College Vista Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4681 Eagle Rock Blvd., Los Angeles, California 90041
- CMS Provider Number
- 555030
- Inspections on file
- 36
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at College Vista Post-acute during CMS and state inspections, most recent first.
The facility did not develop or implement individualized care plans with measurable objectives and interventions for four residents with complex medical needs, including one on anticoagulant therapy, one with impaired immunity, one with severe vision impairment, and one requiring a therapeutic diet. The absence of these care plans was confirmed by the DON and dietary supervisor, and relevant monitoring and documentation were not performed as required.
Surveyors found that expired medication was not discarded and controlled drugs were not stored in a separately locked compartment. An LVN and the DON confirmed that expired glucose gel remained in the medication room past its expiration date, and Lorazepam for two residents with severe cognitive impairment was stored with non-controlled medications in a single-locked refrigerator, contrary to facility policy.
Two residents dependent on care were observed asleep in bed with their bodies and briefs exposed, as their blankets were left to the side. Both the DON and a CNA acknowledged the exposure as a dignity and privacy issue, which was not in line with the facility's policy to maintain resident dignity and privacy.
A resident with cellulitis and depression was discharged home with home health services, but the MDS was incorrectly coded as a transfer to an acute hospital. Record review and staff interviews confirmed the error, with the MDS Coordinator acknowledging the mistake and the DON confirming the inaccuracy in documentation.
A resident receiving Lovenox for DVT prophylaxis was not adequately monitored for side effects, specifically signs and symptoms of bleeding, as required by facility policy. Despite administration of the medication, there was no documentation in the electronic medical record to show that staff monitored for adverse effects, and this was confirmed by the DON during record review and interview.
A resident with multiple medical conditions was prescribed Lovenox for DVT prophylaxis, to be administered subcutaneously. An LVN was observed preparing to administer the medication intramuscularly, initially stating the incorrect route and not checking the MAR before preparation. The error was identified before administration, but the incident revealed a failure to follow proper medication administration procedures for high-risk medications.
Surveyors found unsanitary conditions in the kitchen, including white residue under the sink, paint remnants on the floor from a fallen tile, and exposed drywall. Both the Dietary Supervisor and Maintenance Supervisor confirmed these findings and acknowledged the potential for food contamination, which was inconsistent with the facility's food safety policy.
Two residents with cognitive impairment were asked to sign Arbitration Agreements without proper explanation or notification of their right to refuse or rescind. Staff failed to provide information in an understandable manner, and agreements were backdated due to missing records. This resulted in a violation of residents' rights to make informed decisions about their care.
A resident with severe cognitive impairment and multiple fall risk factors experienced a fall resulting in a fracture, but the facility did not complete a new fall risk assessment or revise the care plan as required. Staff did not implement the facility's fall prevention protocols, such as the Falling Star Program or visual alerts, and the DON confirmed that assessments and care plan updates were not performed according to policy.
A resident with hepatic encephalopathy and cirrhosis of the liver filed a grievance after a disturbance with their roommate. Although a room change was made, the facility failed to provide a written grievance decision as required by policy. The Social Service Director did not document the grievance in progress notes or provide a report to the family, deferring communication to the DON and Administrator. The facility's policy required a written summary, but only a nursing progress note was given to the family.
A resident at high risk for pressure injuries developed a Stage 2 pressure injury due to the facility's failure to provide necessary care and interventions. The resident, with conditions such as hepatic encephalopathy and morbid obesity, was not repositioned every two hours or kept clean and dry, leading to the injury. Despite a care plan indicating the need for frequent repositioning and skin care, the injury was confirmed upon discharge to home health services.
A resident did not receive necessary wound care as ordered by the physician, leading to discharge with staples still in place. The TXN failed to assess and document the resident's skin condition, and the LVN copied previous notes instead of conducting her own assessment. This resulted in a lack of proper wound care and communication among staff.
A resident was discharged without proper coordination of Home Healthcare services and Lovenox injection instructions, leading to a lapse in necessary medical care. The facility lacked documentation and a policy for ensuring referrals and communication for discharged residents, as acknowledged by the DON.
A resident at an LTC facility suffered second-degree burns after smoking a cigarette while on oxygen, due to inadequate supervision and failure to adhere to the facility's smoking policy. The resident, known for non-compliance, accessed smoking materials and lit a cigarette, resulting in a flash fire. The facility did not implement the resident's care plan interventions or maintain control of smoking materials, and lacked designated staff for smoking supervision.
A resident with COPD was involuntarily secluded by an LVN who blocked access to the patio with a table, preventing the resident from smoking outside scheduled times. The resident's care plan required supervision for smoking due to oxygen use, but the LVN's actions led to the resident feeling upset. The facility's policy on resident protection was not followed.
A resident receiving continuous oxygen therapy was left unsupervised and lit a cigarette, resulting in second-degree burns due to a fire. The facility's smoking policy lacked specific actions for noncompliant residents, particularly those using oxygen. The resident, with a history of COPD and moderate cognitive impairment, was usually supervised, but staff failed to remove his oxygen on this occasion.
A resident with dementia experienced agitation, leading to a transfer to a hospital. The facility failed to notify the resident's responsible party in a timely manner, informing them nearly seven hours after the change in condition. The Director of Nursing intended to notify the family but became busy, resulting in a delay that violated the facility's policy and the resident's rights.
A resident was found unresponsive and not breathing, but the LVN delayed CPR to check the code status, contrary to facility policy. The resident, with a full code status, was later pronounced dead at a hospital. The facility's emergency cart was also inadequately stocked, lacking essential CPR items.
A resident with respiratory failure, pneumonia, and COPD did not receive adequate respiratory care in a facility. Despite expressing feeling unwell and requesting an oxygen tank replacement, the LVN did not conduct a respiratory assessment or notify the physician. The facility also failed to develop a care plan or notify the physician of changes in the resident's condition. When the resident was found unresponsive, CPR was delayed while the LVN verified the code status, contributing to the resident's transfer to a hospital where she later passed away.
The facility failed to ensure call lights were within reach for four residents, as required by policy and care plans. A resident with dementia had her call light behind the bed headboard, while another's was hanging off the bed. Two other residents had their call lights either touching the floor or wrapped around equipment. Staff confirmed the importance of accessible call lights to prevent accidents and ensure timely assistance.
A resident with a full code status was found unresponsive, but CPR was delayed as staff verified the code status. Despite the facility's policy for immediate CPR, the LVN and CNAs did not start CPR until the code status was confirmed from the paper chart, leading to a delay in life-saving measures.
A facility failed to follow enhanced standard precautions when an LVN provided care to a resident with a G-tube without wearing a gown, despite the resident being on enhanced precautions due to long-term G-tube use. The LVN acknowledged the oversight, and the DON confirmed the necessity of PPE to prevent infection spread. The facility's policy requires gowns and gloves during high-contact care activities.
A resident was transported to the shower room without proper body coverage, exposing their upper legs, which compromised their dignity. The incident was observed by the DON, who instructed the CNA to cover the resident. The resident had conditions including diabetes and hyperlipidemia and was capable of making decisions. Interviews with staff emphasized the importance of maintaining resident dignity.
A resident at risk for pressure ulcers was found on a low air loss mattress incorrectly set for a weight over 350 lbs, while the resident weighed 197.4 lbs. This setting error, confirmed by an LVN, contradicted the facility's policy requiring mattress settings based on weight, potentially compromising pressure ulcer prevention.
A facility failed to ensure a physician documented a response to a pharmacist's recommendation regarding the use of Seroquel for a resident. The pharmacist suggested reevaluating the medication and considering a gradual dose reduction, but the physician's response was not recorded. The facility did not follow its policy to act on medication review recommendations.
A facility failed to ensure the correct route of medication administration for a resident, as the bubble pack labels did not match the physician's orders and MAR. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed medications to be administered via a gastrostomy tube, but the labels indicated oral administration. An LVN identified the discrepancy during a medication verification process, highlighting the importance of matching physician orders with medication labels to prevent errors.
Failure to Develop and Implement Individualized Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans with measurable objectives, timeframes, and interventions for four residents with diverse and significant medical needs. For one resident receiving Lovenox, an anticoagulant, there was no care plan addressing interventions and goals related to the medication, despite physician orders and administration records confirming its use. The Director of Nursing (DON) acknowledged that a care plan was necessary for anticoagulant therapy to guide staff in monitoring for adverse effects such as bleeding and to provide appropriate interventions in emergencies, but no such plan was present. Another resident with impaired immunity due to a viral infection, specifically HIV, had a care plan that included monitoring for delirium as an intervention. However, there was no evidence that staff were monitoring or documenting signs and symptoms of delirium as required. The DON confirmed that the care plan did not specify the frequency of monitoring or documentation, and that this monitoring was not being performed, despite its importance in preventing complications related to immune deficiency. A third resident with severe vision impairment due to glaucoma and diabetes had no care plan addressing their specific activity needs. The DON stated there was no coordination with the activity director to develop a plan tailored to the resident's visual impairment, which could lead to isolation or behavioral issues. Additionally, a fourth resident with diabetes and chronic kidney disease did not have a care plan addressing their nutritional needs, including interventions for monitoring food brought from outside the facility. The dietary supervisor and DON both confirmed the absence of a care plan for this resident's therapeutic diet, despite the risk of noncompliance with dietary restrictions.
Improper Storage and Handling of Expired and Controlled Medications
Penalty
Summary
Surveyors identified that the facility failed to properly store and discard expired medication and did not store controlled substances in accordance with facility policy and professional standards. During an observation in the medication storage room, a box of expired Microdot glucose gel was found in a cabinet. The LVN present acknowledged that the medication was expired and had not been noticed or discarded as required. The DON confirmed that expired medications were supposed to be checked and removed weekly but admitted missing the removal of the expired glucose gel at the end of the previous month. Additionally, the facility did not store Lorazepam, a controlled medication, in a separately locked compartment as required. Two vials of Lorazepam for one resident and one vial for another were found stored with non-controlled medications in a single-locked medication refrigerator. Both the LVN and DON confirmed that Lorazepam should be double locked and stored separately from non-controlled medications, in line with facility policy. The residents involved had significant cognitive impairments and required substantial assistance with daily activities.
Residents Left Exposed in Bed, Violating Dignity and Privacy
Penalty
Summary
Two residents were not treated with respect and dignity when their bodies were left exposed while they were asleep in bed. For one resident with dementia and alcoholic cirrhosis, observations showed that the resident's brief was visible and their gown was up, exposing the chest, arms, and lower body, with the blanket placed to the side. The resident was dependent on care and unable to make medical decisions, and the DON confirmed that the resident's lower body was exposed and identified this as a dignity issue. For another resident with a history of cerebral vascular accident and hemiplegia, who was also dependent on care and had moderately impaired cognition, observations revealed that the resident's lower body and brief were exposed, with the blanket placed to the side. A CNA present during the observation acknowledged that the resident's body was exposed and stated this was a privacy issue. A review of the facility's policy on promoting and maintaining resident dignity indicated that residents should be treated with respect and dignity, and their privacy should be maintained. The policy emphasized the importance of caring for residents in a manner that maintains or enhances their quality of life and recognizes their individuality. The observed incidents were not in accordance with this policy, as both residents were left exposed and their privacy was not maintained.
Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. The MDS was incorrectly coded to indicate that the resident had been transferred to an acute hospital, which did not reflect the actual discharge disposition. This error was identified during a review of the resident's records, which included an admission for cellulitis of the right lower limb and depression, physician orders for discharge home with home health, and progress notes confirming the resident left the facility in stable condition to go home. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the discharge status was inaccurately documented in the MDS. The MDS Coordinator acknowledged the mistake and stated that the discrepancy was not noticed until pointed out by the surveyor. The Director of Nursing also confirmed the inaccuracy in the documentation. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately reflect the resident's discharge location and care needs, which was not met in this instance.
Failure to Monitor and Document Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of potential side effects for a resident who was receiving Lovenox, an anticoagulant medication. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox injections for DVT prophylaxis. Despite receiving the medication as ordered, there was no documentation in the electronic medical record to indicate that the resident was monitored for signs and symptoms of bleeding, a known risk associated with anticoagulant therapy. During interviews and record reviews, the Director of Nursing confirmed that staff are expected to monitor and document any side effects of Lovenox, including bleeding, in the electronic medical record. However, a review of the resident's Medication Administration Record and electronic medical record revealed no evidence that such monitoring occurred during the period the resident received Lovenox. The facility's policy on high-risk medications, including anticoagulants, requires staff to monitor for adverse consequences and document these observations, but this was not followed in this case.
Failure to Ensure Proper Administration Route for Anticoagulant Medication
Penalty
Summary
Facility staff failed to ensure that a resident receiving anticoagulant therapy was free from significant medication errors. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox to be administered subcutaneously for deep vein thrombosis prophylaxis. The physician's orders and the facility's policies clearly indicated that Lovenox should be given via the subcutaneous route. During medication administration, a licensed vocational nurse (LVN) was observed preparing to administer Lovenox to the resident. The LVN initially stated that the medication was to be given intramuscularly and was about to proceed with this incorrect route. Upon further review and verification, the LVN realized the error and acknowledged that the medication should be administered subcutaneously, as per the physician's order. The LVN also admitted to not checking the Medication Administration Record (MAR) prior to preparing the injection, which contributed to the near-miss error. Interviews with the LVN and the Director of Nursing (DON) confirmed that administering Lovenox intramuscularly would have been a significant medication error, as the correct route is subcutaneous. The facility's policies require staff to verify the medication, dose, and route against the MAR before administration, especially for high-risk medications like anticoagulants. The failure to follow these procedures resulted in a deficiency related to medication administration practices.
Unsanitary Kitchen Conditions and Food Contamination Risk
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and sanitary kitchen environment. During the initial kitchen tour, white residue was found underneath the sink by the drainage pipe, and white paint remnants were present on the kitchen floor due to a fallen tile. Additionally, there was an area of exposed drywall in the kitchen. These conditions were confirmed during interviews with both the Dietary Supervisor and the Maintenance Supervisor, who acknowledged the presence of residue, paint chips, and exposed drywall. Both supervisors stated that these unsanitary conditions had the potential to contaminate food prepared for residents. The facility's policy and procedure on food safety and storage indicated that food should be stored, prepared, distributed, and served in accordance with professional standards to prevent contamination. The policy defined contamination as the unintended presence of potentially harmful substances, including microorganisms, chemicals, or physical objects, and noted that foodborne illness could result from ingestion of contaminated food or beverages.
Failure to Properly Explain Arbitration Agreement and Inform Residents of Rights
Penalty
Summary
The facility failed to properly explain the Arbitration Agreement to two residents, both of whom had moderately impaired memory and cognition as documented in their Minimum Data Set assessments. One resident was asked to sign the agreement during a physical therapy session without any explanation or opportunity to read the document, and was not informed of the right to refuse or rescind the agreement. The resident later expressed concern about potentially giving up the right to present disputes in court and stated a desire to discuss the agreement with family before signing. Another resident was approached by two staff members and asked to sign the Arbitration Agreement without any explanation of its contents, being told only that it was "not something bad." The resident was unaware of the right to refuse to sign or to rescind the agreement, and the date on the form was entered by someone else without the resident's knowledge. Both residents' agreements were backdated by the Director of Admission due to missing electronic records, and the Director admitted to not providing a proper explanation or being aware of the residents' right to rescind. Interviews with staff revealed a lack of understanding regarding the Arbitration Agreement and the residents' rights associated with it. The facility's policy requires that the agreement be explained in a manner understandable to the resident or representative, explicitly inform them of their right not to sign, and grant the right to rescind within 30 days. These requirements were not met, resulting in a violation of the residents' rights to make informed decisions about their care.
Failure to Revise Care Plan and Implement Fall Prevention After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident who was at high risk for falls, following a significant event where the resident sustained a fall resulting in a humerus fracture. The resident had a history of osteoarthritis and glaucoma, with severely impaired memory and cognition, and required varying levels of assistance with daily activities. Upon admission, the resident was assessed as high risk for falls, with a fall risk score of 17, and exhibited multiple risk factors including intermittent confusion, being chair bound, balance problems, use of assistive devices, polypharmacy, and multiple predisposing diseases. Despite these risk factors and the occurrence of a fall, the facility did not complete a new fall risk assessment after the incident, nor did they update the resident's care plan to reflect the change in condition. The care plan remained unchanged after the fall, and the resident was not placed in the facility's Falling Star Program, which is intended for residents with high fall risk scores. The facility's policies required fall risk assessments upon admission, annually, and after significant changes, but these were not followed in this case. Interviews with staff revealed a lack of awareness and implementation of fall prevention protocols, such as the use of a yellow star sticker to alert staff to residents at risk for falls. The DON confirmed that the required assessments and care plan revisions were not completed as per facility policy, and that the resident should have been included in the Falling Star Program based on their risk score and fall history.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to provide a written grievance decision to a resident who filed a grievance, as required by their policy. The resident, who had been admitted with hepatic encephalopathy and cirrhosis of the liver, experienced a disturbance with their roommate. The grievance form indicated that a room change was made to address the issue, and it was noted that the resident and their family were satisfied. However, the form lacked signatures from the resident or their family, and verbal consent was noted without a date. Interviews with facility staff revealed that the Social Service Director (SSD) was informed of the incident and filled out the grievance form but did not document the grievance in the residents' progress notes. The SSD did not provide a grievance investigation report to the family due to previous issues with them and deferred communication to the Director of Nursing (DON) and Administrator (ADM). The facility's policy required a written summary report, but the DON admitted that no such report was prepared, and only a nursing progress note was provided to the family.
Failure to Prevent Pressure Injury in High-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and interventions to prevent pressure injuries for a resident, resulting in the development of a facility-acquired Stage 2 pressure injury. The resident, who was at high risk for pressure injuries due to conditions such as hepatic encephalopathy, cirrhosis of the liver, morbid obesity, and moderate cognitive impairment, was not turned, repositioned, or offloaded every two hours while in bed. Additionally, the resident was not kept clean and dry after bowel movements or wetness from urine due to incontinence. The resident's Braden Score Assessment indicated a high risk for developing pressure injuries, and the care plan included interventions such as keeping the skin clean and dry and frequent repositioning. Despite these measures, the resident developed a Stage 2 pressure injury on the intergluteal cleft, which was noted on 2/16/25. The Treatment Nurse initially classified the injury as a pressure injury but later reclassified it as moisture-associated skin damage (MASD) due to the appearance of the skin. The facility's policy on pressure injury prevention and management emphasizes the prevention of avoidable pressure injuries and the provision of treatment to heal existing injuries. However, the facility's failure to adhere to these protocols resulted in the resident developing a pressure injury, which was confirmed upon discharge to home health services. The home health assessment noted the presence of a Stage 2 pressure injury with skin irritation, redness, and infection.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide necessary wound care according to the physician's orders for a resident who had undergone surgery. The Treatment Nurse (TXN) did not assess or provide wound care for the resident's surgical incision at the right hip, which had staples, from a specified date. Additionally, the TXN did not assess or provide wound care for the resident's left shin and perineal area on several occasions, as required by the physician's orders. The resident was admitted with a right hip fracture and required surgical wound care. The facility's records indicated that the resident had a surgical wound on the right hip with staples and another wound on the right lateral thigh. However, the TXN failed to conduct a thorough assessment and document the resident's skin condition weekly, as required. The TXN also discontinued the wound care order prematurely, assuming that the staples had been removed during an orthopedic appointment, which was not the case. The Licensed Vocational Nurse (LVN) involved did not assess the resident's skin condition accurately and copied previous notes instead of conducting her own assessment. This lack of proper documentation and communication among the nursing staff led to the resident being discharged with staples still in place, without appropriate instructions for wound care and follow-up. The Director of Nursing acknowledged these failures, emphasizing the importance of thorough assessments and accurate documentation to prevent such deficiencies.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, resulting in the resident not receiving necessary Home Healthcare services and Lovenox injections as prescribed by the physician. The resident was discharged with a bag of medications, including Lovenox syringes, without proper instructions on administration. The resident's representative expressed concerns about the lack of guidance and attempted to contact the facility for clarification but received no response. Interviews with facility staff revealed that the Registered Nurse instructed the resident's representative to contact the insurance company to set up home health services, but there was no documented evidence that the Social Service Designee coordinated these referrals. The Director of Nursing acknowledged the absence of a policy for contacting and documenting referrals for discharged residents, emphasizing the importance of ensuring residents receive required services upon discharge to prevent health decline.
Resident Suffers Burns Due to Inadequate Smoking Supervision
Penalty
Summary
The facility failed to ensure a resident was free from accident smoking hazards, leading to a serious incident. The resident, who was non-compliant with the facility's smoking policy, went to the outdoor patio to smoke a cigarette while on oxygen. This resulted in a flash fire that caused second-degree burns to the resident's face and hands. The resident was subsequently transferred to a burn center for further treatment. The facility did not implement the resident's care plan interventions, which required supervision while smoking. Despite being aware of the resident's non-compliance with the smoking schedule and policy, the facility staff failed to supervise the resident adequately. The resident was able to access smoking materials and light a cigarette while on oxygen, which was against the facility's policy. The facility's nursing staff did not maintain control of the resident's smoking materials as per the policy. Additionally, the care plan was not updated to reflect the resident's non-compliance with smoking protocols. The facility also lacked a designated staff member responsible for supervising residents while smoking, contributing to the incident.
Removal Plan
- Complete body assessment and inventory of Resident 1's personal belongings on readmission.
- Interdisciplinary team will provide education to Resident 1 on readmission regarding Resident Smoking policy, smoking information, and storage of smoking paraphernalia by nursing in a lockbox.
- All delivery/packages will be opened by the Activity Director in front of the resident to check for smoking paraphernalia.
- Daily room sweep by the assigned department manager and Manager of the Day on weekends.
- Resident 1 will be on one-on-one monitoring.
- Interdisciplinary team conducted care conference with Residents 2 and 3 that are smokers to discuss smoking safety, facility's smoking practices, and plan of care.
- Smoking safety assessment and care plans for Residents 2 and 3 were reviewed and revised by the Director of Nursing.
- Staff conducted room sweep for all residents with resident's permission to ensure there is no smoking paraphernalia stored in the rooms.
- Smoking schedule was revised by the interdisciplinary team to reflect assigned department who will oversee smoking schedule.
- Director of Staff and Development will in-service staff with various topics related to smoking safety and policy.
- Inservice to Activity Department regarding resident's package delivery.
- New hire or staff who were not able to attend the in-service will be educated prior to start of their scheduled shift.
- Interdisciplinary team created a preliminary Resident Smoking policy that reflects additional safety measure for non-compliance.
- The interdisciplinary team will obtain a written or verbal consent from the resident prior to the resident opening the package or delivery.
- The Nursing management team will oversee assigned caregivers and residents during designated smoking times.
- Interdisciplinary team will review admission and readmission to verify if resident uses tobacco.
- Activity Department or designee will deliver packages to the resident and will open the package in front of the resident.
- Department Managers or designee will conduct room rounds and Manager for the Day on weekends.
Involuntary Seclusion of Resident by LVN
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion, which is defined as the separation of a resident from other residents or confinement to their room against their will. This incident involved a licensed vocational nurse (LVN) who blocked a door leading to the outdoor patio with a long table, preventing a resident from accessing the patio. The resident, who was a smoker, was upset by this action as it restricted their movement within the facility. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and was using oxygen therapy. The resident's care plan included interventions for smoking safety, such as removing the oxygen tank before smoking and seeking staff supervision. Despite these interventions, the resident was non-compliant with the smoking schedule and protocols. On the night of the incident, the resident requested to smoke outside of the scheduled times, leading to a confrontation with the LVN. The LVN's actions were documented in a written statement, which indicated that the table was placed in a way that made it difficult for a wheelchair to pass. The Director of Nursing (DON) confirmed that the LVN intentionally blocked the resident's access to the patio, which was considered a form of seclusion causing psychosocial distress. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' rights and the prevention of harm, which was not upheld in this situation.
Failure to Ensure Smoking Safety for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive smoking policy that ensured the safety of a resident who was noncompliant with the smoking policy. The resident, who was receiving continuous oxygen therapy, was allowed to keep a cigarette and lighter in his possession, which led to a serious incident. On the specified date, the resident was left unsupervised on the patio and lit a cigarette while still connected to an oxygen supply, resulting in a fire. The incident caused the resident to sustain second-degree burns on his face and hands, necessitating hospital transfer. The resident had a history of COPD exacerbation, respiratory failure, epilepsy, and muscle weakness, and was assessed as having moderate cognitive impairment. Despite these conditions, the facility's smoking safety assessments only recommended smoking cessation discussions and supervised smoking, without addressing the specific risks associated with oxygen therapy. Interviews with the Director of Nursing revealed that the facility's smoking policy lacked specific actions for noncompliant residents, particularly those using oxygen. The policy did not include increased monitoring or safety measures to prevent such incidents. The resident reported that staff usually removed his oxygen before smoking but failed to do so on this occasion, leading to the accident.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of a resident's responsible party in the event of a change in condition. Resident 1, who was diagnosed with unspecified dementia, cognitive communication deficit, and dysphagia, experienced a change in condition due to agitation. Despite the facility's policy requiring notification of the resident's responsible party, the family member was informed nearly seven hours after the change in condition and after the resident had been transferred to a general acute care hospital. The incident began when Resident 1 exhibited signs of agitation, including stealing other residents' nasal cannulas and belongings. A Licensed Vocational Nurse (LVN) observed these behaviors and documented them in a Change in Condition Evaluation. The LVN was instructed by the Director of Nursing (DON) not to contact the family member, as the DON intended to do so herself. However, the DON became busy and did not notify the family member until much later, resulting in a significant delay in communication. The facility's policies clearly state the requirement to inform the resident's representative of any significant changes in condition, treatment alterations, or transfers. The DON acknowledged the oversight and admitted that the family member should have been informed prior to the resident's transfer to the hospital. This failure to communicate in a timely manner violated the resident's rights and the facility's own policies, potentially impacting the resident's well-being.
Failure to Initiate Immediate CPR and Inadequate Emergency Cart Stocking
Penalty
Summary
The facility failed to provide immediate CPR to a resident, identified as Resident 41, who was found unresponsive, without a pulse, and not breathing. The Licensed Vocational Nurse (LVN 1) delayed initiating CPR because they first checked the resident's code status and called for assistance instead of starting CPR immediately. This delay occurred despite the facility's policy and procedure, which required immediate CPR initiation in such situations unless a Do Not Resuscitate (DNR) order was present. Resident 41 had a full code status, meaning they wished to be revived if their heart stopped beating or they stopped breathing. The resident was admitted with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On the day of the incident, the resident was found unresponsive in bed by LVN 1, who then left the room to verify the resident's code status before starting CPR. This delay in initiating CPR was critical, as the resident was later transferred to a General Acute Care Hospital, where they were pronounced dead. Additionally, the facility's emergency cart was found to be inadequately stocked with essential items needed for CPR, such as an Ambu-bag, glucometer, and pulse oximeter. This lack of preparedness could have further contributed to the delay in providing life-saving measures. The facility's policy required that emergency carts be fully stocked and ready for use, but this was not adhered to, as evidenced by the missing items during the surveyor's inspection.
Removal Plan
- (DON) had a 1:1 in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation.
- The Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy.
- The facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added. The updated form will be utilized by licensed nurses. The emergency cart was checked by the DON for appropriate supplies and equipment. No issues were identified.
- The Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift.
- The RNC and Respiratory Therapy Consultant initiated Code Blue drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room, between rooms, activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system. The licensed nursing and CNAs staffs who were not scheduled to work will participate in the Code Blue drill during their scheduled shift.
- The RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified.
- Newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift.
- DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations.
- Licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated.
- The POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented.
- DON or designee to complete weekly mock code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations.
- The DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations.
Failure to Provide Adequate Respiratory Care and Emergency Response
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with respiratory failure, pneumonia, and COPD, who was receiving continuous oxygen therapy. The resident expressed feeling unwell and requested a replacement for what she believed was an empty oxygen tank. However, the Licensed Vocational Nurse (LVN) did not conduct a respiratory assessment or notify the primary physician, despite the resident's medical history and symptoms. The facility did not evaluate the need for a physician's order for oxygen therapy upon the resident's admission, nor did they notify the physician to administer oxygen at the prescribed rate. Additionally, the facility failed to develop a resident-centered care plan addressing the resident's respiratory needs and did not notify the physician of changes in the resident's condition, as required by the facility's policies. When the resident was found unresponsive, the LVN delayed initiating CPR while attempting to verify the resident's code status, contrary to the facility's emergency response policy. This delay, along with the lack of proper respiratory assessment and physician notification, contributed to the resident's transfer to a hospital where she was found pulseless and later passed away.
Removal Plan
- Administrator notified the facility Medical Director of Immediate Jeopardy incident.
- Licensed nurses identified was in-serviced by the DON regarding Physician notification when there is a change of condition focusing on respiratory system, respiratory assessment, and management of disease such as COPD, respiratory failure with hypoxia and oxygen therapy. Identified license nurse was suspended pending investigation.
- The DON and Registered Nurse (RN) Supervisor reviewed the 13 residents with oxygen therapy orders, COPD diagnosis and respiratory distress with hypoxia for signs of respiratory distress or change of condition.
- The Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) nurse reviewed in-house residents with diagnosis of COPD and respiratory failure with hypoxia for the implementation of resident centered care plans.
- Licensed nurses will check that residents are receiving the appropriate oxygen therapy as ordered at the start of their shift. When placing residents from oxygen concentrators to oxygen tanks, licensed nurses will verify the oxygen order to ensure that the liters per minute being administered matches the order.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, as required by the facility's policy and the residents' care plans. Resident 34, who was admitted with diagnoses including unspecified dementia and Alzheimer's disease, was observed with her call light behind the bed headboard and out of reach. During an interview, Resident 34 stated she did not know where her call light was located, and a certified nursing assistant confirmed that the call light should be within reach to prevent accidents and falls. Resident 17, admitted with metabolic encephalopathy and unspecified dementia, was observed with the call light hanging off the bed and touching the floor, making it inaccessible. A certified nursing assistant confirmed that the call light should be within reach to allow the resident to alert staff for assistance and prevent accidents. The Director of Nursing also emphasized the importance of having the call light within reach to avoid distress and potential accidents. Residents 29 and 31 also experienced similar issues with their call lights. Resident 29's call light was found hanging from the bed and touching the floor, while Resident 31's call light was wrapped around a feeding pump, making it inaccessible. Staff members confirmed that the call lights should be within reach to enable residents to call for help and prevent accidents. The facility's policy on call light accessibility was not adhered to, leading to the potential for delayed care and increased risk of falls for these residents.
Delay in CPR Initiation Due to Code Status Verification
Penalty
Summary
The facility failed to ensure that five out of five employees had the necessary competencies and skills to provide cardiopulmonary resuscitation (CPR) for a resident, identified as Resident 41, who required life-saving measures. This deficiency was identified during a review of the incident where Resident 41 was found unresponsive in bed. Despite having a POLST indicating full code status, there was a delay in initiating CPR due to the staff's inability to immediately verify the resident's code status. Resident 41 had a history of acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident's POLST, signed by both the resident and a physician, indicated that CPR should be attempted in the event of cardiac arrest. However, when the resident was found unresponsive, the Licensed Vocational Nurse (LVN) on duty delayed CPR to verify the code status, which was not immediately available in the electronic medical records. This delay occurred despite the facility's policy that CPR should be initiated immediately unless a Do Not Resuscitate (DNR) order is confirmed. Interviews with staff revealed that the LVN and Certified Nursing Assistants (CNAs) present did not start CPR until the LVN confirmed the code status from the paper chart. The Director of Nursing (DON) confirmed that the facility's policy required immediate CPR initiation, and any delay could result in adverse outcomes. The facility's policies emphasized the importance of high-quality CPR and immediate action in emergencies, which were not adhered to in this case, leading to a delay in life-saving measures for Resident 41.
Failure to Follow Enhanced Standard Precautions
Penalty
Summary
The facility failed to adhere to their enhanced standard precaution protocol, which is designed to prevent the transmission of multi-drug resistant organisms (MDROs) in skilled nursing facilities. This deficiency was observed when a Licensed Vocational Nurse (LVN) provided care to a resident without wearing the appropriate personal protective equipment (PPE), specifically a gown, while handling the resident's gastrostomy tube (G-tube). The resident, who had severe cognitive impairment and was on enhanced standard precautions due to long-term G-tube use, was at risk of exposure to infectious organisms due to this oversight. The incident was confirmed through interviews and record reviews. The LVN acknowledged the failure to wear a gown during the procedure, despite the presence of a blue sticker indicating the need for enhanced standard precautions. The Director of Nursing (DON) confirmed that enhanced standard precautions were necessary for residents who could expose staff to bodily fluids, such as during G-tube care, to prevent the potential spread of infections. The facility's policy on enhanced barrier precautions, revised in April 2024, mandates the use of gowns and gloves during high-contact resident care activities, including device care of feeding tubes.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified and respectful manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) transporting a resident to the shower room without appropriate body coverage. During the observation, it was noted that the resident's left and right upper legs were exposed while being transported in a shower chair through the hallway. This incident was observed by the Director of Nursing (DON), who instructed the CNA to cover the resident appropriately to maintain dignity and privacy. The resident involved in the incident had been admitted to the facility with diagnoses including type 2 diabetes mellitus, hypokalemia, and hyperlipidemia. The resident was noted to have the capacity to understand and make decisions. Interviews with the CNA and the DON highlighted the importance of ensuring residents' bodies are fully covered to uphold their dignity and prevent feelings of exposure or discomfort. The facility's policy on promoting and maintaining resident dignity, dated December 19, 2022, emphasizes the responsibility of all staff members to respect resident rights and dignity.
Incorrect Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set correctly according to the resident's weight, which is crucial for the prevention of pressure ulcers. The resident, who was at risk for developing pressure ulcers, was observed lying on a mattress set at a level intended for individuals weighing over 350 pounds, while the resident's actual weight was 197.4 pounds. This incorrect setting was identified during an observation and interview with an LVN, who confirmed that the mattress should have been set at a lower level based on the resident's weight. The resident, who had severe cognitive impairment and required assistance with mobility, was at risk for pressure ulcers as indicated by their Braden Scale assessment. The facility's policy required that support surfaces be used according to physician orders and evidence-based practices, which included setting the mattress according to the resident's weight. The Director of Nursing acknowledged that incorrect settings could lead to ineffective pressure ulcer management, placing the resident at risk for developing pressure ulcers or other complications.
Failure to Document Physician Response to Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician acted upon and documented the rationale for the consultant pharmacist's recommendation regarding the use of the psychotropic medication Seroquel for a resident. The consultant pharmacist had recommended reevaluating the necessity of the medication, considering a gradual dose reduction (GDR), and documenting the rationale for continuing therapy if deemed necessary. However, the physician's response to this recommendation was not documented in the resident's clinical records. The resident involved had been admitted with diagnoses including metabolic encephalopathy and cellulitis. The resident's medication review report indicated an active order for Seroquel to manage psychosis symptoms. Despite the consultant pharmacist's recommendation, there was no documented evidence that the facility had notified the resident's primary physician or obtained a response regarding the continued use of Seroquel. The facility's policy required action on all medication regimen review recommendations, but this was not followed in this case.
Medication Administration Route Discrepancy
Penalty
Summary
The facility failed to ensure that the route of medication administration matched the label on the bubble pack, the physician's orders, and the Medication Administration Record (MAR) for a resident. This deficiency was observed during a review of the resident's medication administration process. The resident, who had diagnoses including metabolic encephalopathy, parkinsonism, and unspecified dementia, was prescribed Bromocriptine Mesylate and Divalproex Sodium to be administered via a gastrostomy tube. However, the bubble pack labels indicated oral administration, which did not align with the physician's orders. During an observation, a Licensed Vocational Nurse (LVN) verified the medications and noted discrepancies between the bubble pack labels and the MAR. The LVN acknowledged the importance of matching the physician's orders with the medication labels to prevent potential medication errors, such as choking. The facility's policy on medication administration emphasized the need for licensed nurses to administer medications as ordered by the physician and to verify the medication source with the MAR to ensure accuracy in resident name, medication name, form, dose, route, and time.
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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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