Chestnut Ridge Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 525 South Central Avenue, Glendale, California 91204
- CMS Provider Number
- 056190
- Inspections on file
- 64
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Chestnut Ridge Post Acute Llc during CMS and state inspections, most recent first.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with type 1 DM experienced a documented hypoglycemic episode after receiving ordered insulin, with blood glucose dropping to 60 mg/dL and then rising to 72 mg/dL after treatment with juice and food. The LVN administered insulin, treated the low blood sugar, and monitored the resident, but did not notify the MD as required by the resident’s orders and facility policies, and there was no documentation of MD notification in the EHR. This failure to follow provider notification orders and hypoglycemia management policy led to the cited deficiency.
A resident with shingles and blisters on the lower back and bilateral buttocks had a physician’s order for daily wound care, but nursing staff failed to assess, monitor, and document the skin condition on admission and weekly thereafter as required by facility policy and practice. The TXN and IP confirmed there was no documentation of ongoing assessment of the blisters, and a covering LVN reported she was not informed she needed to complete weekly skin checks. The DON verified that the admission skin assessment and subsequent weekly skin checks were not completed or documented, despite policies requiring documentation of wound assessments and admission skin assessments.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
The facility did not ensure that POLST and advance directive documents were consistently filed and readily accessible in the current medical charts for multiple residents, including those with impaired cognition and serious health conditions. During a medical emergency, staff were unable to locate a resident's POLST, resulting in default initiation of CPR. Staff interviews and record reviews revealed that required documents were often missing, stored in old charts, or not obtained, contrary to facility policy.
Staff failed to immediately initiate CPR and call a code blue when a resident was found unresponsive. Instead, staff delayed action by searching for the resident's code status and did not use the backboard or Ambu-bag during resuscitation. CPR was performed incorrectly, with inadequate compressions and no rescue breaths, and EMS had to move the resident to the floor to continue efforts. These failures resulted in the resident's death and placed all full code residents at risk.
A resident with severe respiratory conditions did not receive prescribed respiratory medications as ordered, with numerous missed and undocumented doses. Staff failed to monitor or assess the resident for respiratory distress after new symptoms and abnormal lab and x-ray results were identified. Critical results were not effectively communicated to the physician, and the care plan was not updated to address the resident's worsening condition. The resident was later found unresponsive and died despite resuscitation efforts.
Licensed nurses did not administer or document multiple scheduled doses of prescribed respiratory medications for a resident with COPD, emphysema, and respiratory failure. The resident, who was oxygen-dependent and required total staff assistance, missed numerous doses of Acetylcysteine, Budesonide, and Ipratropium-Albuterol over several months, despite physician orders and care plan interventions requiring these treatments. The DON and physician confirmed the medications were not given as ordered, in violation of facility policy.
A resident with multiple respiratory conditions and impaired cognition had abnormal lab and chest x-ray results indicating a possible infection. Nursing staff failed to verify that these results were received by the physician or nurse practitioner, and there was no documentation of provider notification or follow-up. As a result, the resident did not receive timely medical intervention for the abnormal findings, and required notification procedures were not followed.
A resident with severe respiratory illnesses, dependent on staff for all care, did not have timely documentation of medication administration by nursing staff. Instead, LPNs entered medication records days or weeks after administration, often only after being alerted by medical records audits. Staff could not recall specific details about medication administration, and documentation was not completed as required by facility policy.
An agitated resident with a history of behavioral disturbances was left unattended in a shared room after a CNA unsuccessfully attempted to intervene, resulting in the resident striking another bedbound resident multiple times with metal wheelchair footrests and causing severe facial injuries. The injured resident required emergency medical care, while another roommate witnessed the attack and expressed fear. Staff were aware of the aggressive resident's history and care plan requirements but failed to implement appropriate interventions or utilize available methods to ensure the safety of all residents present.
A resident with anxiety disorder and moderate cognitive impairment was not assessed or provided with psychosocial support after witnessing and being threatened during a violent incident involving another resident with severe behavioral disturbances. Despite the resident expressing fear and emotional distress, staff did not follow up or notify social services, contrary to facility policy.
A resident did not receive the necessary behavioral health care and services as required. The facility did not provide appropriate behavioral health interventions and supports, as observed and documented by surveyors.
A resident with severe cognitive impairment and a history of wandering was identified as being at risk for elopement, but no care plan was developed to address these behaviors. Staff and DON confirmed the absence of a care plan, despite facility policy requiring interventions and measurable objectives for such risks.
A resident with a history of schizoaffective and psychotic disorders exhibited aggressive behaviors, including choking a CNA and later threatening staff with a knife. After readmission from psychiatric care, the facility did not develop or communicate an individualized behavioral care plan or interventions to staff, despite repeated incidents of aggression and facility policy requirements for comprehensive, person-centered care planning.
Two incidents of abuse occurred when a resident verbally and physically assaulted another resident and later choked a CNA. Both events were witnessed by staff and a family member, but were not reported to the abuse coordinator, ombudsman, police, or state health authorities as required by policy. The affected resident experienced emotional distress, and the lack of timely reporting increased the risk of recurrence and harm.
A resident with dementia and high elopement risk wandered away from an LTC facility due to insufficient staff intervention and training. Despite the resident's care plan requiring frequent monitoring and behavioral intervention, staff failed to act when the resident became agitated and refused to re-enter the facility. The resident was missing for over two hours before being found by law enforcement and placed on a 72-hour hold.
A resident with dementia and high elopement risk managed to leave the facility unsupervised due to inadequate monitoring. The receptionist left his post without coverage, allowing the resident to exit without triggering the wander guard alarm. Facility staff interviews highlighted a failure to adhere to supervision protocols, leading to the resident's elopement and police involvement.
A resident with moderate cognitive impairment requested access to her medical records, but the facility failed to provide the necessary release form, violating her rights. The Administrator instructed the Medical Records Staff to provide the form but did not ensure it was done. The staff claimed the resident later declined the records, which the resident denied, and this was not documented.
The facility failed to ensure the accessibility of the survey binder containing past survey results for residents, as required by policy. During a resident council meeting, residents expressed their unawareness of the survey report's location and the facility's corrective actions. The DON confirmed the binder's importance but could not locate it, as it was taken by MR staff and not returned.
The facility failed to complete quarterly MDS assessments for four residents within the required timeframe, with delays ranging from 27 to 33 days. The MDS Nurse cited a backlog of assessments as the reason for the delays. The DON acknowledged the issue, noting that late assessments could hinder timely updates to care plans. The facility's policy requires MDS completion within 14 days of the ARD, which was not followed.
A facility failed to develop comprehensive care plans for several residents, including one with dementia and others on psychoactive medications, leading to deficiencies in care. A resident with dementia lacked a care plan for their condition, while two residents on psychoactive medications did not have plans to guide safe medication use. Another resident's refusal to store their nasal cannula properly was not addressed in their care plan.
The facility failed to provide proper respiratory care for four residents, including not posting oxygen warning signs for two residents, administering oxygen without a physician's order for one resident, and improper storage and timely replacement of nebulizer equipment for two residents, leading to potential health risks.
The facility failed to maintain proper food storage and sanitation practices, risking foodborne illnesses for residents. Open food items lacked labels and dates, and expired items were found in the kitchen. The Sanitizer Bucket Log, Ice Machine Cleaning Log, and Cleaning and Maintenance Schedule Log had missing entries, indicating inconsistent sanitation practices. The Dietary Service Supervisor admitted to not ensuring logs were completed accurately, contrary to facility policies.
The facility failed to implement its infection control program, leading to deficiencies involving six residents. Issues included unlabeled and improperly stored medical equipment, failure to change feeding syringes, lack of disinfection of reusable equipment, and inadequate hand hygiene practices. These oversights were confirmed through observations and staff interviews, highlighting potential risks of infection spread.
A resident with dementia and psychotic disorder was prescribed Quetiapine and Zolpidem without obtaining informed consent, violating their rights. The facility's policy requires a physician to explain medication effects and alternatives, but documentation was incomplete, lacking the physician's signature.
A resident with communication challenges was not provided with a communication board, despite recommendations from a Speech-Language Pathologist. Staff struggled to understand the resident's needs, leading to frustration and unmet needs. The Director of Nurses acknowledged the availability of communication boards, but staff were unaware of them.
A resident with hemiplegia and dysphagia was not provided necessary assistance during mealtimes, leading to difficulty eating independently. Despite documented needs for supervision and assistance, the resident was left alone, struggling to cut and consume food. A CNA and the DON confirmed the resident required help due to right-side weakness, highlighting a failure to adhere to the facility's ADL support policy.
A resident with severe cognitive impairment and total dependence on staff had their low air loss mattress set incorrectly for a much higher weight than their actual 204 pounds. This error, confirmed by a Treatment Nurse, increased the risk of further skin breakdown and hindered wound healing, as the mattress was too hard. The manufacturer's manual specifies adjusting air pressure based on the patient's weight and comfort, which was not followed.
A facility failed to provide appropriate rehabilitation services and devices for a resident with limited mobility and contractures. The resident was observed with rolled towels between their contracted arms instead of the recommended splints. The facility's physical therapist and rehabilitation director stated that splints should have been used, as rolled towels are not effective. The resident had not been referred for reassessment since 2021, despite the need for appropriate devices to prevent further decline.
The facility failed to maintain a safe environment for two residents. A resident's bed alarm was non-functional, increasing fall risk, while another resident on oxygen therapy had tobacco in their room, posing a fire hazard. Staff acknowledged these oversights, which violated facility policies.
A resident with cognitive impairment was administered medication without proper identity verification. The LVN failed to use multiple identifiers as required by the facility's policy, relying only on the resident's last name. The resident lacked an ID band, and there was no profile picture in the EHR, increasing the risk of medication errors.
Two residents in a LTC facility were found to be on unnecessary psychotropic medications due to inadequate monitoring and documentation. One resident was prescribed Risperidone and Trazodone without specific behavioral indications, and no gradual dose reduction was attempted. Another resident was given Lorazepam without a physician's order after the original order expired. The facility failed to follow its policies on psychoactive drug monitoring and medication administration.
The facility failed to ensure proper storage and labeling of medications. A non-functioning thermometer in the medication room led to unrecorded temperatures, risking medication potency. A resident's medications were improperly labeled with only a room number, not the resident's name, risking medication errors. Additionally, opened multi-dose bottles lacked open dates, crucial for determining expiration. Staff acknowledged these lapses, which violated the facility's policy on medication storage and labeling.
A resident with dysphagia was not provided with the prescribed mechanical soft diet, receiving regular texture food instead, due to an error in the facility's dietary order system. This oversight, lasting from July to October, placed the resident at risk for aspiration and choking. The resident's care plan and physician's orders were not followed, as observed during a dining session where the resident was eating unassisted.
A resident was not screened for the pneumococcal vaccine within the required timeframe upon admission, as per facility policy. The resident, with moderately impaired cognition and requiring assistance with daily activities, was not offered the vaccine until 22 days after admission due to the Infection Preventionist being occupied with other tasks. Both the IP and DON acknowledged the oversight.
A resident's bed siderails were found stained and soiled, with the resident reporting they had been dirty since admission. Despite informing the maintenance supervisor, no cleaning was done. CNA confirmed the siderails were dirty, and housekeeping admitted to not cleaning them, although they are high-touch areas requiring daily cleaning. The facility's policy mandates a clean and comfortable environment.
Two residents with cognitive impairments were involved in an altercation where one poured water on the other, leading to a confrontation. Despite staff awareness, the incident was not reported or investigated, contrary to the facility's abuse policy. The DON and ADM were unaware until informed by surveyors, highlighting a lapse in protocol adherence.
A facility failed to report a resident altercation within the required timeframe. A resident alleged that another resident poured water on him, which was witnessed by an LVN and known by a CNA, but neither reported it promptly. The incident was reported to authorities eight days later. Both residents involved had moderately impaired cognitive skills and required assistance with daily activities. The facility's policy mandates immediate reporting of abuse allegations, which was not followed.
A resident with mental health and hypertension diagnoses went out on pass and did not return as expected. The facility failed to escalate the situation by notifying the MD, DON, or SW, delaying law enforcement notification. The resident returned over 24 hours later, missing medications and appearing disheveled. Staff interviews confirmed the failure to address the resident's absence promptly, highlighting a breach in supervision and safety protocols.
A resident with severe cognitive impairment and a history of wandering was inadequately supervised, leading to an altercation with another resident and a fall. Despite care plans requiring frequent monitoring, documentation showed insufficient supervision. Staff interviews revealed inconsistencies in monitoring practices, and facility policies on wandering were not effectively implemented.
A resident with dementia and behavioral disturbances was inadequately monitored and lacked a specific care plan, leading to an altercation and a fall. Despite known wandering behavior, the facility did not provide necessary supervision or conduct an IDT meeting to address the resident's needs. Observations showed the resident was found on the floor without an alarm, highlighting insufficient safety measures.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Notify Physician After Resident Hypoglycemic Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a diabetic resident’s hypoglycemic episode despite explicit orders and facility policies requiring such notification. The resident was admitted with diagnoses including type 1 diabetes, duodenal ulcer, and muscle weakness, and was documented as cognitively intact, requiring varying levels of assistance with activities of daily living. Active physician orders and the resident’s diabetes care plan both directed staff to call the provider immediately if the resident’s blood glucose was less than 70 mg/dL and to call as soon as possible when blood glucose values were regularly 70–100 mg/dL for possible regimen adjustment. On the day of the incident, progress notes documented that the resident’s pre-lunch blood glucose was 371 mg/dL and that insulin was administered as ordered. After lunch, the resident’s blood glucose was rechecked and found to be 60 mg/dL. In response, the nurse provided juice and a parfait, and a subsequent blood glucose check showed an increase to 72 mg/dL. The resident was monitored and noted to have no signs of distress. However, there was no documentation in the progress notes that the physician was notified of the hypoglycemic episode, despite the blood glucose level being below 70 mg/dL. During interviews, the LVN who provided care stated that she administered insulin per order, treated the low blood sugar with juice and a parfait, rechecked the blood sugar, and continued to monitor the resident, but forgot to notify the physician of the change in condition. Review of the electronic health record by the DON, QA nurse, and medical records director confirmed there was no documentation that the physician was notified of the hypoglycemic event. Facility policies on Management of Hypoglycemia and Change in a Resident’s Condition or Status required immediate provider notification for blood glucose less than 70 mg/dL and prompt physician notification of changes in a resident’s medical condition, particularly when there were specific instructions to notify the physician of such changes. The failure to notify the physician after the documented hypoglycemic episode constituted the cited deficiency.
Failure to Assess and Document Shingles-Related Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and document a resident’s shingles-related blisters in accordance with its wound care and admission assessment policies and usual practice. The resident was originally admitted with diagnoses including anxiety disorder and hypertension and had moderately impaired cognitive skills, requiring varying levels of assistance with ADLs. A physician’s order directed that the shingles rash on the resident’s bilateral buttocks be cleansed with normal saline, patted dry, and covered with foam dressing daily for 14 days. On admission, a CNA observed red, painful dots on the resident’s lower back area, and the Treatment Nurse (TXN) later confirmed seeing red blisters due to shingles on the lower back when she assessed the resident. The TXN stated that the RN supervisor was responsible for documenting the resident’s skin condition related to the blisters but did not do so, and there was no documentation in the clinical record that the blisters were assessed, documented, and monitored for two weeks starting from the initial assessment date. The TXN also reported that she had been off work for the past two weeks and that the covering nurses did not complete the Weekly Skin Check for the resident during that period. The Infection Preventionist (IP) confirmed awareness that the resident had shingles and blisters upon admission and verified that there was no documentation indicating that the skin condition due to shingles had been assessed, documented, and monitored since admission. A covering LVN reported providing wound care for the resident for the prior two weeks but stated she did not know, and it was not endorsed to her, that she should assess and complete the Weekly Skin Check for the resident. The DON confirmed that the RN supervisor did not assess and document the resident’s shingles blisters on the Skin Check upon admission and that nurses did not assess and document the Weekly Skin Check on the specified subsequent weeks. Review of the facility’s wound care policy showed that nurses are required to record all assessment data obtained when inspecting wounds and any change in the resident’s condition in the medical record, and the admission assessment policy requires nurses to conduct and document physical and skin assessments at admission. The DON stated that, although the wound care policy did not specify follow-up frequency, the facility’s practice was to reassess and document shingles blisters weekly to monitor healing.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Maintain Readily Accessible POLST and Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) and advance directives (AD) were consistently and readily retrievable in the current medical charts for 11 out of 100 sampled residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that staff were unable to locate these critical documents during medical emergencies. In one instance, when a resident was found unresponsive and pulseless, nursing staff could not find the resident's POLST or code status in the current chart and, as a result, initiated CPR by default, treating the resident as full code. The Director of Nursing later found the resident's POLST in an old chart, confirming that the document was still valid at the time of the emergency but had not been placed in the current chart as required by facility policy. Further review of additional residents' records showed similar issues, with several POLST and AD documents missing from current medical charts. Interviews with staff, including nurses and the social worker, confirmed that these documents were either not obtained, not printed, or were kept in locations such as email inboxes or old charts rather than being filed in the residents' current medical records. The facility's policy and procedures, as well as the social worker's job description, require that POLST and AD documents be obtained within 48 to 72 hours of admission and be accessible in the medical record to all facility staff. However, staff interviews revealed a lack of consistent adherence to these procedures, with some staff unaware of whether residents had POLST forms or failing to ensure the documents were properly filed. The deficiency affected residents with a range of medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, dementia, quadriplegia, and other serious health issues. Many of these residents had impaired or severely impaired cognition and lacked the capacity to make decisions, making the presence and accessibility of POLST and AD documents especially critical. The failure to maintain these documents in the current medical charts was acknowledged by both the Director of Nursing and the social worker, who confirmed that the documents should be readily available in the chart and not stored elsewhere.
Failure to Provide Qualified Emergency Response and CPR
Penalty
Summary
Facility staff failed to provide care by qualified persons according to a resident's written plan of care, specifically in the response to a full code resident who was found unresponsive. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately initiate a code blue or begin CPR when the resident was discovered unresponsive. Instead, staff delayed action by first attempting to verify the resident's code status and searching for the POLST form, rather than starting life-saving measures as required by facility policy and professional standards. Interviews and record reviews confirmed that staff were unclear about the correct sequence of actions and did not follow established protocols for emergency response. When CPR was eventually initiated, staff did not place the resident on a firm, flat surface or use the available backboard, as required to ensure effective chest compressions. Instead, CPR was performed on the bed, and the backboard was not utilized. Additionally, staff failed to provide rescue breaths using the Ambu-bag, despite its availability, and instead left the resident on a non-rebreather mask, which is not appropriate during CPR. EMS personnel arriving at the scene observed that CPR was being performed incorrectly, with inconsistent and inadequate chest compressions, and had to move the resident to the floor to continue resuscitation efforts. Documentation and interviews revealed further deficiencies in staff knowledge and execution of CPR, including incorrect compression rates, lack of rescue breaths, and failure to use proper equipment. The facility's own policies, as well as American Heart Association guidelines, were not followed. As a result, the resident was pronounced deceased after prolonged and inadequate resuscitation efforts. The failure to provide qualified and timely emergency care placed all full code residents at risk of not receiving proper life-saving measures during a code blue event.
Failure to Provide and Document Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident with multiple respiratory diagnoses, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and had significantly impaired cognition. Despite physician orders for scheduled respiratory medications—Acetylcysteine, Budenoside, and Ipratropium-Albuterol—there were numerous missed and undocumented administrations over several months, as evidenced by gaps in the Medication Administration Record (MAR). These medications were specifically ordered to manage the resident's COPD, chest congestion, and shortness of breath, but the resident did not consistently receive them as prescribed. In addition to missed medications, the facility did not adequately monitor or assess the resident for respiratory distress or changes in condition, even after new symptoms and abnormal findings were identified. When a nurse practitioner noted cough, congestion, abnormal lung sounds, and respiratory distress with low oxygen saturation, and when abnormal laboratory and chest x-ray results were received indicating possible infection, there was no documented assessment or monitoring of the resident's respiratory status. The care plan was not revised to address the new or worsening symptoms, and there was no evidence of nursing interventions being initiated in response to these changes. Furthermore, the facility failed to ensure timely and effective communication of critical lab and diagnostic results to the resident's physician. Although results were faxed and texted, there was no confirmation that the physician or nurse practitioner received or reviewed the information. Nurses did not follow up with phone calls or verify receipt, and there was no documentation of provider notification or discussion of the abnormal findings. This lack of communication delayed necessary medical evaluation and treatment. Ultimately, the resident was found unresponsive and pulseless, and despite CPR, was pronounced dead. The facility's policies required prompt assessment, monitoring, and provider notification for changes in condition, but these procedures were not followed.
Failure to Administer Prescribed Respiratory Medications
Penalty
Summary
Licensed nurses failed to administer prescribed respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure with hypoxia, recurrent pneumonia, and vascular dementia. The resident was oxygen-dependent and required staff assistance for all activities of daily living. The care plan specifically included interventions to administer medications as ordered for impaired gas exchange and ineffective airway clearance. A review of the Medication Administration Records (MAR) for three months revealed that multiple scheduled doses of three critical respiratory medications—Acetylcysteine Inhalation Solution, Budesonide Inhalation Suspension, and Ipratropium-Albuterol Inhalation Solution—were not documented as administered. Specifically, there were 25 undocumented doses of Acetylcysteine, 31 undocumented doses of Budesonide, and 60 undocumented doses of Ipratropium-Albuterol. Physician progress notes during this period consistently indicated the need to continue regular breathing treatments as scheduled, and nursing notes documented episodes of shortness of breath and diminished lung sounds. During interviews, the Director of Nursing confirmed the absence of documentation for the administration of these medications and acknowledged that the resident did not receive them as ordered. The attending physician also confirmed that missing several doses of these medications, especially consecutively, could trigger a COPD exacerbation. Facility policy required medications to be administered in accordance with prescriber orders, but this was not followed in this case.
Failure to Notify Physician of Abnormal Lab and Diagnostic Results
Penalty
Summary
The facility failed to verify receipt or follow up with the attending physician or nurse practitioner regarding abnormal laboratory and diagnostic results for a resident who exhibited signs of infection. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, respiratory failure with hypoxia, recurrent pneumonia, and aneurysm, was admitted with significant cognitive impairment and was dependent on staff for all care. Orders were placed for a chest x-ray and laboratory tests due to respiratory symptoms, and results showed an elevated white blood cell count and abnormal chest x-ray findings suggestive of an infectious process. Despite these abnormal findings, there was no documented evidence that the physician or nurse practitioner was notified of the results. The results were faxed and texted by the RN to the nurse practitioner and physician, but there was no confirmation of receipt or response. Interviews revealed that the nurse did not verify whether the results were received and did not follow up with the physician. The physician and nurse practitioner both stated they never received the results, and the facility did not have the correct contact information for text communication. The facility's policy required direct communication and documentation of physician notification, especially in cases of significant change in condition, but this was not followed. The lack of communication and verification resulted in the resident not receiving necessary medical intervention for the abnormal findings. The resident subsequently experienced a significant decline, was found unresponsive, and was pronounced deceased. There was no documentation of a change in condition report or assessment related to the abnormal laboratory or diagnostic results, and the required notification procedures were not followed as outlined in the facility's policies.
Failure to Timely Document Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when licensed nursing staff failed to document medication administration for a resident with significant respiratory conditions, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and required multiple inhaled medications as part of their treatment plan. The Medication Administration Record (MAR) and audit reports revealed that documentation of medication administration was not completed at the time medications were given, but instead was entered days or even weeks later, often only after audits identified missing entries. The audit of the resident's MAR for December showed numerous instances where scheduled medications were administered at times different from those ordered, and documentation was delayed until prompted by the facility's Medical Records Assistant (MRA). Interviews with the involved LVNs confirmed that they could not recall specific details about medication administration for the resident, including which medications were given or the exact times of administration. The LVNs admitted to documenting medication administration retroactively after being notified of missing documentation during audits, rather than at the time of administration as required by facility policy. The facility's policy stated that staff must document medication administration immediately after giving each medication and before administering the next one. The DON confirmed that timely documentation is necessary for accurate monitoring of medication effectiveness and adverse reactions. However, the practice observed was that documentation was completed only after audits identified missing entries, and there was no contemporaneous record of medication administration or reasons for late documentation in the resident's progress notes.
Failure to Protect Residents from Physical Abuse During Behavioral Incident
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when an agitated resident, with a documented history of behavioral disturbances and aggression, was left unattended in a shared room with two other residents. The agitated resident was observed swinging two metal wheelchair footrests in the air, exhibiting aggressive behavior. A certified nurse assistant (CNA) attempted to verbally redirect the resident and remove the footrests but was unsuccessful and left the room to seek assistance, leaving the agitated resident alone with the other two residents, both of whom had significant cognitive and physical impairments. While the CNA was away, the agitated resident struck one of the roommates multiple times in the head with the metal footrests, causing severe facial lacerations, bruising, and pain. The injured resident, who was bedbound and unable to defend herself, required emergency medical attention and was transferred to an acute care hospital for evaluation and treatment of her injuries, which included a forehead hematoma, periorbital laceration, and a possible nasal bone fracture. The other roommate, also bedbound, witnessed the attack and expressed fear for her life. Interviews and record reviews revealed that staff were aware of the aggressive resident's behavioral history, including prior incidents of agitation and aggression, and that care plans specified the need for staff intervention to protect others. However, staff failed to implement appropriate interventions to ensure the safety of the roommates during the incident. The facility's policies on abuse prevention and resident safety did not provide specific guidance for managing an agitated resident in possession of a dangerous object, and staff did not utilize available methods such as overhead paging to request immediate assistance, resulting in a failure to prevent harm.
Failure to Provide Psychosocial Support After Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to provide medically related social services to support a resident's psychosocial well-being after the resident witnessed and was threatened during a violent incident involving another resident. The incident occurred when a resident with severe cognitive impairment and behavioral disturbances became agitated, removed metal wheelchair footrests, and began swinging them aggressively in a shared room. Staff attempted to intervene but were unable to de-escalate the situation before the agitated resident struck another bedbound roommate, causing visible injuries. During this event, another resident in the room, who was also bedbound and had a diagnosis of anxiety disorder and moderate cognitive impairment, was directly threatened and feared for her safety. Following the incident, the resident who witnessed and was threatened by the aggressive behavior reported experiencing fear, anxiety, and emotional distress. Despite these clear signs of psychosocial trauma, no nursing or facility staff checked on or followed up with this resident after the event. Interviews with staff confirmed that they were unaware of the resident's emotional state and had not assessed her for trauma or distress. The Director of Nursing and the Registered Nurse involved both acknowledged that the resident should have been assessed for psychosocial well-being and that the Social Services Designee should have been notified to provide support. A review of facility policy indicated that staff are responsible for identifying and addressing factors negatively affecting residents' psychosocial functioning, including resident-to-resident altercations and behavioral problems. The policy also states that social services staff are responsible for providing or arranging for mental and psychosocial counseling services as needed. In this case, the facility did not follow its own policy, resulting in a failure to provide necessary social services to a resident who experienced significant emotional distress after a violent incident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents in need. The lack of appropriate behavioral health care and services was directly observed and documented during the survey.
Failure to Develop Care Plan for Resident at Risk of Wandering and Elopement
Penalty
Summary
A comprehensive, person-centered care plan was not developed for a resident who was assessed to be at risk for wandering and elopement. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and cognitive communication disease, was documented as having severe cognitive impairment and requiring moderate to substantial assistance with mobility and self-care. The resident's Elopement Evaluation indicated a risk for wandering and elopement, and staff interviews confirmed that the resident wandered around the facility and was at risk for elopement. Despite these assessments and observations, a review of the resident's active care plans revealed that no care plan had been initiated to address the behaviors of wandering or risk of elopement. The Director of Nursing acknowledged the absence of such a care plan and stated that interventions should have been included to inform staff of specific actions to take. The facility's policy required care plans to include measurable objectives, timeframes, and interventions addressing the underlying sources of problem areas, but these requirements were not met for this resident.
Failure to Develop and Communicate Individualized Behavioral Care Plan After Resident Aggression
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and sufficient staffing to address and manage the behavioral health care needs of a resident diagnosed with schizoaffective disorder-bipolar type and psychotic disorder. After an incident in which the resident choked a CNA, resulting in a temporary involuntary psychiatric commitment, the resident was readmitted to the facility. Upon readmission, the facility did not thoroughly evaluate the resident's behavioral aggressiveness or develop and communicate individualized, comprehensive care plan interventions to all staff, despite the resident's recent history of violent behavior. Documentation and interviews revealed that the interdisciplinary team (IDT) did not discuss or document the resident's aggressive behavior or history of violence in the care plan or IDT notes. Progress notes following the resident's readmission indicated further episodes of verbal and physical aggression, but no individualized behavioral interventions were developed or implemented to prevent further incidents or protect staff and other residents. Staff assigned to supervise the resident were not provided with specific care plans or instructions on managing the resident's behaviors, only general directions to keep the resident safe and prevent fights. This lack of individualized assessment, care planning, and communication led to another serious incident in which the resident, while unsupervised, obtained a bread knife, threatened staff, and acted violently in the facility lobby. The resident's roommate and other cognitively impaired residents were placed at risk during these events. Facility policies required comprehensive, person-centered care plans and thorough behavioral assessments, but these were not followed, as evidenced by the absence of specific interventions and monitoring for the resident's aggressive behaviors.
Failure to Timely Report Resident-to-Resident and Resident-to-Staff Abuse
Penalty
Summary
The facility failed to immediately report two separate incidents involving abuse and physical altercations between residents and a staff member. On the morning of 5/3/2025, one resident verbally abused another by yelling profanity, then physically pushed the other resident's wheelchair, spun him around, and grabbed his jacket. Multiple staff members and a housekeeper witnessed the incident, and the affected resident reported feeling upset, sad, and discouraged. Despite being reported to the charge nurse and witnessed by several staff, the incident was not reported to the abuse coordinator, ombudsman, police, or the state health department as required by facility policy. Later the same day, the same resident attacked a Certified Nurse Assistant (CNA) by choking her in another resident's room. This incident was witnessed by a family member, who intervened and reported the event to facility leadership. The police were called, and the resident was transferred to a general acute care hospital under a 5150 psychiatric hold. The facility's progress notes documented the physical aggression, but the incident was not reported to the appropriate authorities within the required timeframe. Interviews with staff, including CNAs, LVNs, and the Director of Nursing, confirmed that both incidents met the facility's criteria for abuse and should have been reported immediately, but were not. The facility's policies require all allegations of abuse or mistreatment to be reported promptly, no later than two hours if abuse is involved. The failure to report these incidents resulted in emotional distress for the affected resident and had the potential for recurrence and harm to other residents and staff.
Inadequate Staff Training Leads to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary knowledge, training, and skills to address the behavioral healthcare needs of a resident diagnosed with dementia and assessed at high risk for elopement. The resident, who had a history of elopement and was known to exhibit wandering behavior, was not adequately monitored or assisted according to their care plan. On the evening of 11/27/2024, the resident became agitated and refused to re-enter the facility after being out on pass with a family member. Despite the resident's care plan indicating the need for frequent monitoring and intervention in cases of behavioral problems, the staff did not take appropriate action to address the situation. The Registered Nurse (RN) on duty failed to implement the resident's care plan, which included interventions such as speaking in a calm manner, diverting attention, and removing the resident from the situation to an alternate location if necessary. Instead, the RN instructed the family member to follow the resident and contact law enforcement, rather than sending facility staff to intervene. As a result, the resident was missing for two and a half hours before being found by local law enforcement and subsequently placed on a 72-hour hold due to being a danger to themselves. Interviews with facility staff revealed a lack of awareness and training regarding the resident's elopement risk and behavioral needs. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) were not fully informed of the resident's high elopement risk, and the Director of Nursing (DON) acknowledged that the facility did not have a competency checklist for dementia care. The facility's policy and procedures indicated that staff should be trained to support residents in distress, but the deficiency in staff training and intervention contributed to the resident's elopement and subsequent hospitalization.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with severely impaired cognition and memory, who was assessed at high risk for elopement due to dementia. The resident, admitted on 10/23/2024, had a history of elopement attempts and expressed a desire to leave the facility. Despite being equipped with a wander guard, the resident managed to elope from the facility on 11/14/2024, and as of 11/15/2024, had not been found by the facility staff. The incident occurred when the receptionist, responsible for monitoring the lobby area, left his post to use the restroom without ensuring coverage. The receptionist had previously observed the resident sitting in the activity room with a packed plastic bag, indicating a potential attempt to leave. The facility's video footage confirmed that the receptionist was absent from his post when the resident exited the facility without supervision. The wander guard alarm did not activate, and the receptionist was unsure if the resident was wearing the device at the time of elopement. Interviews with facility staff, including the LVN, ADON, and DON, revealed that the receptionist did not follow protocol to find coverage before leaving his post, contributing to the resident's unsupervised departure. The facility's policies emphasized the importance of resident supervision and safety, but these were not adequately implemented, resulting in the resident's elopement and subsequent police involvement to locate the resident.
Failure to Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to personal and medical records upon request, violating the resident's rights. Resident 1, who was admitted with a primary diagnosis of polyneuropathies and had moderate cognitive impairment, requested a copy of her medical records in August 2024. Despite having the capacity to understand and make decisions, Resident 1 did not receive the medical release form necessary to obtain her records. The facility's policy required that residents have access to their records within 5 days of a request, but this was not adhered to. Interviews revealed that the Administrator instructed the Medical Records Staff to provide the release form to Resident 1 but did not follow up to ensure it was done. The Medical Records Staff claimed that Resident 1 later expressed disinterest in obtaining her records, a statement that Resident 1 denied. The staff did not document this alleged change of mind. The facility's policy and procedure on resident rights and release of information were not followed, leading to the deficiency in providing the resident access to her medical records.
Inaccessible Survey Binder
Penalty
Summary
The facility failed to ensure that the survey binder containing past survey results was accessible and available to all residents, including those who attended the resident council meeting. This deficiency was identified during interviews, observations, and record reviews. Residents expressed their lack of awareness regarding the availability and location of the survey report and the corrective actions taken by the facility. The Director of Nurses (DON) acknowledged the importance of making the survey binder accessible, but during an observation, the binder could not be located in its designated place. The report highlights that the survey binder was taken by the Medical Record (MR) staff to her office and was not returned, leading to its inaccessibility. The facility's policy and procedure on Resident Rights, which guarantees residents the right to examine survey results, was not adhered to. This oversight had the potential to leave residents and their legal representatives uninformed about the facility's past deficiencies and the measures taken to address them.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for four sampled residents were completed within the required time frame. The MDS Nurse acknowledged that the assessments for Residents 2, 30, 60, and 77 were completed late, with delays ranging from 27 to 33 calendar days past the deadline. The MDS Nurse attributed the delays to a backlog of assessments that she was unable to complete on time. The Director of Nurses (DON) was aware of the late assessments and expressed concern that delays could prevent timely updates to care plans if there were changes in the residents' conditions. The facility's policy and procedure, revised in July 2017, mandates that MDS assessments be completed and submitted in accordance with federal and state timeframes, specifically within 14 calendar days following the Assessment Reference Date (ARD). However, this policy was not adhered to, resulting in the identified deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, leading to deficiencies in care. Resident 58, who was diagnosed with dementia, schizophrenia, and anxiety disorder, did not have a care plan addressing their dementia. This oversight was confirmed during a review of the resident's records and interviews with the LVN and DON, who acknowledged the absence of a care plan for dementia, which is crucial for guiding staff in providing appropriate care and interventions. Residents 3 and 70, both receiving psychoactive medications, also lacked care plans to address the use of these medications. Resident 3, diagnosed with schizoaffective disorder and dementia, was receiving Olanzapine without a corresponding care plan to guide staff on monitoring and managing potential side effects. Similarly, Resident 70, who was on multiple psychotropic medications for dementia and psychotic disorder, did not have a care plan detailing interventions for safe medication management. Interviews with nursing staff highlighted the importance of such care plans in ensuring resident safety and effective monitoring of medication effects. Resident 63, diagnosed with COPD and bronchiectasis, refused to place their nasal cannula in a bag when not in use, yet this behavior was not addressed in their care plan. Despite having the mental capacity to make medical decisions, the resident's preference was not documented or planned for, as confirmed by interviews with the DON and observations. The facility's policy requires comprehensive care plans to be developed within a specific timeframe, but this was not adhered to, resulting in potential risks to resident care and safety.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, leading to several deficiencies. Resident 258 and Resident 63, who were receiving oxygen therapy, did not have oxygen in use warning signs posted on their doorways, which is against the facility's policy. This oversight was confirmed by interviews with staff, who acknowledged the importance of such signage due to the presence of smokers in the facility, which could pose a fire hazard. Resident 258 was also receiving oxygen therapy without a physician's order since admission, which was a significant oversight. The lack of a physician's order for oxygen administration was confirmed during interviews with the nursing staff and the Director of Nursing (DON), who acknowledged that oxygen is a drug and should have a physician's order prior to administration to prevent potential oxygen toxicity. Additionally, the facility failed to store and change nebulizer equipment for Residents 26 and 55 according to policy. Resident 26's nebulizer mask was found stored unsanitarily in a drawer without a protective bag, posing a risk for respiratory infection. Similarly, Resident 55's nebulizer mask was not changed every seven days as required, which was confirmed by the Infection Preventionist and the DON, indicating a risk for infection due to prolonged use of the same equipment.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices, which placed residents at risk for foodborne illnesses. During an inspection, several open food items were found without labels or open dates, including a liquid whole egg carton, apple sauce, cottage cheese, sliced watermelon, buttermilk ranch dressing, and sliced potatoes. The facility's policy requires that newly opened food items be labeled with an open date and a use-by date, which was not adhered to. Additionally, expired food items such as Parmesan cheese, turkey salad, nutmeg, and turmeric were found in the kitchen, contrary to the facility's policy that no food should be kept beyond its expiration date. The facility also failed to maintain proper sanitation practices. The Sanitizer Bucket Log, which is supposed to be filled out after each meal and use, had missing entries for several dates, indicating that the kitchen was not sanitized according to the facility's policy. The Dietary Service Supervisor (DSS) acknowledged the missing entries and stated that it was the responsibility of the kitchen staff to complete the log. Furthermore, the Ice Machine Cleaning Log and the Cleaning and Maintenance Schedule Log had multiple missing entries, indicating a lack of consistent monitoring and documentation of cleaning practices. The DSS admitted to not following up with the staff to ensure that logs were filled out accurately and consistently. The facility's policy requires the Food and Nutrition Services Director to write a cleaning schedule designating tasks by job title or employee, which was not effectively implemented. These deficiencies in food storage, expiration monitoring, and sanitation practices highlight a significant lapse in maintaining sanitary conditions in the facility's kitchen, potentially exposing residents to health risks.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program for six sampled residents, leading to several deficiencies. For Resident 258, the nasal cannula, handheld nebulizer circuit, and oxygen humidifier were not labeled with the date of initial use, and the nebulizer circuit was not stored in a plastic bag. This oversight was confirmed by interviews with the LVN, RN, and Infection Preventionist Nurse, who acknowledged that the lack of labeling and proper storage could lead to the equipment harboring bacteria and viruses, potentially spreading infections. Resident 86's feeding syringe was not changed every 24 hours as required, which was confirmed during an observation and interview with the Director of Staff Development. The syringe, used for flushing the G-tube and administering medications, was found to be unchanged for two days, increasing the risk of infection. The Director of Nursing confirmed that the facility's policy required the syringe to be changed daily to prevent infection. For Resident 55, the blood pressure monitor was not cleaned and disinfected before and after use, as observed during a nurse's routine check. This practice was against the facility's policy, which mandates disinfection of reusable equipment between uses to prevent infection spread. Additionally, staff failed to perform hand hygiene while distributing meal trays to Residents 43 and 257, as observed during meal service. The CNA admitted to not washing hands between assisting the two residents, which was against the facility's hand hygiene policy designed to prevent cross-contamination.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications prescribed to a resident, identified as Resident 99, who was receiving Quetiapine and Zolpidem. The resident was admitted with diagnoses including dementia, psychotic disorder, and cognitive communication deficit, and was noted to have severely impaired cognitive status. Observations and interviews revealed that the resident was confused and agitated, and staff redirected the resident's attention as needed. However, the facility did not have a documented informed consent for the psychotropic medications, which is required by their policy. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the informed consent for the psychotropic drugs was not obtained as per policy, which requires a physician to explain the medications' effects and alternatives to the resident or their responsible party. The facility's policy mandates that informed consent should be documented with the physician's signature, which was missing in this case. This oversight violated the resident's rights to be informed and involved in their care decisions, as outlined in the facility's policies on informed consent and resident rights.
Failure to Provide Communication Board for Resident
Penalty
Summary
The facility failed to provide a communication board for a resident with significant communication challenges, resulting in the resident's needs not being effectively communicated or met. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, aphasia, and cognitive communication deficits, was recommended by a Speech-Language Pathologist to use a communication board to facilitate communication. Despite this recommendation, the resident was observed struggling to communicate her needs during meal times, as staff members were unable to understand her gestures and nonverbal cues. Multiple staff members, including CNAs, were observed attempting to guess the resident's needs without the aid of a communication board, leading to prolonged periods of misunderstanding and frustration for the resident. Interviews with staff revealed that they were unaware of the existence of communication boards in the facility, despite the Director of Nurses stating that such tools were available. The facility's policy on accommodating individual needs emphasized the importance of promoting communication and maintaining dignity, which was not upheld in this case.
Failure to Assist Resident During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance to a resident during mealtimes, which led to the resident's inability to eat independently. The resident, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia, required supervision and assistance with eating due to right-side weakness. Despite these needs being documented in the resident's care plan and nutritional screening, the resident was observed eating alone without assistance, struggling to cut and consume a piece of chicken. The resident's inability to reach the fork and use her right arm was evident, and no staff was present to assist her during the meal. The deficiency was further highlighted when a CNA confirmed that the resident should have been assisted during mealtimes, as the chicken was too large for her to manage independently. The CNA acknowledged the resident's right-side weakness and the necessity for assistance in cutting the food into manageable pieces. The Director of Nurses also confirmed that the resident should have received assistance during meals to prevent potential risks such as malnutrition and weight loss. The facility's policy on supporting activities of daily living, including dining assistance, was not adhered to in this instance.
Incorrect LAL Mattress Settings for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with skin breakdown and pressure injuries by not ensuring the correct settings on a low air loss mattress (LAL Mattress). The resident, who was admitted with diagnoses including COPD, muscle weakness, and generalized osteoarthritis, was totally dependent on staff for daily activities and had severe cognitive impairment. Despite the resident's weight being recorded as 204 pounds, the LAL Mattress was incorrectly set for a person weighing 550 pounds, which was observed during a facility visit. The Treatment Nurse confirmed that the mattress settings were incorrect and should have been set at 250 pounds based on the resident's actual weight. The incorrect settings made the mattress too hard, potentially preventing wound healing and increasing the risk of further skin breakdown. The manufacturer's manual for the mattress indicated that the air pressure should be adjusted based on the patient's weight and comfort levels, which was not adhered to in this case.
Failure to Provide Appropriate Rehabilitation Services and Devices
Penalty
Summary
The facility failed to provide appropriate rehabilitation services and devices to maintain or improve mobility for a resident with limited mobility and contractures in both arms. The resident, who was admitted with diagnoses including dementia, schizophrenia, and anxiety disorder, was observed with rolled towels placed between their contracted arms instead of the recommended splints. The resident's care plan indicated limitations in shoulders, elbows, and fingers, with interventions to prevent further contractures using pillows or splints. However, the use of rolled towels was not effective or recommended by the facility's physical therapist and rehabilitation director. The physical therapist and rehabilitation director both stated that splints should have been used to prevent further contractures, as rolled towels are not a standard practice and are not therapeutic. The resident had not been referred to rehabilitation for reassessment since 2021, despite the need for appropriate devices to prevent further decline. The Director of Nurses confirmed that towels were inadequate for preventing contractures and acknowledged the need for reevaluation. The facility's policy indicated that residents with limited ROM should receive appropriate treatment and services to prevent further decrease, which was not adhered to in this case.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for two residents, leading to potential risks. For Resident 87, the bed alarm, which was intended to monitor the resident's movements and prevent falls, was found to be non-functional. The bed pad sensor was not connected to the bed alarm monitor, and the monitor's light was off, indicating it was not operational. Certified Nursing Assistants (CNAs) acknowledged the malfunction and admitted to not checking the alarm due to being occupied with other duties. This oversight placed Resident 87, who has dementia and muscle weakness, at risk of falls when attempting to get out of bed without assistance. Resident 63, who is a smoker and receives oxygen therapy, was found to have a bag of tobacco at the bedside, which is against the facility's policy. The resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis, was observed with tobacco and a pipe in his room, despite being on oxygen therapy. The Social Worker Designee and Registered Nurse Supervisor confirmed the presence of tobacco and acknowledged that it was not safe for the resident to have smoking materials in the room due to the risk of fire. The facility's policies clearly state that residents on oxygen therapy should not have smoking materials in their possession or in their rooms. The Director of Nursing reiterated that smoking materials should be managed by the activities staff and not kept with residents, especially those on oxygen therapy. The failure to adhere to these policies posed a significant safety risk to Resident 63 and others in the facility.
Failure to Verify Resident Identity Before Medication Administration
Penalty
Summary
The facility failed to verify the identity of a resident before administering medication, which was not in accordance with the facility's policy and procedure. The incident involved a resident who was admitted with diagnoses including diabetes mellitus and hypertension. The resident had moderately impaired cognitive skills and required varying levels of assistance with daily activities. On the day of the incident, the resident was administered a multivitamin-mineral tablet without proper identity verification. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not use the required identifiers to confirm the resident's identity. The resident did not have an identification band, and there was no profile picture available in the electronic health record (EHR). The LVN only called the resident's last name, which was insufficient according to the facility's policy. The Director of Nursing confirmed that the facility's policy required multiple identifiers, such as an ID band, photograph, and verification with other personnel, to prevent medication errors.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as required by their policy and procedure. Resident 58, diagnosed with schizophrenia and depression, was prescribed Risperidone and Trazodone without adequate monitoring or documentation of the behaviors that warranted their use. Despite being nonverbal and bedbound, the resident was noted to have no specific episodes of behavior that justified the continued use of these medications. The facility's staff did not properly track or document the resident's behaviors, which prevented the assessment needed to initiate a gradual dose reduction (GDR). The Director of Nurses (DON) acknowledged that the indications for the medications were not specific enough and that the facility's consultant pharmacist's recommendations for GDR were not adequately reviewed or acted upon. Resident 4 was administered Lorazepam without a physician's order, which is a violation of the facility's medication administration policy. The resident, who had severe cognitive impairment, was given Lorazepam on multiple occasions after the original order had expired. The nursing staff failed to obtain a new order before administering the medication, and there was no documentation in the Medication Administration Record (MAR) to support the administration of Lorazepam. The DON confirmed that the medication should not have been given without a valid order and that the resident should have been reassessed for the need for Lorazepam. The facility's policies on psychoactive drug monitoring and antipsychotic medication use were not followed, leading to the inappropriate use of psychotropic medications for both residents. The lack of specific documentation and monitoring of behaviors, as well as the failure to reassess the need for continued medication use, contributed to the deficiencies identified by the surveyors. The facility's failure to adhere to its own policies and federal regulations put the residents at risk for unnecessary medication use.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. In the medication room, the thermometer was not functioning, and the temperature was not recorded in the Daily Room Temperature Log, which is essential to maintain the potency of medications. The Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) confirmed that the temperature was not documented, and the thermometer was not working, indicating a lapse in monitoring the medication storage conditions. Additionally, the facility did not label multi-dose medication bottles with the resident's name, as required. For Resident 257, who was admitted with hypertension and muscle weakness, opened bottles of Ascorbic acid, Vitamin E, and Vitamin D3 were found in the medication cart labeled only with the room number. The LVN acknowledged that the resident's name should have been on the bottles to prevent medication errors, especially if the resident was moved to a different room. Furthermore, the facility failed to label opened multi-dose bottles with the open date, which is crucial for determining the expiration of liquid medications. LVN 7 observed that bottles of Pro-Stat, bismuth subsalicylate, Geri-Lanta, and sterile normal saline were not labeled with the open date. The Infection Preventionist (IP) and the Director of Nursing (DON) emphasized the importance of labeling to ensure medication potency and prevent infection. The facility's policy and procedure on medication labeling and storage, dated February 2023, required medications to be stored under proper conditions and labeled with the resident's name and the open date for multi-dose vials.
Failure to Provide Correct Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident with dysphagia, who was ordered by the physician to be served a regular diet with mechanical soft texture. Despite the physician's order, the resident received regular texture food instead of the required mechanical soft texture from July 16, 2024, to October 3, 2024. This oversight placed the resident at risk for aspiration and choking. The resident, who was initially admitted on April 1, 2015, and readmitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, had a care plan indicating a risk for aspiration and choking during meals. The care plan included interventions such as a mechanical soft diet with thin liquids and assistance during meals. However, during a dining observation on October 1, 2024, the resident was seen eating alone with no assistance and using a spoon to cut a large piece of chicken, indicating a failure to adhere to the prescribed diet texture. Interviews with facility staff revealed that the Dietary Service Supervisor was unaware of the mechanical soft texture order due to an error in transferring the diet order into the system, resulting in the resident receiving a regular texture diet. The Director of Nurses confirmed that the resident's diet order had been mechanical soft texture since July 16, 2023, and acknowledged the risk of aspiration or choking due to the incorrect diet texture being provided.
Failure to Timely Screen and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to screen and offer the pneumococcal vaccine to a resident upon their initial admission, as required by the facility's policy. The resident, who was admitted with diagnoses including depression and low back pain, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. The facility's policy mandates that assessments of pneumococcal vaccination status be conducted within five working days of admission. However, the Infection Preventionist (IP) did not screen the resident for the vaccine until 22 days after admission due to being occupied with other tasks. During interviews, both the IP and the Director of Nursing acknowledged the oversight. The IP admitted to not screening the resident in a timely manner, which delayed informing the resident about the vaccine and its protective benefits against pneumonia. The Director of Nursing confirmed that staff should screen residents for the pneumococcal vaccine upon admission to ensure they are informed and offered the vaccine to protect against pneumococcal infection.
Failure to Maintain Sanitary Bed Siderails
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident 160, who was observed with stained and soiled upper bed siderails. Resident 160, admitted to the facility with diagnoses including depression and low back pain, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. During an observation, Resident 160 reported that the siderails had been dirty since admission and that the maintenance supervisor was informed, but no cleaning was done. The resident expressed discomfort using the siderails due to their unclean state. Certified Nursing Assistant (CNA) 5 confirmed the siderails were dirty and stated that housekeeping was responsible for cleaning them. Housekeeping staff acknowledged that bed siderails are high-touch areas requiring daily cleaning to prevent infection spread but admitted to not cleaning Resident 160's siderails. The Director of Nursing also stated that staff should clean the siderails daily to maintain a sanitary environment. The facility's policy indicated that residents should be provided with a safe, clean, and comfortable environment.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its written abuse policy and procedure for two residents involved in a resident-to-resident altercation. Resident 106, who has schizophrenia and anxiety disorder, was allegedly physically abused by Resident 29, who also has schizophrenia and dementia. The incident occurred when Resident 29 poured a cup of water on Resident 106 while he was sleeping, leading to a confrontation in front of the nursing station. Despite the altercation, there was no documentation or investigation conducted by the facility. Interviews with staff revealed that the incident was not reported to the Director of Nursing (DON) or the Administrator (ADM) until informed by the surveyor. Licensed Vocational Nurse (LVN) 4 and Certified Nursing Assistant (CNA) 3 were aware of the altercation but did not report it, assuming the DON was already informed. The DON and ADM confirmed they were unaware of the incident and acknowledged that a thorough investigation should have been conducted to prevent recurrence and protect the residents. The facility's policy on abuse reporting and investigation requires immediate initiation of an investigation upon receiving a report of abuse. However, this procedure was not followed, as evidenced by the lack of documentation and investigation into the altercation between the two residents. The incident was only reported to the Department on a later date, indicating a failure to adhere to the facility's established protocols for handling such incidents.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe, as per their policy. The incident involved two residents, Resident 106 and Resident 29, where Resident 106 alleged that Resident 29 poured water on him while he was asleep. This altercation was witnessed by LVN 4, who did not report it to the Abuse Coordinator or any other designated authority within the stipulated time. Additionally, CNA 3, who was aware of the incident, also failed to report it immediately. The Social Services Director eventually reported the incident to the enforcement agencies eight days later. Resident 106, who has diagnoses of schizophrenia and anxiety disorder, was admitted to the facility on 9/13/2024. The Minimum Data Set (MDS) indicated that Resident 106 had moderately impaired cognitive skills and required assistance with daily activities. Resident 29, who has schizophrenia and dementia, was readmitted to the facility and also had moderately impaired cognitive skills. The altercation occurred shortly after Resident 29 was transferred to Resident 106's room, and there was no documentation of the incident in the progress notes of either resident. Interviews with staff revealed a lack of communication and reporting. LVN 4 assumed the Director of Nursing (DON) was aware of the incident because she was present in the facility at the time, but the DON stated she was not informed until the surveyor brought it to her attention. The Administrator also confirmed that neither he nor the DON knew about the altercation until the surveyor's notification. The facility's policy requires all allegations of abuse to be reported immediately to the appropriate agencies, which was not adhered to in this case.
Failure to Supervise Resident on Temporary Leave
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who went out on pass (OOP) and did not return at the expected time. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, bipolar type, and hypertension, was allowed to leave the facility with an estimated return time of 12:00 PM. However, the resident did not return until more than 24 hours later, during which time the facility did not escalate the situation by notifying the Medical Doctor (MD), Director of Nurses (DON), or Social Worker (SW) for guidance. The resident's absence was not reported to law enforcement or other appropriate agencies until more than 24 hours after the expected return time. This delay in notification was a result of the staff's failure to escalate the issue to upper management when the resident did not return. Interviews with the DON, SW, and nursing staff revealed that the resident's whereabouts should have been addressed immediately, and the failure to do so was acknowledged as a safety issue. The resident returned to the facility feeling tired, with untidy clothes and dirty hands and feet, and had missed two days of scheduled medications, including those for depression, hypertension, and schizophrenia. The facility's policy and procedure for signing residents out was not adequately followed, as the OOP order did not specify the duration the resident was allowed to be out, and the staff did not ensure the resident's safety by knowing their whereabouts or providing necessary medications during the absence.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment and a history of wandering behavior. The resident, diagnosed with dementia and Alzheimer's disease, was admitted with a care plan that required monitoring every hour and visual checks every two hours. However, documentation showed that the resident was only monitored every shift, and there was no evidence of 1:1 supervision as needed, despite the resident's known wandering behavior. An altercation occurred between the resident and another resident when the wandering resident entered the other's room, resulting in a physical assault. Although the resident did not sustain injuries from the altercation, the incident highlighted the lack of adequate supervision. Interviews with facility staff, including the DON and an LVN, revealed inconsistencies in monitoring practices, with staff acknowledging that the resident's wandering was a known issue but not consistently addressed according to the care plan and physician orders. Further observations showed the resident was found on the floor in their room, with no immediate response from the attending CNA, who was assisting another resident in the same room. The CNA was unaware of the resident's fall, indicating a lapse in supervision. The facility's policies on wandering and elopement were not effectively implemented, as evidenced by the lack of a person-centered approach to prevent such incidents, despite the resident being identified as a fall risk.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to comprehensively assess and address the behavioral symptoms of a resident diagnosed with dementia, leading to a deficiency in care. The resident, who was admitted with diagnoses including dementia with behavioral disturbances, schizoaffective disorder, anxiety disorder, and Alzheimer's disease, displayed wandering behavior and had a history of entering other residents' rooms. Despite these behaviors, the facility did not develop a specific dementia care plan or conduct an interdisciplinary team (IDT) meeting to address the resident's needs. The resident's care plan indicated a need for monitoring due to the risk of injury from wandering, with interventions including visual checks every two hours and 1:1 supervision as needed. However, documentation showed that the resident was only monitored hourly for a short period and did not receive the required 1:1 supervision. An altercation occurred when the resident entered another resident's room, resulting in the resident being physically assaulted. Despite this incident, the facility did not adjust the care plan to provide adequate supervision or address the resident's wandering behavior effectively. Observations revealed that the resident was found on the floor in their room without any alarm sounding, indicating a lack of appropriate safety measures. Staff interviews confirmed that the resident's wandering was considered normal, yet no specific interventions were in place to prevent incidents. The Director of Nursing acknowledged that a dementia care plan was not created or implemented, and there was no record of an IDT meeting to address the resident's dementia-related behaviors.
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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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