Chico Terrace Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 188 Cohasset Lane, Chico, California 95926
- CMS Provider Number
- 055516
- Inspections on file
- 47
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Chico Terrace Care Center during CMS and state inspections, most recent first.
A Spanish-speaking resident with sepsis, pneumonia, and ESRD had a documented care plan noting a language barrier and directing staff to use an interpreter or language line, but staff did not consistently follow this plan. The DON expected staff to explain medications in the resident’s language using Spanish-speaking staff or interpreter services, yet an LN reported only sometimes using Spanish-speaking staff and not always explaining medications. A Spanish-speaking CNA stated they were only occasionally used to translate and not recently for medications. The resident reported that staff did not always obtain a translator, that it could take a long time when requested, that medications were often given without explanation, and that overall communication about their condition and updates was poor.
A resident with sepsis, pneumonia, and ESRD experienced loose stools documented daily over an eight-day period, yet the physician was not notified as required by facility policy, which calls for MD notification after three days of loose stools. During this time, nurses administered stool softeners on multiple days without consistently reviewing bowel elimination records or assessing the resident, despite ongoing loose stools documented by CNAs. The DON and DSD confirmed the expectations for bowel monitoring and timely MD notification, while two LNs acknowledged they often relied on verbal reports rather than reviewing documentation before giving stool softeners. The resident reported that staff did not ask about bowel movements and described communication about his condition as poor.
A resident with sepsis, pneumonia, and ESRD had a physician’s order for daily Bisacodyl with instructions to hold the medication for loose stools. CNAs documented loose stools for this resident over multiple consecutive days, yet nursing staff continued to administer the stool softener on several of those days and did not notify the physician after three days of loose stools as expected. The physician was not contacted until after an extended period of ongoing loose stools, at which point the Bisacodyl order was changed to PRN. This conduct did not follow the physician’s order or the facility’s medication administration policy requiring medications to be given according to provider directions.
The facility allowed multiple uncertified NAs in training to provide independent, hands-on resident care without supervision by a CNA or LN, despite policies and job descriptions stating that NAs could not perform direct care until completing theory, clinical skills, and demonstrating competency. Review of staffing records and the state registry showed several NAs were scheduled alone on various shifts to perform routine care and 1:1 observation before state certification, and some worked more than four months from hire without becoming certified. Interviews with an NA, a CNA, an LVN, the NATP instructor, and the DSD confirmed that NAs who had completed the facility’s NATP were functioning like CNAs, performing tasks such as changing, peri care, and ambulation, sometimes only "somewhat" supervised, while the governing body and leadership were unaware that NAs were working beyond the four‑month certification timeframe.
The governing body did not ensure that hiring and staffing practices complied with federal and state requirements for nurse aide (NA) certification and competency. Policy documents assigned the governing body responsibility for quality assurance and for overseeing hiring processes intended to ensure only qualified, legally authorized staff provided care. Despite this, multiple NAs in training, who had completed a Nurse Aide Training Program (NATP) but were not yet certified by the state, were hired and scheduled to work independently on various shifts, providing direct resident care such as feeding, changing, and 1:1 observation without pairing with a CNA or licensed nurse. Some NAs remained uncertified for months while continuing to provide independent care or accompany residents to appointments. NATP and staff development leaders stated that NAs were not supposed to provide unsupervised care before certification, acknowledged that some had been working somewhat independently, and confirmed that no additional competency testing was done after hire. A senior operations leader confirmed that the governing body oversaw the facilities and NATP and that administrators and the governing body were ultimately responsible for ensuring regulatory compliance in NA hiring and use.
A resident with moderate cognitive impairment and multiple medical conditions did not receive timely access to medical records, as required by facility policy. Despite multiple requests and submission of legal documents by the family, records were not released within the two-working-day timeframe due to the facility's belief regarding the validity of the Advance Health Care Directive. Both the Administrator and DON confirmed the delay and acknowledged the failure to meet policy requirements.
A LVN was verbally abusive to a resident during dietary education, making statements about death in relation to the resident's eating habits. The incident was reported by the resident's family and overheard by another staff member. The LVN's actions were found to be in violation of the facility's abuse prevention policy, despite having completed required abuse training.
The facility failed to ensure dietary staff were properly trained and competent, leading to unsanitary kitchen conditions and inconsistent food preparation. Observations revealed that equipment was not cleaned according to standards, and staff did not follow professional practices to prevent cross-contamination. Additionally, standardized recipes were not adhered to, resulting in poor meal quality. These deficiencies were confirmed through staff interviews and resident feedback.
The facility failed to follow standardized recipes, leading to inconsistent meal preparation and potential impacts on resident satisfaction and health. Staff deviated from recipes due to unavailable ingredients and corporate restrictions, resulting in meals that did not meet nutritional and satisfaction standards. Residents expressed dissatisfaction with meal seasoning, and test tray evaluations confirmed issues with flavor and consistency.
The facility failed to offer evening snacks to residents as per policy, affecting four residents who were not offered snacks despite expressing interest. Observations showed that nursing stations lacked necessary snack stock, contrary to facility policy. Interviews confirmed that snacks should be available, but the deficiency in snack availability was evident.
The facility failed to maintain food safety standards, with unclean equipment, improper staff hygiene, and inadequate pest control measures. Observations revealed rust, dried food, and dust on kitchen equipment, while staff did not follow proper hygiene practices, increasing contamination risks. Additionally, pest control was insufficient, and chemical safety was compromised with high chlorine levels and improper ice machine cleaning.
The facility failed to maintain kitchen sanitation, with damaged and uncleanable surfaces observed in the refrigerator/freezer room and cook's area. Worn cabinets, chipped paint, and evidence of cockroaches were noted, with staff acknowledging maintenance challenges due to limited resources.
The facility failed to maintain an effective pest control program, as cockroach traps and evidence of cockroach presence were found in the kitchen. Staff were unaware of the pest issues, and there was no system to track or monitor pest control efforts. The pest control vendor's reports indicated ongoing cockroach problems, but treatments were only conducted outside, and interior traps were not regularly checked.
Two residents in an LTC facility did not receive their scheduled showers due to a lack of coordination with dialysis and wound care schedules. One resident, with multiple health conditions, reported infrequent showers, while another had not received any showers since admission. The facility's policies on dignity and residents' rights were not adhered to, leading to unmet care needs.
The facility failed to ensure food was palatable and easy to consume, as observed during a survey. Residents reported that the food lacked seasoning, and the meat was difficult to cut. A staff member did not follow the recipe for Ranch-style chicken correctly, leading to improperly prepared meals. The Regional Registered Dietitian and surveyors found the food lacked seasoning, and residents expressed dissatisfaction with the food's flavor and texture.
A facility failed to obtain physician orders for a resident's suprapubic catheter care upon admission, leading to a lack of necessary catheter changes and site care. The resident, who was competent, reported no follow-up appointments for catheter changes, and staff interviews confirmed the admission process was incomplete, lacking necessary assessments and orders.
A resident with multiple health issues, including a fractured arm and depression, was not consistently assisted out of bed for meals and toileting, impacting her quality of life and discharge goals. Despite being cognitively intact and expressing willingness to participate in therapy if medicated for pain, there was a lack of coordination between nursing and therapy services. The facility's policies on dignity and residents' rights were not adhered to, leading to the deficiency.
The facility failed to ensure CNAs and LNs had the necessary competencies, leading to deficiencies in resident care. A resident with dementia fell when left unattended, contrary to their care plan. Two residents did not receive phosphorus binders correctly due to staff's lack of understanding, and a nurse was unable to properly administer an inhaler. These incidents highlight significant gaps in staff training and competency.
A facility failed to conduct a Care Conference meeting with the IDT, physician, resident, and responsible party before discharging a resident with multiple medical conditions. The resident was discharged without meeting therapy goals, and the responsible party was not involved in a meeting to discuss discharge abilities or trained on assisting with mobility. The discharge was impromptu, and the rehabilitation department was notified only on the day of discharge, leading to the resident being unable to stand or transfer at home.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to follow its policy on weight monitoring and care planning. The resident was not weighed as required, and the Interdisciplinary Team did not conduct weekly weight variance meetings for ten weeks. The care plan was not updated to address the weight loss, and the absence of a Registered Dietitian contributed to the oversight.
The facility failed to provide palatable, attractive, and nutritious food, leading to numerous resident complaints about cold, flavorless, and poorly presented meals. The transition to a new menu system caused confusion among staff, contributing to the issues with food quality and consistency.
The facility failed to maintain proper food storage temperatures, with a refrigerator consistently above the safe threshold, posing a risk of foodborne illness. Additionally, unsanitary practices were observed, including the use of a soiled towel around a floor drain and stacking wet food storage containers, compromising kitchen sanitation.
A resident with a history of stroke and dementia experienced an unwitnessed fall, resulting in new pain and a skin tear. Despite increased pain levels and vocalizations, the facility failed to notify the physician promptly. An x-ray was delayed, and the physician was not informed of the results indicating a possible hip fracture until 24 hours later, causing unnecessary pain and suffering.
A facility failed to create a Person-Centered baseline care plan within 48 hours for a resident with frequent falls, dysphagia, and dementia. The resident was admitted without a documented care plan for fall prevention, which was only addressed upon readmission. The DON confirmed the oversight and acknowledged the lack of awareness regarding the severity of the resident's fall history.
A resident with a history of dysphagia, aphasia, and dementia experienced a fall resulting in severe pain, which was inadequately managed by the facility. Despite signs of pain, including yelling and guarding, the resident was only given mild pain medication, and there was a delay in obtaining an x-ray and notifying the physician. The x-ray later revealed a possible fracture, leading to hospital treatment. Staff interviews confirmed the need for more timely intervention.
The facility failed to ensure dietary staff followed menus and recipes, leading to deficiencies in meal preparation. A cook served non-creamy rice due to missing ingredients and substituted baked tilapia with ravioli without ensuring nutritional adequacy or consulting the CDM or RD. Challenges in transitioning to a new menu system and space limitations contributed to these issues.
The facility failed to maintain comfortable air temperatures in resident rooms and hallways on Station 2, leading to discomfort among residents. Despite policies to protect residents from extreme temperatures, the air conditioning system issues identified in October 2023 were not addressed, resulting in room temperatures exceeding the recommended range during a period of high outside temperatures. Residents reported feeling uncomfortable and having difficulty sleeping due to the heat.
The facility failed to secure the urinary catheter tubing for a resident with neuromuscular dysfunction of the bladder and overactive bladder. Despite the facility's policy requiring catheters to be anchored, the resident was observed multiple times without a leg strap. Staff confirmed the importance of securing the catheter to prevent it from being pulled or dislodged.
The facility failed to ensure an as-needed psychotropic medication had a 14-day end date for a resident with anxiety disorder and insomnia. The resident's physician order for lorazepam did not include an end date, contrary to facility policy, which was acknowledged by the DON, Administrator, and Pharmacist.
Failure to Inform Spanish-Speaking Resident About Medications in Understandable Language
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Spanish-speaking resident was fully informed and understood their medications in a language they could understand. The resident was admitted with sepsis, pneumonia, and end stage renal disease, and their medical record identified Spanish as their primary language. The care plan documented a potential communication problem related to a language barrier and directed staff to provide an interpreter or use a language line. The DON confirmed that the resident is Spanish speaking and stated that the expectation is for nursing staff to explain medications in the resident’s own language using Spanish-speaking staff or the facility’s interpreter service. Despite this, interviews showed that staff did not consistently follow the care plan or the DON’s expectations. A licensed nurse acknowledged that the resident is Spanish speaking, that the nurse does not speak Spanish, and that Spanish-speaking staff are only sometimes used to communicate with the resident; the nurse also stated they do not always explain what medications the resident is taking. A CNA who speaks Spanish reported that staff occasionally use them to translate for the resident but that they had not recently translated regarding medications. The resident reported that staff do not always obtain a translator, that it can take up to 30 minutes when one is requested, that nursing staff do not always tell them what medications they are taking, and that they simply take the medications without knowing what they are. The resident also stated that communication with staff about their condition has been poor and expressed a desire for nursing staff to answer questions and provide updates.
Failure to Notify Physician of Resident’s Prolonged Loose Stools and Inappropriate Use of Stool Softeners
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition as required by its “Change of Condition Notification” policy. That policy states the facility will promptly inform the resident, consult with the attending physician, and notify the resident’s representative or family when there is a significant change in condition, including sudden and marked changes manifested by signs and symptoms different than usual. For one resident admitted with sepsis, pneumonia, and end stage renal disease, CNA documentation showed the resident had loose stools every day from 11/30/25 to 12/8/25. The Director of Staff Development confirmed CNAs are expected to report loose stools to the nurse and that nurses are expected to contact the physician after three days of loose stools. However, the physician was not notified until 12/8/25, after eight days of loose stools. Record review and interviews further showed that during this period the resident was given a stool softener on 12/4/25, 12/5/25, and 12/6/25 despite the ongoing loose stools documented since 11/30/25. The DON stated nurses are expected to review bowel elimination documentation and assess the resident before administering a stool softener and confirmed the physician should have been contacted after three days of loose stools. Licensed Nurse A reported typically not reviewing CNA bowel documentation and relying instead on verbal reports from CNAs or other nurses, and stated that after three days of loose stools she would notify the doctor. Licensed Nurse B stated that if a resident had loose stools for three days they would contact the doctor but acknowledged not always reviewing bowel elimination documentation before giving stool softeners. The resident reported that staff do not ask about bowel movements and described communication with staff about his condition as poor.
Failure to Hold Stool Softener and Notify Physician for Ongoing Loose Stools
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to hold a stool softener when a resident experienced loose stools, and failure to assess bowel documentation and notify the physician after three days of loose stools. Resident 1 was admitted with diagnoses including sepsis, pneumonia, and end stage renal disease. A physician’s order dated 11/17/25 directed that Bisacodyl, a laxative, be given once daily with instructions to hold the medication for loose stools. Review of the electronic MAR for 12/2025 showed that Bisacodyl was held from 12/1/25 to 12/3/25 due to loose stools, but then administered from 12/3/25 to 12/6/25, and refused by the resident on 12/7/25. The order was not changed to an as-needed basis until 12/8/25 after the physician was notified. Interviews and record reviews with the DSD, DON, and IP confirmed that CNAs documented loose stools for Resident 1 daily from 11/30/25 through 12/8/25. The DSD stated that CNAs are expected to report loose stools to the nurse and that nurses should contact the physician after three days of loose stools. The DON confirmed that Bisacodyl was administered on 12/4/25, 12/5/25, and 12/6/25 despite documentation of ongoing loose stools since 11/30/25, and that the physician was not contacted until 12/8/25, after eight days of loose stools. The IP stated that medications causing loose stools should not be given when a resident is having loose stools and that the physician should be contacted after three days of loose stools. The facility’s Medication - Administration policy indicated that all medications must be administered by licensed nursing staff according to physician orders, which was not followed in this case.
Uncertified Nurse Aides Providing Independent Direct Care and Working Beyond Four-Month Limit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that uncertified nurse aides (NAs) in training did not provide direct, hands-on resident care without supervision by a certified nursing assistant (CNA) or licensed nurse, and failure to ensure NAs did not work beyond four months without state certification. Facility documents showed an approved Nurse Aide Training Program (NATP) and a hiring policy requiring compliance with CDPH regulations, as well as a job description stating NAs could not perform direct resident care until theory and clinical skills were completed and competency demonstrated. Despite this, review of CNA/NA employee lists, daily assignments, and the California Nurse Aide Registry revealed multiple NAs who were hired, graduated from NATP, and then assigned to provide direct resident care independently before they were state certified. Record review showed that several NAs (identified as NA 1, NA 2, NA 3, NA 4, NA 5, and NA 6) were scheduled on various shifts to work independently, unpaired with a CNA, providing direct resident care such as routine daily care and 1:1 observation. Some of these assignments occurred immediately after graduation from NATP but before certification, and others occurred while the aides remained uncertified for extended periods. One NA (NA 4) graduated from NATP and was hired on the same date and remained uncertified months later while being assigned to independent direct care and to accompany residents to appointments. Another NA (NA 3) was hired early in the year and did not become certified until many months later, yet was assigned to independent direct care and 1:1 care prior to certification. Additional NAs (NA 7, NA 8, NA 9) were documented as having hire dates and certification dates that exceeded four months, indicating they worked in the facility beyond the four‑month limit without timely certification. Interviews corroborated that NAs in training were performing direct resident care. A CNA reported being trained through the facility’s NATP and working for several months. An LVN stated that after NAs were “signed off,” they performed direct resident care and CNAs acted as standbys or guides. An NA graduate (NA 2) stated they had recently completed NATP, were waiting to retake the state CNA test, had been working for about two months, and could do everything a CNA could do, including changing, peri care, and ambulating residents. NA 2 acknowledged they were not supposed to provide direct care independently but had done so at times, being only “somewhat watched” by CNAs. The NATP instructor and Director of Staff Development stated that NAs were not supposed to provide direct care without CNA or licensed nurse supervision until certified, but also stated that graduated NAs were hired as NAs in training and did not receive additional competency testing because the program staff were confident in their abilities. The governing body representative later acknowledged oversight responsibility for the NATP and hiring of NAs at the facilities and was unaware that multiple NAs had worked beyond four months without state certification.
Governing Body Failed to Prevent Uncertified Nurse Aides From Providing Independent Direct Care
Penalty
Summary
The governing body failed to provide adequate oversight of the administrator and hiring processes to ensure that nurse aides were state certified and had required competencies before providing independent resident care. Facility operational documents showed that the governing body was responsible and accountable for quality assurance and had engaged administrative services to develop and implement policies, including those related to hiring and employment verification. The hiring policy for one facility stated that the facility was committed to hiring qualified and legally authorized individuals and to following all applicable federal and state regulations, including California Department of Public Health (CDPH) requirements, but this policy was not effectively implemented to prevent uncertified nurse aides from providing direct care. Record reviews of CNA/NA employee lists, daily assignments, and the California Nurse Aide Registry showed that multiple nurse aides in training, who were not yet state certified, were hired and then assigned to work independently providing direct resident care without being paired with a CNA or licensed nurse. Specific examples included several nurse aides who, after graduating from a Nurse Aide Training Program (NATP) but before state certification, were scheduled on various shifts to provide direct resident care such as feeding and changing residents, and in one case to provide 1:1 direct observation care. Some aides worked independently on multiple dates and shifts, and at least one aide remained uncertified for months while continuing to be assigned to independent resident care and to accompany residents to appointments. Additionally, several aides worked beyond four months from hire or NATP graduation before obtaining certification, or remained uncertified until termination. Interviews with the NATP instructor and the director of staff development revealed that the NATP provided 60 hours of theory and 100 hours of clinical training at one facility, and that students were selected and hired across three facilities. The NATP instructor stated that NAs were not supposed to provide direct resident care without supervision until state certified and that graduates were hired as NAs in training. However, they acknowledged that NAs had been providing care somewhat independently, particularly on night shifts, and that they had only recently adjusted assignments for closer observation. They also stated they were unaware that NA graduates were not permitted to work as uncertified NAs at the other two facilities, which did not have NATPs, and confirmed that no additional competency testing was done after hire because they relied on the NATP training. In a separate interview, a vice president of operations confirmed that the governing body oversaw the three facilities and the NATP, that only one facility was an approved NATP site, and acknowledged that NAs should not be feeding and changing residents and that administrators and the governing body were ultimately responsible for ensuring compliance with federal and state regulations regarding NATP and NA hiring.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for one resident, as required by its own policy. The policy stated that copies of a resident's medical record must be provided within two working days of a written request. In this case, the first documented request for records was received on 11/03/25, but the records were not released until 11/07/25, exceeding the required timeframe. The delay was attributed to the facility's belief that the resident lacked capacity and that the Advance Health Care Directive (AHCD) was invalid, despite documentation and statements confirming that the resident's family member was authorized to make medical decisions. The resident involved had diagnoses including essential hypertension, type 2 diabetes mellitus, and mild protein-calorie malnutrition, with a BIMS score indicating moderate cognitive impairment. Multiple requests for records were made by the resident's family, who had submitted both an AHCD and a Durable Power of Attorney to the facility. Both the Administrator and the Director of Nursing confirmed the delay and acknowledged that the records were not released within the required timeframe, despite recognizing the family member as the authorized decision-maker.
Verbal Abuse by LVN During Dietary Education
Penalty
Summary
A Licensed Nurse (LVN) at the facility was verbally abusive to a resident while providing care. The LVN made statements to the resident such as, "you are going to leave here in a pine box" and "if you do not eat, you will die," during dietary education. These statements were reported by the resident's family and overheard by another staff member. The facility's policy defines verbal abuse as any oral, written, or gestured communication that is belittling or derogatory and directed at any resident, and the statements made by the LVN were determined to be abusive and in violation of this policy. The resident involved had a food preference for yogurt, which was brought in by family and encouraged as a good source of protein. The LVN had documented providing education about the importance of nutrition for health and rebuilding strength. Despite having completed mandatory annual abuse training, the LVN engaged in behavior that was considered unprofessional and abusive according to facility standards and the abuse prevention policy.
Deficiencies in Dietary Staff Training and Food Safety Practices
Penalty
Summary
The facility failed to ensure that dietary staff were adequately trained and competent in maintaining sanitation and following professional standards of practice. Observations revealed that fixed kitchen equipment, such as refrigerators, steamers, and mixers, were not cleaned according to policy or standards of practice. The equipment had visible food residues and dust, indicating a lack of proper cleaning and sanitization. Staff interviews confirmed that the cleaning processes were not followed correctly, with some staff unaware of the need to rinse soap off before sanitizing or the requirement for sanitizer to remain wet for a specific duration to be effective. Additionally, staff did not consistently adhere to professional standards to prevent cross-contamination during food production. Instances were observed where staff failed to change gloves or wash hands after touching their face or other surfaces, and some staff did not wear aprons or changed them as needed. These actions increased the risk of cross-contamination, compromising food safety and hygiene in the facility. The facility also failed to follow standardized recipes, leading to inconsistencies in meal preparation. Staff interviews and observations indicated that recipes were not followed accurately, with incorrect ingredient quantities and substitutions being made without proper authorization. This resulted in meals that did not meet the expected quality or nutritional standards, as reported by residents who found the food lacking in seasoning and difficult to consume. The facility's failure to adhere to standardized recipes and ensure proper training and competency of dietary staff contributed to the deficiencies identified during the survey.
Inconsistent Recipe Adherence and Meal Preparation
Penalty
Summary
The facility failed to ensure that standardized recipes were followed, leading to inconsistencies in meal preparation and potential impacts on resident satisfaction and health. The Dietary Manager (DM) and Regional Dietary Manager (RDM) acknowledged challenges with the menus, including unavailable ingredients and inaccurate recipe yields. The Facility Registered Dietitian (FRD) noted issues with recipes requiring numerous ingredients that were rarely used, creating budget and storage challenges. Despite these concerns, the spring menu had not been finalized, and the DM confirmed that corporate controlled the order guide, limiting their ability to procure suitable ingredients. During observations, staff did not adhere to standardized recipes, resulting in deviations from planned meals. For instance, a cook used white bread instead of croissants for a Ham & Swiss sandwich, and another cook did not follow the recipe for Ranch-style chicken, omitting ranch dressing and adding unauthorized cooking oil. These deviations were confirmed by the DM, who stated that corporate restrictions prevented ordering appropriate ingredients. Additionally, a cook preparing pureed cookies did not measure ingredients, resulting in an incorrect consistency, which she attributed to recipe inaccuracies. The facility's recipes did not consistently produce palatable meals, as evidenced by test tray evaluations and resident feedback. The Regional Registered Dietitian (RRD) and surveyors noted that the Ranch-style chicken lacked ranch dressing flavor, and potatoes were under-seasoned. Residents expressed dissatisfaction with the seasoning of meals, and the DM and RDM confirmed that no residents required a 2-gram sodium diet, allowing for salt use in cooking. These findings highlight the facility's failure to provide meals that meet nutritional and satisfaction standards, as required by their policies.
Failure to Provide Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently offer evening bedtime snacks to all residents as per the facility's policy. This deficiency was identified for four sampled residents who reported not being offered snacks by the staff, although they expressed a desire to receive them. The facility's policy, dated 4/1/14, stated that snacks should be available at the nurse's station for residents and additional snacks could be provided upon request. However, during interviews, residents indicated that they were not offered snacks and had to request them if they wanted any. Additionally, the facility did not maintain adequate snack stock at the nursing stations as required by their policy. Observations revealed that both nursing stations lacked the necessary snacks, such as sandwiches, cheese sticks, crackers, and fresh fruit, in their refrigerators or freezers. Interviews with the Dietary Manager and Licensed Vocational Nurse confirmed that snacks should be available at specific times and that the charge nurse could access the kitchen to restock snacks if needed. Despite these provisions, the lack of snack availability at the nursing stations was evident, potentially affecting the nutrition status and wellbeing of all residents.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in several areas, leading to potential foodborne illness risks for residents. Observations revealed that fixed equipment such as refrigerators, steamers, and mixers were not clean, with rust, dried food, and dust present. The facility's policies on equipment cleaning were not followed, as evidenced by the unclean state of the industrial can opener and other kitchen appliances. Additionally, the facility's storage areas, including cabinets and shelving, were in disrepair and not easily cleanable, further contributing to potential contamination. Dietary staff did not adhere to proper hygiene practices, which increased the risk of cross-contamination. Staff members were observed not changing aprons between tasks, touching their faces with gloved hands, and handling food without gloves. These actions were contrary to the facility's infection control policies, which require clean aprons and proper handwashing to prevent contamination. The lack of adherence to these policies was confirmed through interviews with staff and record reviews. The facility also had issues with pest control and chemical safety. Evidence of roaches was found under a sink, and the facility's pest control measures were inadequate, as the maintenance technician failed to monitor and report pest activity. Additionally, the chlorine concentration in the sanitizer machine was too high, and the ice machine was not cleaned according to manufacturer recommendations, leading to mineral deposit buildup. These deficiencies in pest control and chemical safety further compromised the facility's ability to provide safe food services to its residents.
Deficiency in Kitchen Sanitation Due to Uncleanable Surfaces
Penalty
Summary
The facility failed to maintain essential conditions for kitchen sanitation, as observed during a survey. The floor in the refrigerator/freezer room was damaged and uncleanable in three locations, and multiple areas in the kitchen had worn and chipped paint, creating surfaces that could not be cleaned effectively. Additionally, the wood cabinets in the cook's food preparation area were worn and uncleanable, and the area under the corner sink was not clean, containing cockroach traps and evidence of cockroaches. The drawers in the cook's area, which held serving utensils and clean towels, were grimy, gouged, and difficult to open and close, further contributing to the uncleanable conditions. Interviews with staff revealed that the maintenance technician conducted regular monthly inspections of the kitchen, including cleaning filters, coils, and checking grease traps. However, he acknowledged the challenges in maintaining the facility due to being the sole maintenance staff and having to manage the budget constraints. The Regional Registered Dietitian confirmed the uncleanable condition of the floor in the refrigerator/freezer room. Despite these efforts, there were no immediate plans to replace the wood cabinets or address the floor gouges and worn paint, leading to the deficiency in maintaining a sanitary kitchen environment.
Ineffective Pest Control Program in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the lack of a system to track and monitor pest control issues. During an observation, cockroach traps and evidence of cockroach presence were found in a cabinet under a food preparation sink in the facility kitchen. The facility's policy indicated that a pest control company should inspect the facility and provide a written report with recommendations, but there was no documentation of such reports being received or acted upon. Interviews with facility staff revealed a lack of awareness and communication regarding pest issues. The Dietary Manager and the Facility Registered Dietitian both stated they were unaware of any pest problems in the kitchen, despite the presence of cockroach traps and droppings. The Maintenance Technician admitted to placing traps under the sink but failed to monitor them or notify relevant staff about the pest evidence. He also lacked records of pest control services and relied on text messages to communicate with the pest control vendor. The pest control vendor's service inspection reports indicated ongoing issues with cockroaches since August 2024, with treatments only conducted on the outside perimeter of the building. The Maintenance Technician acknowledged that the interior traps were not regularly checked, and the area under the sink was not cleaned or maintained in a cleanable condition. This lack of effective pest control measures and communication among staff had the potential to result in disease transmission or trigger allergies or asthma for the 72 residents living at the facility.
Failure to Provide Scheduled Showers and Coordinate Care
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers, which is a deficiency in providing care and assistance for activities of daily living. Resident 18, who was admitted with multiple diagnoses including bacteremia, metabolic encephalopathy, diabetes, end-stage kidney failure, and depression, reported receiving only one shower every seven to ten days. Record reviews confirmed that Resident 18 missed several scheduled showers over a three-month period, with no follow-up to coordinate showers on non-dialysis days. Licensed Nurse D confirmed the lack of follow-up and coordination for Resident 18's showers. Resident 370, admitted with conditions such as multiple sclerosis, surgical aftercare, heart failure, and respiratory failure, had not received any showers since admission. The lack of coordination between shower schedules and wound care was confirmed by Licensed Nurse D and Licensed Nurse F. The Director of Nursing acknowledged that showers should have been coordinated with wound care and dialysis schedules for both residents. The facility's policies on showering and bathing, quality of life, and residents' rights emphasize the importance of providing care that promotes dignity and respect. However, the failure to provide scheduled showers and coordinate care for these residents indicates a deficiency in adhering to these policies, resulting in unmet care needs for the residents involved.
Food Palatability and Preparation Deficiency
Penalty
Summary
The facility failed to ensure that food was palatable and easy to consume, as observed during a survey. Four residents reported that the food lacked seasoning, and the meat was difficult to cut with the provided knife. During an observation, a staff member, [NAME] B, prepared Ranch-style chicken but did not follow the recipe correctly. The chicken was not drained after baking for 15 minutes, and an unknown amount of cooking oil was used instead of greasing the baking sheet as directed. Additionally, ranch dressing was not applied to some chicken pieces due to a misunderstanding about residents' dietary restrictions, despite no residents being documented as lactose intolerant. The Regional Registered Dietitian (RRD) and surveyors evaluated test trays and found that the food lacked seasoning, with mashed potatoes tasting bland and the chicken lacking ranch dressing flavor. The pureed cookie was noted to be sticky and gummy. Interviews with residents revealed dissatisfaction with the food, with complaints about the chicken being overdone, difficult to cut, and lacking flavor. The facility's dietary management confirmed that there was a misunderstanding regarding residents' dietary preferences, as only one resident had a restriction related to lactose, which did not apply to the use of ranch dressing.
Failure to Obtain Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician orders for a suprapubic catheter change and site care were obtained upon admission for a resident. This oversight was identified during a review of the resident's medical records, which showed no orders for catheter changes or site care from the time of admission until several months later. The resident, who was competent to make decisions, reported that the catheter had not been changed or cleaned since admission, and there were no follow-up appointments scheduled for the catheter change. Interviews with facility staff revealed that the admission process was incomplete, as the necessary assessments and orders for the resident's catheter care were not obtained. The Licensed Nurse responsible for the admission did not perform a physical assessment to observe the catheter, and the Director of Nursing confirmed that the admission process was lacking in ensuring necessary treatments were in place. The deficiency was acknowledged by the staff, indicating a need for improvement in the admission process to prevent such oversights.
Lack of Coordination in Resident Care
Penalty
Summary
The facility failed to ensure proper coordination of care for Resident 43, who was admitted with multiple diagnoses including a fractured left humerus, heart disease, pulmonary embolism, polyneuropathy, severe protein malnutrition, high blood pressure, and depression. Despite being cognitively intact, Resident 43 required substantial assistance with transfers, bathing, and toileting. The resident expressed feelings of neglect and frustration due to not being assisted out of bed daily, particularly for meals and toileting, which hindered her progress towards discharge goals. Observations and interviews revealed that Resident 43 often remained in bed with unkempt hair and expressed dissatisfaction with her care, stating that she was willing to participate in therapy if pain medication was administered beforehand. The Licensed Nurse confirmed that pain management was necessary for the resident to attend therapy, yet there was a lack of coordination between nursing and therapy services to ensure this occurred. The facility's policies on dignity and residents' rights were not adhered to, as Resident 43 was not consistently assisted out of bed for meals and toileting, impacting her quality of life and independence. Interviews with the facility's Administrator and Medical Director confirmed the need for better coordination of care to meet Resident 43's goals, including medication management for pain and assistance with activities of daily living. The Medical Director emphasized the importance of getting the resident out of bed to build endurance, while the Rehab Director acknowledged the potential benefits of occupational therapy in promoting the resident's independence. Despite these acknowledgments, the lack of timely and coordinated care led to the deficiency noted in the report.
Deficiencies in Staff Competency and Medication Administration
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) possessed the necessary competencies to care for residents, leading to several deficiencies. One significant incident involved Resident 35, who was left alone in the dining room despite having a care plan that required staff presence to prevent falls. Resident 35, diagnosed with dementia and other health issues, fell when left unattended, as confirmed by interviews with staff and another resident who witnessed the fall. The facility's policy on dementia care emphasizes the need for staff support and resources, which were not adequately provided in this case. Another deficiency was identified in the administration of phosphorus binder medications for Residents 18 and 373. The LNs failed to understand the proper administration of these medications, which are crucial for residents with end-stage kidney disease. Resident 18 experienced delays in receiving medication, resulting in cold meals, while Resident 373's family had to provide the medication themselves due to the facility's failure to supply it. Interviews with the LNs revealed a lack of knowledge about the medication's purpose and administration timing, indicating a gap in training and competency. Additionally, LN A demonstrated a lack of competency in administering an inhaler to Resident 373. During a medication pass observation, LN A admitted to not knowing the proper procedure for inhaler administration, which could result in the resident not receiving the correct dosage. The Director of Nursing confirmed the competency issue, acknowledging that improper administration would prevent the resident from receiving the intended medication dosage. These incidents highlight significant gaps in staff training and competency, impacting resident care and safety.
Failure to Conduct Proper Discharge Planning and Training
Penalty
Summary
The facility failed to conduct a Care Conference meeting with the Interdisciplinary Team (IDT), the attending physician, the resident, and the resident's responsible party (RP) before discharging a resident. The resident, who had multiple medical conditions including fractures, parkinsonism, and dementia, was discharged without meeting his therapy goals. The resident's RP was not involved in a meeting to discuss the resident's discharge abilities or trained on how to assist the resident with mobility at home. The facility's policy required that if the IDT and the attending physician determined a resident might be appropriate for discharge, social services staff would coordinate a discussion of discharge needs with the IDT, the resident, and the RP. However, there was no documentation of such a meeting occurring for the resident in question. The resident's RP expressed concerns about the resident's high fall risk and was not informed about the resident's therapy levels or trained on how to assist with mobility. Interviews with facility staff revealed that the discharge was impromptu, and the rehabilitation department was only notified on the day of discharge. The Director of Rehabilitation confirmed that no training was provided to the RP on how to assist the resident. The resident's RP stated that she was not aware of any discharge meeting and was not informed about the resident's therapy level, leading to the resident being unable to stand or transfer upon returning home. The facility's failure to conduct a proper discharge meeting and provide necessary training had the potential to negatively impact the resident's well-being after discharge.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to provide adequate care and services for a resident experiencing unplanned weight loss. The resident, who had multiple medical conditions including fractures, parkinsonism, prostate cancer, anemia, dementia, and depression, was not weighed according to the facility's policy. The policy required weekly weights for the first four weeks after admission, but there were no weights documented for the third and fourth weeks, nor was a weight recorded upon the resident's readmission from the hospital. Additionally, the facility did not conduct weekly monitoring of the resident's weight by the Interdisciplinary Team (IDT) for the first ten weeks after admission. This lack of monitoring meant that significant weight loss was not addressed in a timely manner. The resident experienced an 18.8-pound weight loss over two months, with no documented IDT weight variance meetings or interventions implemented during this period. The absence of a Registered Dietitian (RD) from the facility during a critical time further contributed to the oversight. The resident's care plan, which was supposed to address nutritional problems, was not reviewed or revised to reflect the actual weight loss. There were no new interventions added to the care plan to prevent further weight loss. The Director of Nursing (DON) acknowledged that there should have been an IDT weight variance meeting upon the resident's readmission and that the care plan should have been updated with appropriate interventions, but these actions were not taken.
Deficiency in Food Quality and Presentation
Penalty
Summary
The facility failed to provide food that is palatable, attractive, and nutritious, as evidenced by multiple complaints from residents and observations during the survey. The facility's policy, which requires the Dietary Manager to develop menus in collaboration with the Dietitian, was not effectively implemented. Residents expressed dissatisfaction with the food quality, noting that it was often cold, lacked flavor, and was poorly presented. Specific complaints included dry chicken, mushy vegetables, and cold coffee, with some residents relying on friends and family to bring them food. Interviews with residents revealed consistent dissatisfaction with the meals provided. One resident described the food as the worst they had experienced in any hospital, citing issues such as dry noodles, unpalatable rice, and a lack of flavor in the fish. Another resident refused a lunch entree due to its lack of flavor and requested an alternative meal. These complaints were echoed in the Resident Council Meeting minutes and a Resident Satisfaction Survey, which highlighted concerns about the repetitive menu, poor food quality, and inadequate portion sizes. The Certified Dietary Manager (CDM) and Regional Dietician (RD) acknowledged the challenges faced by the facility following a recent switch in food services. The CDM reported receiving numerous complaints about the food's appeal and temperature, attributing these issues to the new menu system. The RD noted that the transition had been difficult for staff, with confusion arising from the need to use a spreadsheet system to ensure nutritional equivalents. The RD also confirmed that changes to the menu should be logged for review, and staff should be aware of the appropriate channels for reporting issues when management is unavailable.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain proper food storage temperatures, as evidenced by multiple observations of a refrigerator not being maintained at the required temperature for safe food storage. The Registered Dietician's audit and subsequent observations revealed that the refrigerator's internal temperature was consistently above the safe threshold of 40 degrees Fahrenheit, reaching as high as 49 degrees Fahrenheit. This failure to maintain appropriate temperatures could potentially compromise food safety and increase the risk of foodborne illness among residents. Additionally, the facility did not adhere to sanitary practices in the kitchen, as observed with the use of a soiled towel around a floor drain to prevent water splashing. This practice was noted during several observations and interviews, with the towel being used for an extended period, indicating a lack of proper maintenance and cleaning of the kitchen area. The presence of a dirty towel and splashing water in the kitchen environment poses a significant risk to maintaining a sanitary food preparation area. Furthermore, the facility was found to be stacking wet food storage containers, which is against professional food safety standards. Observations confirmed that these containers, used for food storage and preparation, were not allowed to air dry before being stacked, which could lead to contamination. The Certified Dietary Manager acknowledged this practice, confirming that it was not in line with sanitary food handling procedures. These deficiencies collectively highlight significant lapses in maintaining a safe and sanitary kitchen environment, potentially endangering the health of all residents.
Failure to Notify Physician of Post-Fall Pain
Penalty
Summary
The facility failed to identify and act upon a change in condition by not notifying the physician of post-fall pain for a resident, resulting in a delay of treatment and unnecessary pain and suffering. The resident, who had a history of dysphagia, aphasia following a cerebral infarction, muscle weakness, frequent falls, and dementia, was admitted to the facility without pain. However, after an unwitnessed fall, the resident was found with a skin tear and new pain with movement. Despite the resident's increased pain levels and vocalizations indicating discomfort, the facility did not notify the physician promptly. The resident's pain was assessed as mild to moderate, and an x-ray was ordered after the physical therapist reported the resident's pain. However, the x-ray was not conducted in a timely manner, and the physician was not notified of the results until 24 hours later, which indicated a possible fracture to the right hip. Interviews with facility staff revealed that the resident was confused and unable to communicate pain levels effectively, which should have been recognized as a sign of pain. The Director of Nursing confirmed that the delay in conducting the x-ray and notifying the physician contributed to the delay in evaluating the resident at the hospital. This oversight in communication and timely action led to the resident experiencing unnecessary pain and suffering.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a Person-Centered baseline care plan within 48 hours of admission for a resident, identified as Resident 4, which is a requirement to meet the resident's immediate needs. Resident 4 was admitted with significant medical conditions, including frequent falls, dysphagia, aphasia following a cerebral infarction, muscle weakness, and dementia. Despite these conditions, no baseline care plan was documented for fall prevention during the resident's initial admission. This oversight was identified during a review of the resident's care plans, where it was noted that a baseline care plan was only created upon the resident's readmission. During an interview and clinical record review with the Director of Nursing (DON), it was confirmed that there was no documented evidence of a baseline care plan being developed within the required 48-hour timeframe following Resident 4's admission. The DON acknowledged that the expectation was for the baseline care plan to be developed promptly, especially given the resident's history of frequent falls. The DON also noted that the severity of the resident's past falls was not fully understood until informed by the resident's spouse three days after a fall occurred.
Inadequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced a fall resulting in a substantial injury. The resident, who had a history of dysphagia, aphasia, muscle weakness, frequent falls, and dementia, was admitted without reported pain. However, after an unwitnessed fall, the resident exhibited signs of pain, including yelling and guarding, which were not promptly addressed with appropriate pain management. Following the fall, the resident was assessed with mild pain and was administered Acetaminophen, a mild pain medication. Despite the resident's continued expressions of pain, including yelling and guarding when moved, there was a delay in obtaining an x-ray and notifying the physician about the severe pain. The x-ray, which was completed the day after the fall, revealed a possible fracture, leading to the resident being sent to an acute care hospital for treatment. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the resident's behavior could indicate pain and that the x-ray should have been conducted more promptly. The Director of Nursing acknowledged that the physician should have been informed of the severe pain to consider stronger pain medication. This oversight resulted in untreated severe pain and a delay in appropriate treatment for the resident.
Failure to Follow Dietary Menus and Recipes
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the dietary menus and recipes, leading to deficiencies in meal preparation. During an observation, it was noted that the rice served was not creamy as per the menu, due to the absence of the required ingredient, cream. The cook confirmed that the recipe was not followed, and neither the Certified Dietary Manager (CDM) nor the Registered Dietitian (RD) were consulted about this change. Additionally, the cook substituted baked tilapia with ravioli without ensuring nutritional adequacy or consulting the CDM or RD. The substitution was made based on availability rather than nutritional equivalence, and it was not selected from a pre-approved spreadsheet. This lack of consultation and adherence to the menu protocol was confirmed by the cook. Interviews with the CDM and RD revealed challenges in the transition to a new menu system, which required more detailed tracking of menu changes. The CDM explained that space limitations and her absence due to illness contributed to the inability to purchase necessary ingredients. The RD acknowledged the need for a log to review menu changes and emphasized the importance of notifying appropriate personnel when management is unavailable.
Failure to Maintain Comfortable Air Temperatures
Penalty
Summary
The facility failed to maintain comfortable air temperatures in resident rooms and hallways on Station 2, leading to discomfort among residents. The facility's policy on extreme weather, which aims to protect residents from harm due to extreme temperatures, was not effectively implemented. Despite having a maintenance policy that requires ambient temperatures to be maintained between 71 and 81 degrees Fahrenheit, temperatures in several rooms and hallways exceeded this range, reaching up to 82.5 degrees Fahrenheit. This issue persisted from early June 2024, during a period of high outside temperatures ranging from 82 to 102 degrees Fahrenheit. The deficiency was linked to a failure to address known issues with the air conditioning system. An invoice from a heating and air conditioning company dated 05/24/24 indicated that the unit had been diagnosed with issues as early as 10/25/23, but repairs were not made. The Maintenance Director (MD) did not receive the invoice due to an incorrect email address, and the Administrator did not follow up on the air conditioning unit's status, leaving it to the MD. As a result, residents reported feeling uncomfortable, tired, and having difficulty sleeping due to the heat. Portable air conditioning units were used in hallways but were insufficient to cool resident rooms effectively.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to secure the urinary catheter tubing for a resident diagnosed with neuromuscular dysfunction of the bladder and overactive bladder. The resident, who had moderate cognitive impairment, was observed on multiple occasions without a leg strap securing the catheter tubing. This was noted during observations on three separate days, and the absence of the leg strap was confirmed by both a Licensed Vocational Nurse (LVN) and a Certified Nursing Aide (CNA). Both staff members acknowledged the importance of the leg strap in preventing the catheter from being pulled or dislodged. The facility's policy on catheter care, which was revised in 2011, mandates that catheters be anchored to prevent excessive tension. Despite this policy, the resident's catheter was not secured as required. Interviews with the Director of Nursing and the Administrator confirmed that catheters should be secured with a leg strap or fast lock to prevent dislodgement. The Administrator also stated that catheters should be secured unless the resident refused, which was not indicated in this case.
Failure to Ensure 14-Day End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure an as-needed psychotropic medication had a 14-day end date for one resident reviewed for psychotropic medications. The facility's policy required that any psychoactive medication ordered on a PRN basis must not exceed 14 days unless the physician documented the reason for continued usage and wrote a new order. However, the resident's physician order for lorazepam, dated 03/05/2024, did not include an end date, which was acknowledged by the Director of Nursing (DON) and the Administrator during interviews. The Pharmacist also confirmed that PRN medications should have a 14-day stop date unless otherwise documented by the physician. The resident involved had a diagnosis of anxiety disorder and insomnia and was admitted to the facility on 07/26/2019. The resident's quarterly Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antianxiety medication. The resident's care plan, revised on 09/22/2023, noted the use of antianxiety medication for anxiety evidenced by agitation. Despite these details, the physician's order for lorazepam lacked the required 14-day end date, leading to the identified deficiency.
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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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