness in one eye, was cognitively intact and required assistance with several activities of daily living. Upon admission and during subsequent care plan meetings, the resident expressed a desire to execute an Advance Directive but needed help completing the form due to her visual impairment. Despite these requests, the necessary assistance was not provided. Documentation in the resident's records, including the Minimum Data Set and care plan, indicated that the resident was capable of making her own decisions and had specifically requested CPR in the event of an emergency but did not want to be transferred to a hospital. The Social Services Worker acknowledged the resident's request but failed to communicate with the Ombudsman, who could have assisted in completing and witnessing the Advance Directive. The Social Services Worker incorrectly believed that the lack of a designated decision-maker, such as a child, prevented the resident from completing the document, and did not take further action. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the resident was eligible to complete an Advance Directive and that the facility's policy required staff to offer assistance in establishing such directives. The policy also required regular review of advance directives and documentation of offers to assist residents. However, these procedures were not followed in this case, resulting in the resident's wishes not being formally documented for an extended period.
Failure to Notify Physician of Repeated Hypotensive Episodes
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for a resident who experienced eight episodes of hypotension related to the use of Losartan Potassium-HCTZ. Despite the resident having a history of subdural hemorrhage, syncope, end stage renal disease requiring dialysis, atherosclerotic heart disease, and atrial fibrillation, there was no documentation that the physician or the resident's responsible party was notified of these repeated low blood pressure readings. The medication order specifically instructed staff to hold the medication if the systolic blood pressure was less than 110 mmHg, which occurred on multiple occasions. The resident reported experiencing syncope both during dialysis treatments and while in bed at the facility, and attributed these symptoms to the new blood pressure medication. The resident communicated these symptoms to the LVN, who confirmed that the medication was held on several dates due to low blood pressure readings. However, the LVN did not notify the physician or the responsible party, nor did she document a change of condition in the medical record regarding these hypotensive episodes. The DON stated that any deviation from a resident's baseline blood pressure, especially when accompanied by symptoms such as syncope, should be reported to the physician and documented as a change of condition. The facility's policy required that sudden or serious changes in a resident's condition be communicated to the physician prior to the end of the assigned shift. Despite these requirements, there was no evidence that the physician was notified or that appropriate documentation was made for the resident's repeated episodes of hypotension and related symptoms.
Inaccurate MDS Assessment of Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of range of motion (ROM) for a resident with a history of cerebrovascular accident (CVA) and documented contractures in the left upper and bilateral lower extremities. Despite multiple records, including the admission nursing assessment and history and physical, indicating the presence of contractures, the Minimum Data Set (MDS) assessment did not reflect any impairment in the resident's functional limitation in ROM. The MDS nurse acknowledged that the MDS was inaccurately completed and should have indicated impairment on one side. Observations of the resident confirmed visible contractures and functional limitations, such as the left upper extremity being contracted and the resident's inability to use the left hand due to weakness. The resident also reported numbness and required assistance with repositioning. The facility's policy required comprehensive assessments of residents' physical needs upon admission and at regular intervals, but this process was not followed accurately in this case, resulting in an incomplete and inaccurate MDS assessment.
Failure to Provide Oral Hygiene Assistance to Dependent Resident
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living, specifically oral care, to a resident who was unable to perform these tasks independently. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and gastroesophageal reflux disease, was assessed as cognitively impaired and dependent on staff for transfers and daily decision-making. Despite these needs, the resident did not receive regular oral hygiene care as required. Observations revealed the resident had visible signs of poor oral hygiene, including drooling, dried and cracked lips, a yellow patch on the tongue, and yellowish teeth. The resident reported not receiving daily oral care since admission. A CNA confirmed that oral care was not provided regularly, and the DON acknowledged that daily oral hygiene is necessary to prevent oral health problems. Facility policy also required staff to assist residents with oral hygiene, but this was not followed for the resident in question.
Failure to Administer Medications as Ordered with Food or Meals
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for two of seven sampled residents. For one resident with a diagnosis of hypertension, osteoarthritis, and encephalopathy, the physician's order specified that carvedilol should be administered with food. During a medication administration observation, the nurse gave the resident carvedilol along with other medications but did not provide food at the time of administration. The nurse later confirmed that the medication was not given with food as ordered. For another resident with end stage renal disease, anemia, and syncope, the physician's order required sevelamer to be administered with meals. During observation, the nurse administered sevelamer and other medications in the resident's room without a meal present. The resident later stated that he had eaten breakfast earlier and received his medications almost an hour after eating. The nurse confirmed that medications ordered to be given with meals should be administered accordingly to ensure effectiveness and prevent stomach upset. A review of the facility's policy indicated that drugs must be administered in accordance with the written orders of the attending physician. The failure to administer medications as ordered, specifically with food or meals, was confirmed through observation, record review, and staff interviews.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services, specifically dentures, despite multiple requests and documented needs. The resident, who had diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was cognitively intact and expressed ongoing mouth pain and difficulty chewing food. The resident's care plan included interventions for dental evaluation and intervention as needed, and a dental consult was ordered. However, the Social Service Director (SSD) did not follow up with the dental office regarding the resident's eligibility for dental services, resulting in the resident being overlooked for several months. Interviews revealed that the resident repeatedly asked staff for assistance in obtaining dentures but did not receive the necessary support. The SSD acknowledged that the resident was on a list to be checked for dental eligibility but was inadvertently missed. The facility's policy required social services to assist residents with dental appointments and arrangements, but this was not followed in the resident's case. As a result, the resident experienced frustration and continued difficulty with oral health needs.
Failure to Provide Palatable and Preferred Meals
Penalty
Summary
The facility failed to provide palatable and attractive food in accordance with its own policies for one resident. The resident, who had diagnoses including morbid obesity, GERD, and major depressive disorder, was cognitively intact and able to express his preferences and needs. Documentation and interviews revealed that the resident frequently received meals that were unappetizing, with food described as dry, mushy, and visually unappealing. The resident repeatedly voiced dissatisfaction with the taste and texture of the food, specifically noting that vegetables were overcooked and meats were excessively dry, leading him to avoid eating the meals provided. Despite the resident's clear communication of his food preferences and repeated requests for alternatives, the facility did not consistently accommodate these needs. Dietary staff acknowledged the resident's particular preferences and his tendency to refuse food that did not meet his standards, yet the issues persisted. Facility policy required that individual food preferences be accommodated within reason, but observations and interviews confirmed that the resident continued to receive meals he found unacceptable, negatively impacting his willingness to eat and his psychosocial well-being.
Failure to Ensure Resident Use of Adaptive Feeding Equipment
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, osteoarthritis, and schizophrenia, who was dependent on staff for eating and had physician orders for adaptive feeding equipment, was not provided the opportunity to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a Restorative Nursing Assistant used the specialized utensils to feed the resident directly, rather than allowing the resident to attempt self-feeding as ordered. The resident's care plan and physician orders specified the use of these assistive devices to promote independence in eating, and the occupational therapist confirmed that these devices were intended to support the resident's self-feeding abilities. Interviews with facility staff, including the MDS nurse, occupational therapist, and Director of Nursing, verified that the adaptive equipment was present but was not used by the resident as intended. The occupational therapist was unaware that the resident was being fed by staff instead of using the assistive devices, and the Director of Nursing confirmed that the devices were meant for resident use, not staff. Facility policy also indicated that assistive devices are to be provided and supervised for resident use to support independence.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement the facility's infection prevention and control policy for one resident who was on enhanced barrier precautions (EBP) due to a wound requiring daily care. During wound care administration, a registered nurse and a certified nursing assistant did not don the required personal protective equipment (PPE), including an isolation gown, gloves, and mask, as mandated by the facility's EBP policy. This was directly observed by another registered nurse, who confirmed that the staff did not follow the established protocol for PPE use during high-contact care activities such as wound care. The resident involved had a history of hypertension, pain, and epilepsy, and required varying levels of assistance with daily activities, including being dependent for toileting hygiene, showering, and dressing. The resident had a treatment order for a right lateral heel wound, which required cleaning, application of ointment, and dressing changes. Both the Director of Nursing and the observing registered nurse acknowledged that EBP should have been implemented during direct care to protect the resident from infection, as outlined in the facility's revised policy.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who had been admitted with diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was found to have their call light lying on the floor beneath the bed, out of reach. The resident's Minimum Data Set indicated intact cognitive skills but significant physical impairments, including upper and lower extremity impairment on one side and dependence on staff for most activities of daily living, including mobility and hygiene. During observation, the resident was lying in bed and unable to access the call light. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that facility policy requires call lights to be within reach of residents to maintain safety. The resident's care plan also specified that the call light should be kept within easy reach and answered promptly. Review of the facility's policy and procedure further supported this requirement, stating that the call device must be placed within the resident's reach before staff leave the room. Despite these policies and care plan interventions, the call light was not accessible to the resident at the time of observation.
Failure to Prevent Elopement and Timely Response for At-Risk Resident
Penalty
Summary
A resident with a history of psychoactive substance abuse, alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet was admitted to the facility and assessed as being at risk for elopement. Despite this assessment, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk. The resident had a physician's order allowing out on pass (OOP) privileges, but the order was non-specific, lacking details about duration, accompaniment, or supervision requirements. The resident left the facility independently for an OOP and did not return at the expected time. Facility staff did not initiate a search for the resident when he failed to return as scheduled, nor did they notify the DON, administrator, or local authorities in a timely manner. Documentation shows that the resident's absence was noted, and attempts were made to contact him by phone, but no further action was taken to locate him or escalate the situation according to facility policy. The lack of a clear care plan and failure to follow established elopement risk procedures contributed to the delay in recognizing and responding to the resident's absence. Interviews with staff and review of facility policies revealed that staff were unclear about the procedures to follow when a resident did not return from OOP. The facility's policies required timely searches and notifications, but these were not carried out. The resident remained missing for an extended period before the incident was reported to the appropriate authorities, including the police and the Department of Public Health. The failure to implement and follow elopement risk protocols resulted in an Immediate Jeopardy situation.
Removal Plan
- All residents with out on pass order were reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident requests to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes: Cognitive Competency (Recent BIMS), Behavioral Stability (No recent history of elopement), Medical Stability (Medically cleared by Attending Physician), Functional Mobility.
- MDS Coordinator and Registered Nurse Supervisor re-assessed all residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all residents. Residents were identified as low risk or high risk for elopement.
- Elopement Risk Policy and Procedures was revised and updated. The licensed personnel were in-serviced and educated regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies.
- Director of Staff Development/Director of Nursing in-serviced the licensed personnel regarding Policy and Procedure for elopement to emphasize reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement.
- All residents with out on pass order were reviewed and updated including the duration, purpose, companion, and return time. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility.
- Residents on high risk for elopement are potentially affected by the deficient practice. Residents identified as high risk were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station.
- An in-service was provided to Licensed Nurses and direct care givers by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing, How to locate or search the resident, Reporting to governing agencies within 2 hours and CDPH within 24 hours.
- The Director of Nursing/Designee and Director of Staff Development conducted in-service to Licensed Nurses and Certified Nursing Assistants pertaining to the following: Revised Policy and Procedure for Out on Pass, Physician order for out on pass, Duration and companion, Protocol if the resident did not return after specific duration, Resident's decision against medical advice.
- Policy and Procedure for Elopement.
- During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting.
- The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness.
Failure to Provide Behavioral Health Services and Care Planning for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a primary diagnosis of alcohol use disorder and psychoactive substance abuse. Upon admission, the resident's diagnoses included psychoactive substance abuse, unspecified alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet. Despite these diagnoses, there was no documented evidence that the facility developed or implemented a person-centered care plan addressing the resident's behavioral health needs related to substance use. Interviews and record reviews revealed that the resident was allowed to leave the facility on pass without specific orders regarding supervision or duration, and there was no indication that behavioral health interventions or referrals to a psychologist were made. The resident's clinical records, both paper and electronic, lacked documentation of any care plan or interventions targeting the resident's alcohol use or psychoactive substance abuse. Staff interviews confirmed that no such care plan was developed or discussed in the interdisciplinary care team meetings. Facility policies required that residents with substance use disorders receive individualized care plans and behavioral health services, including monitoring for substance use and supporting efforts to prevent further use. However, these policies were not followed in this case, as evidenced by the absence of a care plan, lack of behavioral health service referrals, and insufficient documentation of interventions to address the resident's substance use and associated risks.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident scratched another resident's face. The incident occurred when a resident with severe cognitive impairment, who required substantial assistance with daily activities and was known to exhibit verbal aggression, was being followed by a CNA as the resident wandered the hallways in a wheelchair. Despite being followed, the resident was able to abruptly get up from the wheelchair, enter another resident's room, and scratch the face of a resident who was lying in bed. The CNA reported turning his head away momentarily, during which time the incident occurred, and was unable to prevent the altercation. The resident who was scratched had a history of intact cognitive skills but required assistance with several activities of daily living. The injury was documented as a scratch on the nose, and treatment was ordered by the resident's physician. Interviews with staff indicated that the resident who committed the act was new to the facility and had been exhibiting aggressive behaviors that required close supervision. Staff acknowledged that the incident could have been prevented if the resident had been more closely monitored and redirected when attempting to enter another resident's room. Facility policy and procedures reviewed by surveyors indicated that residents have the right to be free from abuse and that staff are required to monitor individuals with dementia. The failure to adequately supervise and redirect the resident with aggressive behaviors resulted in a physical altercation and injury to another resident, constituting a deficiency in protecting residents from abuse.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution (EBP) policy, which is designed to prevent the spread of multi-drug resistant organisms (MDRO) by using targeted gown and glove use during high-contact resident care activities. Certified Nurse Assistant 1 (CNA 1) did not wear an isolation gown while changing the diaper of Resident 1, who was on EBP. Resident 1 had severe cognitive impairment and was dependent on staff for daily activities, including toileting and personal hygiene. The failure to wear an isolation gown during this high-contact activity was confirmed by CNA 1, who acknowledged the need for such protective measures to prevent infections. Additionally, the facility did not ensure the availability of isolation gowns in three of the five sampled rooms (Rooms A, B, and C) that required EBPs. Observations and interviews confirmed the absence of isolation gowns in these rooms, which were necessary for staff to use when providing care to residents to prevent cross-contamination. The Infection Prevention Nurse (IPN) and Licensed Vocational Nurse 1 (LVN 1) confirmed the deficiency, emphasizing the importance of having easy access to personal protective equipment (PPE) in EBP rooms to prevent the spread of infections among residents, staff, and visitors.
Failure to Document Resident-Initiated Discharge
Penalty
Summary
Facility 1 failed to maintain complete and accurate medical records for a resident who initiated a discharge to another facility. The resident, who had been admitted with multiple medical conditions including atrial fibrillation, paranoid schizophrenia, and various fractures, was evacuated to Facility 2 due to a fire. The resident expressed a desire to be relocated closer to friends and outside doctors, leading to a discharge to Facility 3. However, the facility did not document the resident's discharge coordination or the resident's wishes and preferences in the medical records. Interviews with the facility's staff revealed that there was a lack of documentation regarding the resident's discharge process. The Social Services Designee (SSD 1) did not document conversations with the resident about the discharge, and the Admissions Coordinator (AC) failed to record the resident's request to be transferred to another facility. Additionally, the facility's policy for resident-initiated discharges, which required documentation of the resident's intent to leave and discharge planning, was not followed. The facility's Administrator acknowledged the failure to document the discharge process, which was necessary to avoid confusion and ensure all healthcare team members were aware of the resident's preferences and the discharge details. The lack of documentation could potentially confuse the healthcare team and negatively impact service delivery, as the facility could not provide evidence of the discharge process or the resident's preferences.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the local police department, state survey agency, and ombudsman. The incident involved a resident with functional quadriplegia who reported an alleged physical abuse incident involving aggressive handling by staff, which resulted in pain in the resident's left hand. The resident, who had intact cognition, was dependent on staff for various activities and had a physician's order for an X-ray due to the complaint of pain. However, the resident refused the X-ray, opting to consult with family and a primary physician instead. The Social Services Worker received the report of the alleged abuse from the charge nurse eight hours after the incident was initially reported by the resident. The Director of Nursing acknowledged that the charge nurse, who had been trained in abuse reporting, should have notified the Administrator immediately within the two-hour mandate. The Administrator, who is the facility's Abuse Coordinator, confirmed that the charge nurse failed to follow the facility's policy, which requires immediate reporting of abuse allegations. The facility's policy mandates that all alleged violations involving abuse must be reported immediately to the administrator and relevant authorities, but this was not adhered to in this case.
Failure to Accurately Assess Oxygen Use in Residents
Penalty
Summary
The facility failed to ensure accurate assessment of oxygen use for three residents, which was identified during a survey. Resident 4, who was admitted with multiple diagnoses including end-stage renal disease, type II diabetes, and congestive heart failure, was observed using oxygen at 1.5 liters per minute via nasal cannula. However, the Minimum Data Set (MDS) did not reflect this oxygen therapy, and there was no care plan initiated for it. The MDS Nurse acknowledged the oversight, stating that the resident's oxygen use should have been included in the MDS. Similarly, Resident 5, who had acute respiratory failure with hypoxia and other serious conditions, was observed with an oxygen level of 4 liters per minute via nasal cannula. The MDS for this resident also failed to indicate the use of oxygen, despite a medical order for oxygen therapy. The MDS Nurse admitted to not properly assessing the resident during the look-back period, resulting in the omission of oxygen therapy from the MDS and care plan. Resident 6, diagnosed with chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at 5 liters per minute. Like the other residents, the MDS did not reflect the use of oxygen therapy, and no care plan was initiated. The MDS Nurse confirmed that the MDS should have accurately reflected the resident's oxygen therapy status. The facility's policy requires that all pertinent data and information be documented in the resident's medical record, which was not adhered to in these cases.
Failure to Administer Oxygen as Prescribed and Label Humidifiers
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents by not administering oxygen according to physician's orders and not labeling humidifiers as per the facility's policy. Resident 4, who was admitted with multiple diagnoses including end-stage renal disease and dependence on supplemental oxygen therapy, was observed receiving oxygen at 1.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 2 LPM. There was no label on the humidifier with the resident's name and date, and no documentation of any changes to the oxygen level or physician notification was found in the resident's records. Resident 5, who had severe cognitive impairment and was dependent on supplemental oxygen therapy, was observed receiving oxygen at 4 LPM, while the physician's order specified 2 LPM. Similar to Resident 4, there was no label on the humidifier, and no documentation was found regarding the increase in oxygen level or physician notification. Additionally, there was no care plan addressing oxygen therapy in Resident 5's records. Resident 6, diagnosed with chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at 5 LPM, exceeding the physician's order of 2 LPM with a possible increase to 3 LPM if necessary. Again, the humidifier was not labeled, and there was no documentation of the oxygen level change or physician notification. The facility's policy on oxygen therapy, which requires labeling humidifiers with the resident's name and date, was not followed for any of the three residents.
Inaccurate Documentation of Vital Signs for Hospitalized Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident 1, by documenting vital signs while the resident was not present in the facility. Resident 1, who was admitted to the facility with diagnoses including epilepsy, HIV, and gastrostomy, was transferred to a General Acute Hospital due to a change in condition, specifically tachycardia. Despite being in the hospital from December 22 to December 25, 2024, vital signs were inaccurately recorded in the facility's records for these dates. The inaccurate documentation was identified during a review of Resident 1's weights and vitals summary, which showed recorded vital signs for the period when the resident was hospitalized. Registered Nurse 1 admitted to fabricating these vital signs, acknowledging that they were made up and not based on actual assessments. This was confirmed during interviews with the MDS nurse and another registered nurse, who both stated that the documentation was incorrect as the resident was not in the facility during those days. The facility's policy on documentation requires that all pertinent data and information of each resident be accurately recorded in their medical records. The failure to adhere to this policy by documenting fabricated vital signs could lead to incorrect treatment decisions, as vital signs are crucial for assessing a resident's condition and determining appropriate care. The inaccurate documentation was a result of actions taken by RN 1, who recorded vital signs without conducting actual assessments, leading to a deficiency in maintaining accurate medical records.
Inadequate Infection Control Measures in EBP Rooms
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for two residents and four rooms under enhanced barrier precautions (EBP). Resident 4, who was readmitted with multiple diagnoses including MRSA bacteremia, did not have isolation signage posted outside their room. This lack of signage could lead to staff and visitors being unaware of the necessary precautions to prevent the spread of infection. Resident 7, who required substantial assistance with daily activities and had a gastrostomy tube, was not provided care with the appropriate personal protective equipment (PPE). Staff members, including a Certified Nurse Assistant and a Registered Nurse, admitted to not wearing gowns while providing care, as there were no PPE carts with gowns available outside Resident 7's room. This oversight in PPE availability and usage increased the risk of infection transmission. Additionally, rooms 3, 7, 9, and 11, which had residents on EBP, lacked PPE carts despite having EBP signage. Staff members confirmed the absence of PPE carts and acknowledged the potential for germs to spread due to the lack of gowns and gloves during high-contact care activities. The facility's policies required PPE to be available outside resident rooms and signage to indicate the type of precautions needed, which were not adhered to, leading to the identified deficiencies.
Failure to Provide Padded Side Rails for Seizure Precaution
Penalty
Summary
The facility failed to provide padded side rails for a resident with a seizure disorder, as indicated in the physician's order. The resident, who was admitted in 2003, has a history of seizures, schizophrenia, and repeated falls. The Minimum Data Set (MDS) assessment indicated that the resident was moderately impaired in cognitive skills and required supervision for daily activities. The physician's order, dated November 28, 2023, specified the use of padded side rails as a non-restrictive device for seizure precautions. However, during observations on January 2 and 3, 2025, it was noted that the resident's bed did not have the required padded side rails. Interviews with facility staff, including Licensed Vocational Nurses (LVN) and a Registered Nurse (RN), confirmed the absence of padded side rails and acknowledged the importance of such precautions for residents with seizure disorders. The facility's policy on side rails also indicated the necessity of padding to prevent injuries from involuntary movements. Despite the physician's order and the care plan's directives, the facility did not implement the required safety measures, potentially exposing the resident to injury during a seizure episode.
Failure to Provide Required OT and PT Services Due to Insurance Authorization Delays
Penalty
Summary
The facility failed to provide necessary Occupational Therapy (OT) and Physical Therapy (PT) services to a resident as indicated by the physician's order, care plan, and facility assessment tool. The resident, who was admitted with diagnoses including muscle weakness, gastrostomy, and end-stage renal disease, was assessed to require these therapies to prevent further decline in physical functions. Despite the resident's care plan and rehabilitation screening indicating a need for OT and PT, the services were not provided due to pending insurance authorization. The resident's Minimum Data Set (MDS) indicated a need for supervision and assistance with various activities of daily living, and the care plan included interventions to encourage participation in these activities. However, the MDS also showed that no therapy minutes were recorded, and the resident did not receive the necessary OT and PT services. Interviews with facility staff, including the Director of Rehabilitation (DOR) and the Business Office Manager (BOM), revealed that the delay in providing therapy was due to pending insurance authorization, which had not been communicated to the rehabilitation department. The facility's assessment tool confirmed that PT, OT, and speech therapy are services offered based on residents' needs, but there was no indication that these services should be contingent upon insurance authorization. The facility administrator was unaware of the situation and stated that therapy should have been provided as per the physician's order. This oversight placed the resident at risk for a decline in physical functions and developing contractures, which could negatively affect their overall wellbeing.
Failure to Honor Resident Preferences for CNA Gender
Penalty
Summary
The facility failed to honor the requests of two residents, Resident 37 and Resident 38, to be assisted by female Certified Nursing Assistants (CNAs) instead of male CNAs. Resident 37, who was admitted with conditions including benign lipomatous neoplasm, type 2 diabetes mellitus, and hemiplegia, had intact cognitive skills and was dependent on assistance for personal care. Despite her repeated requests and those of her husband, the facility continued to assign male CNAs to her care, which she found unsatisfactory and uncomfortable. Interviews with various staff members, including a Restorative Nurse Assistant and a CNA, confirmed that Resident 37's preference for female CNAs was known but not honored. Similarly, Resident 38, who had diagnoses including obesity and schizoaffective disorder, also expressed discomfort with male CNAs assisting her with personal hygiene tasks. Despite her moderate cognitive impairment, she clearly communicated her preference for female CNAs to the facility staff. However, the facility continued to assign male CNAs to her care. Interviews with a Registered Nurse and other staff members acknowledged the importance of respecting residents' preferences for the gender of their caregivers, yet these preferences were not accommodated. The facility's policy on accommodating residents' needs and preferences was not followed in these cases. The policy stated that residents' individual needs and preferences should be accommodated to the extent possible, except when health and safety are at risk. The failure to assign female CNAs as requested by Residents 37 and 38 was a violation of their rights to self-determination and had the potential to negatively impact their quality of life and psychosocial well-being.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for two residents, resulting in a violation of their rights. Resident 64 experienced a loss of personal property, including a purse containing important identification cards, upon admission to the facility. The facility's process for documenting and verifying resident belongings was not followed, as the inventory list was incomplete and lacked necessary signatures. This oversight led to the inability to confirm the presence of the missing items, causing distress to the resident and their responsible party. Additionally, Resident 31's bathroom was found to have four missing tiles, which detracted from the homelike environment the facility is required to maintain. The missing tiles were not reported or repaired in a timely manner, despite the facility's policy requiring maintenance issues to be addressed promptly. The lack of attention to the bathroom's condition affected the resident's perception of their living environment, making it feel less comfortable and familiar. Interviews with facility staff revealed a lack of adherence to established procedures for both inventory management and maintenance reporting. Staff members acknowledged the importance of verifying resident belongings and maintaining a homelike environment but failed to execute these responsibilities effectively. The deficiencies in both cases highlight a breakdown in communication and procedural compliance within the facility, impacting the residents' quality of life.
Failure to Update Care Plans for Diet and Dialysis Monitoring
Penalty
Summary
The facility failed to update and revise care plans for two residents, leading to deficiencies in care. For one resident, the care plan was not updated to reflect a change in diet from a regular diet to liquids for oral gratification as tolerated. Despite the physician's orders changing the diet due to the resident's inability to swallow, the care plan continued to indicate a regular diet, which posed a risk of aspiration. Interviews with the LVN and MDS Nurse confirmed that the care plan should have been updated to prevent the resident from consuming a regular diet, which could lead to aspiration. Another resident's care plan was not updated to address intake and output (I&O) monitoring related to dialysis treatment. The resident, who was on dialysis, initially had an order for I&O monitoring for 30 days, but this was not continued or re-evaluated after the period ended. The RN and MDS Nurse acknowledged that the care plan needed to be revised to include ongoing I&O monitoring and potential fluid restrictions, as the resident was at risk for fluid overload due to dialysis. The facility's policies indicated that care plans should be revised as residents' conditions change, but this was not adhered to in this case. The facility's failure to update care plans in accordance with physician orders and facility policies resulted in potential negative impacts on the residents' care. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for ongoing assessment and timely updates to care plans to ensure resident safety and appropriate care.
Deficiencies in Pressure Ulcer Care for Three Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and prevention of pressure injuries. Resident 37's low air loss mattress (LALM) was not set according to their weight, which was 121 lbs, while the mattress was set at approximately 220 lbs. This incorrect setting was observed by the Restorative Nurse Assistant and confirmed by the Infection Preventionist Nurse, who stated that the setting should be below 140 lbs. The facility's policy required the LALM to be adjusted based on the resident's weight to maintain skin integrity and aid in healing. Resident 48 was not repositioned every two hours as per the physician's order and care plan, which was crucial due to their high risk for pressure injuries. Despite having multiple wounds and pressure injuries, Resident 48 was observed in the same position for several hours, and staff interviews revealed that the resident often refused to be turned due to pain. The facility lacked a care plan addressing the resident's refusal to be repositioned, and there was no documented evidence of informing the physician or responsible party about the refusal. Resident 60, admitted with a stage 4 pressure ulcer, did not have an order for a LALM since admission. The Treatment Nurse admitted to forgetting to inform the primary physician and obtain the necessary order. The resident was observed without a LALM until it was placed on 6/13/2024, despite the facility's policy requiring such interventions for residents with stage 3 and 4 pressure ulcers. The oversight in obtaining the LALM order and its delayed application potentially compromised the resident's pressure injury management.
Deficiencies in Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents, Resident 60 and Resident 63, as per professional standards. For Resident 60, the facility did not assess the resident's left upper chest dialysis catheter on two occasions, and the dialysis care plan was not updated when a new AV shunt was placed. This oversight could lead to unnoticed or missed excessive bleeding and infection at the dialysis access sites. Additionally, the documentation of the dialysis communication records was incorrect and incomplete, which could cause confusion in care delivery. For Resident 63, the facility did not re-evaluate the order for intake and output after 30 days, nor did they ensure that licensed nurses contacted the physician regarding fluid restriction. The intake and output records were not documented according to facility policy, and an Interdisciplinary Team meeting was not conducted to discuss the resident's medical treatment and nursing care plan. These deficiencies indicate a lack of proper monitoring and communication regarding the resident's dialysis care needs. The report highlights that the facility's policies and procedures were not followed, leading to incomplete assessments and documentation. The Director of Nursing acknowledged the importance of accurate documentation and assessment to ensure proper care. The facility's failure to adhere to its own policies and procedures for dialysis care and monitoring contributed to the deficiencies observed in the care of Residents 60 and 63.
Failure to Assess and Document Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for two residents, leading to potential safety risks. Resident 32, who was readmitted with conditions such as seizures, hemiplegia, and cerebral infarction, had side rails used daily as a mobility aid and seizure precaution. However, the facility did not conduct the required quarterly reassessments to ensure the continued need and safety of the side rails, as the last assessment was completed in November 2023. This oversight was acknowledged by the Minimum Data Set Nurse, who admitted to not completing the necessary assessments in February and May 2024, contrary to the facility's policy. Resident 61, diagnosed with anxiety disorder, major depressive disorder, and insomnia, was observed with a side rail up without any documented assessment or physician order. The resident's Electronic Health Record lacked any order for side rail use, and staff interviews confirmed that no assessment had been conducted to justify the use of side rails. The facility's policy requires an assessment within seven days of admission and quarterly thereafter, along with obtaining informed consent and a physician's order, none of which were documented for Resident 61. The facility's failure to adhere to its policy on side rail usage and assessment posed a risk of inappropriate use of side rails, which could lead to resident harm. The lack of documentation and reassessment for both residents highlights a significant deficiency in ensuring the safety and appropriateness of side rail use, as required by the facility's own procedures.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 50, by not administering medications as ordered. On the specified date, the Licensed Vocational Nurse (LVN 1) did not administer several 9 AM medications, including Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch, which were crucial for managing the resident's conditions such as hypertension, edema, bowel management, seizures, and pain. Additionally, the LVN administered Dexamethasone at an incorrect time, deviating from the prescribed schedule of 6 AM, 2 PM, and 10 PM, which was intended to manage the resident's malignant neoplasm of the brain. The resident, who was admitted with diagnoses including angioneurotic edema, hypertension, and seizures, required partial assistance with daily activities and had intact cognitive skills. The failure to administer these medications as per the physician's orders was confirmed by both LVN 1 and a Registered Nurse (RN 1), who acknowledged the potential for medical complications, including uncontrolled high blood pressure and seizures, due to the missed doses. The facility's policy and procedure documents, which were reviewed, indicated that medications should be administered in a timely manner and in accordance with prescriber orders, highlighting the deviation from these protocols in this incident.
Failure to Report Medication Irregularities
Penalty
Summary
The facility failed to report medication regimen irregularities to the residents' primary physicians as required by their policy. This deficiency was identified during a review of the medication regimen reviews (MRR) for two residents. The pharmacist's recommendations for these residents were not acted upon in a timely manner, which could have led to the administration of unnecessary medications. Resident 12, who was admitted with diagnoses including heart failure and hyperlipidemia, was prescribed both Vascazen and Vascepa. The pharmacist recommended evaluating the necessity of both medications due to their similar effects. However, this recommendation was not promptly communicated to the resident's physician, potentially leading to the resident taking two medications with the same action. Resident 61, diagnosed with anxiety disorder, major depressive disorder, and insomnia, was prescribed Zyprexa three times daily. The pharmacist recommended verifying the diagnosis and specifying the target behavior for this medication. This recommendation was also not communicated to the resident's physician in a timely manner. The Director of Nursing acknowledged the delay in following up on the pharmacist's recommendations, which should have been reviewed and reported to the residents' doctors to prevent unnecessary medication use.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 28% error rate during a medication pass observation. Licensed Vocational Nurse 1 (LVN 1) did not administer several medications as ordered for one resident, leading to seven medication errors out of 25 opportunities. The errors included the failure to administer Dexamethasone at the correct time and the omission of multiple medications such as Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch. The resident involved had a medical history of angioneurotic edema, hypertension, and seizures, and required partial assistance with daily activities. During the observation, LVN 1 prepared and administered only five of the resident's morning medications, omitting others that were crucial for managing the resident's conditions. The LVN acknowledged the failure to administer these medications and recognized the potential impact on the resident's health, such as uncontrolled blood pressure and the risk of seizures. Interviews with the nursing staff confirmed the medication administration errors and highlighted the importance of adhering to prescribed medication schedules to ensure the resident's well-being. The facility's policies on medication administration emphasize the need for timely and accurate administration of medications as per physician orders, which were not followed in this instance.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not removing expired medications and improperly storing certain medications. Specifically, a box of expired eye gel and a box of expired eye drops were found in the medication storage room, which were not removed as required. Additionally, four unopened Basaglar Kwik Pens and four unopened Trulicity pens, which are medications used to control high blood sugar, were found stored at room temperature instead of in the refrigerator as required by the product labeling. This improper storage rendered the medications expired and unsafe for administration. Furthermore, the facility did not maintain the medication refrigerator properly, as it was found with accumulated ice, which could affect the temperature quality and efficacy of the refrigerated medications. The Director of Nursing acknowledged that the refrigerator should be defrosted and cleaned weekly, but there was no log to confirm when this was last done. These deficiencies were confirmed through observations and interviews with nursing staff, who acknowledged the risks associated with expired and improperly stored medications.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Several deficiencies were noted, including the failure to label foods in the kitchen with 'use by' or open dates, and the failure to discard expired food. Specifically, a resident's personal container with a used napkin was found on top of a Beef Base seasoning, and an opened and undated spray was observed. An opened pack of bread was also found undated. Additionally, expired turkey was found in the refrigerator, which should have been discarded according to the facility's policy. Further observations revealed unsanitary storage practices, such as a bowl on the floor under the dishwashing machine and a water line filter touching the floor drain, which could lead to contamination. A bathroom plunger was improperly stored under the receiving station next to the dishwashing machine. These practices were contrary to the facility's policies, which require proper labeling, storage, and separation of food and cleaning supplies to prevent cross-contamination and ensure safety. The Dietary Supervisor acknowledged these issues during interviews, indicating a lack of adherence to established procedures.
Failure to Monitor Refrigerator Temperatures for Resident Food
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring of refrigerator and freezer temperatures where residents' food brought from home was stored. This deficiency was observed for four out of five sampled residents. The facility's policy required daily temperature checks and recordings to ensure food safety, but from June 1 to June 11, 2024, the temperature logs were incomplete, with no recorded temperatures or comments. During an observation on June 11, 2024, the refrigerator's temperature was found to be at 50°F, which is above the safe threshold of 40°F, placing the food in the danger zone for bacterial growth. The Dietary Supervisor confirmed that the housekeepers were responsible for checking the temperatures, but they failed to do so during the specified period. The supervisor acknowledged that the current temperature of 50°F was unsafe and could lead to food poisoning. The facility's policy, revised in April 2024, stipulated that temperatures should be recorded daily by food service supervisors or designated employees, with acceptable refrigerator temperatures ranging from 35°F to 41°F. The failure to monitor and record temperatures as per the policy had the potential to result in food-borne illnesses among residents.
Arbitration Agreement Venue Selection Omission
Penalty
Summary
The facility failed to ensure that the arbitration agreements for two residents included information about selecting a venue that is convenient for both parties involved. This deficiency was identified during a review of the arbitration agreements signed by the residents, which lacked any mention of a mutually agreeable location for arbitration proceedings. The Admissions Coordinator confirmed that the agreements did not specify a convenient venue and stated that her role was limited to presenting the agreement as it was written, without discussing venue selection. As a result, the residents were not informed of their right to a convenient arbitration location.
Deficient Coordination of Hospice Care Services
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for three residents, leading to deficiencies in hospice care services. Resident 61, who was under hospice care due to end-stage heart failure and other conditions, did not receive documented visits from hospice staff as per the hospice calendar. The hospice binder, which should have contained records of visits and care provided, lacked documentation from the Certified Home Health Aide (CHHA) and other hospice staff, indicating a failure in maintaining accurate records and communication between hospice and facility staff. Similarly, Resident 52, diagnosed with schizoaffective disorder and other serious conditions, did not receive the required hospice visits as outlined in their care plan. The hospice calendar and flow sheet for Resident 52 showed inconsistencies in the frequency of visits by hospice staff, including Registered Nurses (RN) and Skilled Nurses (SN), and there were no documented visits from the CHHA and Spiritual Counselor (SC) for the months of May and June. This lack of documentation and coordination raised concerns about the resident receiving the necessary hospice care. Resident 64, who was admitted with a terminal diagnosis of lung cancer, also experienced deficiencies in hospice care coordination. The hospice plan of care for Resident 64 specified certain frequencies for visits by hospice staff, but the hospice calendar and flow sheet did not reflect these visits accurately. There were no CHHA visits documented, and the SN visits did not meet the required frequency. The absence of a hospice calendar for staff frequency of visits further complicated the coordination of care, leading to potential neglect of the resident's hospice needs.
Inadequate Infection Control for C. diff in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection control practices for a resident diagnosed with Clostridium difficile (C. diff) infection. The resident was admitted with acute and chronic respiratory failure, enterocolitis due to C. diff, and sepsis. The resident's care plan included contact isolation precautions due to the C. diff infection, and a physician's order was in place for Vancomycin treatment. Despite these precautions, the facility did not ensure the use of an EPA-approved disinfectant solution for cleaning the resident's isolation room. Housekeeping staff used cleaning solutions that were not on the EPA's List K, which includes products effective against C. diff spores. Interviews with housekeeping staff revealed a lack of knowledge about whether the cleaning solutions contained bleach or were effective against C. diff. The Infection Preventionist Nurse confirmed that the cleaning solutions used did not meet the necessary criteria for disinfecting C. diff, as they were not listed on the EPA's registered Antimicrobial Products Effective Against Clostridioides difficile Spores list. The facility's policy and procedure for Clostridium difficile, revised in April 2024, required the use of a disinfecting agent recommended for C. diff, such as a bleach solution or an EPA-registered germicidal agent. However, the facility did not adhere to this policy, as evidenced by the use of ineffective cleaning solutions in the resident's room. This oversight placed residents, staff, and visitors at a higher risk for cross-contamination and increased the potential spread of C. diff within the facility and the community.
Unsafe Electrical Practices in Kitchen
Penalty
Summary
The facility staff failed to ensure a safe environment in the kitchen by improperly managing electrical connections. During an observation, a double gang box switch and outlet combo was found with an extension cable plugged in, which powered a bug zapper, a phone charger, and a large black portable air conditioning unit. Additionally, a wall outlet was covered with multiple layers of blue tape, securing a generator plug. The generator's orange cable was observed coming out of the taped outlet, and a sign instructed not to disconnect the cable. The Maintenance Supervisor confirmed that the portable air conditioner should not have been connected to the extension cord, as it lacked a safety switch and posed a fire risk. Furthermore, the generator's cable was not intended for regular outlets, only hospital outlets, and was temporarily used due to the facility's generator being serviced. The facility's policies and procedures, revised in April 2024, indicated that equipment with frayed or ungrounded cords and plugs should not be used, and the maintenance department was responsible for maintaining equipment safely. The Maintenance Supervisor acknowledged that the current setup could potentially result in a fire, placing residents, staff, and visitors at risk. The generator was temporarily used to ensure the facility's operation during the servicing of the main generator, but the improper use of extension cords and taped outlets violated safety protocols.
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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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