Colonial Gardens Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Pico Rivera, California.
- Location
- 7246 S. Rosemead Blvd., Pico Rivera, California 90660
- CMS Provider Number
- 555715
- Inspections on file
- 47
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Colonial Gardens Nursing Home during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment, who required staff assistance with ADLs, developed severe left hip and leg pain after being noted weak while walking in the dining hall and needing help back to her room. The resident reported hip pain rated 8/10 and later stated she had a fall but could not describe when or how it occurred. An X-ray showed an acute complete femoral neck fracture with partial displacement, and the fall was unwitnessed with unknown details. Despite facility policy requiring immediate reporting of suspected abuse, neglect, or injury of unknown source to state officials, the incident was not reported to CDPH, resulting in delayed investigation and, as acknowledged by the DON, placing residents’ safety at risk.
A resident with dementia and moderate cognitive impairment had a fall risk assessment that inaccurately documented mental status as alert and oriented x3 despite clinical records and staff reports of intermittent confusion and limited orientation. The assessment was not updated after the resident sustained a fall, even though an SBAR form documented the event and the resident’s inability to describe it. RN staff and the DON acknowledged that the fall risk assessment should have reflected the resident’s confusion and been reassessed post-fall in accordance with the facility’s fall risk assessment policy, which requires evaluation of functional and psychological factors, including cognition.
A resident with major depressive disorder, HTN, CKD, and moderate cognitive impairment had a care plan identifying paranoid behavior, including delusions that others were trying to kill him, with an intervention to monitor paranoid delusions each shift. Despite this, there was no physician order for behavior monitoring, no associated behavior-monitoring tasks in the MAR, and thus no documented monitoring of paranoid delusions. The resident later believed another resident was talking about him during dinner and responded by punching that resident in the face. Nursing leadership and the DON acknowledged that care-plan-directed monitoring of paranoid delusions is necessary to evaluate medication effectiveness and the need for physician reassessment, consistent with the facility’s comprehensive, person-centered care plan policy.
A resident with severe cognitive impairment, metabolic encephalopathy, and dysphagia experienced decreased oral intake and food falling from the mouth, but nursing staff did not document notifying the MD of this change in condition. A care plan problem for inadequate intake was initiated with an intervention to assess for dehydration, yet the record contained no evidence of dehydration monitoring. Although a UA was ordered after a family member reported this pattern occurred with UTIs, no UA result was found and the contracted lab later reported no specimen had been collected. Later, when the MD ordered transfer to a GACH due to poor intake, pocketing food, and abnormal labs, progress notes showed the hospital had no available bed and could not admit the resident, but there was no documentation that the MD was informed of the delayed transfer or that new orders were obtained.
A resident with sleep apnea and a physician order for nightly BiPAP use did not have a care plan addressing these needs. Despite regular use of the BiPAP machine and relevant diagnoses, facility staff had not created or initiated a care plan to guide care and monitoring, as confirmed by the ADON during record review.
A resident was found with four unsecured prescription medications in their nightstand, accessible and not labeled for self-administration. The resident reported taking the medications independently, despite facility policy prohibiting self-administration without assessment and physician order. Facility leadership confirmed this was not permitted practice and that medications should be stored in locked compartments and administered only by authorized staff.
A CNA did not initiate CPR or assess for breathing and pulse upon finding a resident unresponsive, despite recent BLS training and facility policy requiring immediate action. Instead, the CNA left to notify an RN, resulting in a delay before CPR was started by the RN. The resident, who had a history of heart failure and was full code, did not receive timely life-saving measures.
A resident with severe cognitive and physical impairments was left in a room with a broken window covered only by a wooden panel, allowing cold air to enter. Although the replacement window frame was ready, maintenance staff delayed installation for several days due to other tasks, despite facility policy requiring prompt repairs to maintain a safe and homelike environment.
A resident with cognitive impairment and multiple diagnoses made an abuse allegation, claiming to have been hit and to have injuries. An LVN assessed the resident, found no injuries, and documented the incident but did not notify the physician or the conservator, as required by facility policy. The DON confirmed that this lack of notification delayed possible medical or psychiatric evaluation and left the conservator unaware of the resident's status.
A resident with cognitive impairment alleged to an LVN that he was hit by staff, but the LVN did not report the claim to the Administrator, State Agency, ombudsman, or law enforcement as required, due to disbelief and lack of physical evidence. This failure resulted in delayed notification and investigation of the abuse allegation.
A resident with cognitive impairment and multiple diagnoses reported an abuse allegation to an LVN, who assessed the resident and found no injuries but did not update or create a care plan to address the allegation. The DON confirmed that no care plan was developed, leaving staff without documented interventions or guidance following the report, contrary to facility policy.
A deficiency was cited when a resident's care plan did not include all necessary needs, measurable timetables, or specific actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with cognitive impairment and psychiatric diagnoses was found with two prescribed medications in hand, which had not been properly administered or monitored by staff. The resident had a known history of pocketing medications, and staff failed to ensure the medications were swallowed as required by facility policy, resulting in the resident not receiving the correct dose and creating a risk for medication errors.
The facility did not follow its established abuse reporting protocols after a resident alleged rough treatment by a CNA during shaving. Although staff were trained to report abuse allegations immediately to the DON, ADM, and external agencies, the incident was not reported as required, and facility leadership was not promptly informed. This represents a repeat failure to implement corrective action plans for abuse allegation deficiencies.
A resident with severe cognitive impairment and multiple diagnoses developed forehead discoloration, prompting a physician's order to consult the responsible party about a head CT. After the responsible party declined the CT, the LPN did not inform the physician of this decision, leaving the physician unaware and resulting in no further interventions. The facility's policy required physician notification of such changes, but this was not followed.
A resident with severe cognitive impairment was found with unexplained discoloration on the forehead, but the injury was not reported to CDPH, the ombudsman, or law enforcement as required. Nursing staff recognized the injury as being of unknown origin but did not escalate it to the DON or ADM, and facility leadership did not initiate required notifications or investigations. Facility policy mandates immediate reporting of such incidents to appropriate authorities.
A resident with severe cognitive impairment and multiple diagnoses was found with unexplained discoloration on the forehead. Although the injury was reported to an LVN, it was not escalated to the DON or Administrator as required, and a thorough investigation was not conducted. The facility did not follow its policy to fully investigate injuries of unknown origin, leaving the cause of the injury undetermined.
A resident with severe cognitive impairment and high fall risk experienced a fall, after which staff failed to complete required 72-hour neuro checks, did not perform a post-fall risk assessment, and left the IDT meeting documentation incomplete, omitting post-fall recommendations and care planning.
Surveyors found expired cetirizine hydrochloride and haloperidol decanoate in a medication cart and a medication room refrigerator. An LVN and the DON confirmed these expired medications should not have been present, and facility policy requires outdated drugs to be secured until disposal. Staff interviews indicated that nurses are responsible for checking and removing expired medications.
Surveyors found that personal food items were stored in a kitchen refrigerator, and multiple opened food items—including chocolate syrup, caramel drizzle, whipped cream, chopped onions, and ice cream—were left unlabeled in the walk-in refrigerator and freezer. Staff confirmed that these practices did not follow facility policy, which requires proper labeling and prohibits storage of personal food in kitchen areas.
Two residents did not receive medications as ordered due to a failure to transcribe a supplement order onto the MAR and missing documentation of controlled medication administration. One resident missed all scheduled doses of a calcium supplement, while another had multiple doses of pain and anxiety medications administered without proper signatures on the Narcotic Count Sheet, as the LPN stated she was too busy to document at the time.
Rooms A, B, C, and D each accommodated six residents, surpassing the regulatory maximum of four residents per room. Despite adequate space for beds and dressers and no observed negative effects on care or privacy, the DON confirmed the over-occupancy and noted the facility's ongoing waiver request due to the behavioral and psychological needs of the population.
A resident with a history of COPD, mental health conditions, and moderate cognitive impairment was not permitted to take requested additional smoke breaks, despite his care plan indicating this preference and his capacity to make decisions. Staff interviews revealed that requests for extra smoke breaks were not consistently communicated or honored, leading the resident to feel ignored and his choices unmet.
The facility did not obtain or properly document informed consent before administering psychotropic medications to two residents with dementia and behavioral issues. In both cases, required education about the risks and benefits was not provided or recorded, and consent forms were either missing or incomplete, as confirmed by the DON and nursing staff.
A resident with impaired cognition and mobility was found unable to reach their call light, which was hanging out of reach and reportedly nonfunctional for months. The care plan required the call light to be accessible, but staff failed to ensure this, leaving the resident unable to request assistance as needed.
A resident with multiple health conditions was discharged without receiving the required written notice of discharge, and the Ombudsman was not notified as mandated. Review of records and staff interviews confirmed the absence of discharge documentation, in violation of facility policy requiring written notification to both the resident and the Ombudsman, including details on appeal rights and bed-hold policies.
A resident with multiple complex medical conditions, including dementia and a gastrostomy feeding tube, was readmitted with a significant change in status. The required MDS assessment for this change was not completed within the mandated 14-day period, as confirmed by the MDS nurse and record review. Facility policy required such assessments for significant changes, but none was completed in the specified timeframe.
A resident with a documented diagnosis of depression and prescribed antidepressant medication was not accurately assessed in the MDS, as depression was omitted from the active diagnoses section. The MDS nurse confirmed the inaccuracy, despite facility policy requiring certification of assessment accuracy.
Three residents did not have complete or properly implemented care plans addressing their medical and psychosocial needs, including missing plans for vitamin D deficiency, psychotropic medication management, depression, and oxygen therapy. Staff interviews and record reviews confirmed that care plans were either absent or not followed, resulting in care that did not align with physician orders or resident diagnoses.
A resident receiving enteral nutrition via gastrostomy tube was not kept with the head of bed elevated to the required 30-45 degrees during feeding, as ordered and per facility policy. The bed was observed at only about 20 degrees elevation while feeding was administered, and staff did not correct the position during rounds. The DON and facility policy both confirmed the necessity of proper bed elevation for residents on tube feedings.
A resident with severe cognitive impairment and respiratory diagnoses was administered continuous oxygen at a rate higher than ordered by the physician, and was also left unmonitored without supplemental oxygen while exhibiting respiratory distress. Staff failed to document the oxygen flow rate as required and did not communicate the resident's refusal of oxygen to licensed staff, resulting in a lack of appropriate monitoring and intervention.
Two residents receiving anticoagulant and psychotropic medications were not monitored for side effects or medication efficacy as required by physician orders and care plans. Nursing staff failed to transcribe and implement monitoring orders onto the MAR, resulting in no documentation or assessment of bleeding, sleep patterns, or behavioral symptoms. Facility policy required such monitoring, but it was not completed or communicated to staff.
A resident with severe cognitive impairment and dysphagia did not receive a prescribed Magic Cup supplement with their fortified pureed diet, despite clear physician orders and documentation. The omission was identified during meal service, with both dietary and nursing staff responsible for checking trays prior to distribution, as per facility policy.
A resident with chronic kidney disease and dementia was observed multiple times with a urinary catheter drainage bag touching the floor, contrary to facility policy and infection control practices. Staff interviews confirmed awareness of the requirement to keep catheter bags off the floor, and the facility's policy specified this standard to prevent infection.
Two residents with impaired cognition and mobility were found to have nonfunctional call light systems, with devices either out of reach or not activating visual or audible alerts. Staff confirmed the malfunction and acknowledged that the residents could not summon assistance as required by their care plans. The DON stated that call lights should be checked at every shift change and that the facility's policy requires the system to be functional and routinely maintained.
Several two-person rooms were found to be below the required 80 square feet per resident, with each room measuring between 139.18 and 141.31 square feet. The DON confirmed the rooms were slightly under the regulatory size requirement but stated that care and safety would not be affected.
The facility did not maintain a seven-day bed hold for two residents with severe cognitive impairment after transfer to a hospital, resulting in their assigned beds being given to others and failure to provide proper written notification of bed hold rights as required by policy.
A resident with a history of falls, muscle weakness, and cognitive impairment was found with her call light on the floor and out of reach, despite her care plan and facility policy requiring it to be accessible. Staff confirmed the importance of keeping the call light within reach to prevent falls, but this intervention was not followed.
A resident with dysphagia, Parkinson's Disease, and moderate cognitive impairment experienced two choking episodes, but the facility failed to complete and update the care plan with specific interventions and supervision for all meals. The resident was only supervised during breakfast and lunch, not dinner, despite clear risk factors and physician orders. This lack of comprehensive care planning and supervision led to a fatal choking incident during an unsupervised dinner.
A resident with multiple complex medical conditions experienced a seizure and low oxygen saturation. Staff administered oxygen but did not document a reassessment of O2 saturation or vital signs after the intervention. The resident became unresponsive and later died, with records and staff interviews confirming that required assessments and documentation were not completed according to facility policy.
A resident with dysphagia, Parkinson's Disease, and moderate cognitive impairment, who had a history of choking, was left unsupervised during dinner despite care plan interventions and physician orders for supervised feeding. The resident aspirated and became unresponsive after feeding himself, and later died despite staff and emergency interventions. Staff interviews confirmed that supervision should have been provided for all meals due to the resident's high risk for choking.
A resident admitted with a history of CRE was not placed on contact precautions for two days because staff did not review all hospital records or follow physician orders for isolation. This resulted in a lapse in infection control, as required PPE and isolation measures were not implemented according to facility policy.
A facility failed to promptly implement Contact Precautions and prophylactic treatment for scabies, affecting six residents. A resident diagnosed with scabies returned from a hospital without immediate precautions, and five other residents were exposed without timely treatment. The delay in action increased the risk of scabies transmission.
A resident with a history of wandering and mental health conditions eloped from a facility after multiple attempts, due to inadequate risk assessment and lack of IDT meetings. Despite being in a locked facility, the resident's care plan lacked effective interventions, leading to the resident breaking a window and escaping, resulting in an Immediate Jeopardy situation.
Two residents with impaired cognitive skills were not notified about care conferences, nor were their responsible parties involved, violating their rights to participate in care planning. Despite facility policies emphasizing notification, documentation was lacking, and staff interviews confirmed the oversight.
A resident experienced significant weight loss over several months, but the facility failed to notify the attending physician as required by policy. The resident, with diagnoses including anemia and dementia, lost five pounds between May and June, and an additional nine pounds by August. The Director of Nursing confirmed the lack of notification and documentation, and the attending physician was unaware of the weight loss, which he deemed a necessary change of condition to address.
A resident experienced significant weight loss, but the facility failed to update the nutritional care plan despite recommendations from the RD. The resident, with conditions like anemia and dementia, required assistance with eating. Interviews with staff revealed awareness of the weight loss, but no revisions were made to the care plan, contrary to facility policy.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss over several months without timely referral to the Nutrition Weight Variance Committee. The facility's policy required such a referral after a five-pound loss in one month, which was not followed. The resident's weight loss was not addressed by the Registered Dietician until mid-August, and the attending physician was not informed, delaying necessary evaluation and care plan adjustments.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for one of three sampled residents. The resident had dementia, hypertension, and hyperlipidemia, and an H&P documented that the resident did not have capacity to understand or make medical decisions. An MDS assessment showed moderate cognitive impairment and a need for staff assistance with eating, toileting, and personal hygiene. On 3/6/2026, an SBAR documented that the resident was noted with weakness while walking in the dining hall for lunch, required assistance back to her room, and complained of left hip and leg pain rated eight out of ten. The SBAR also indicated the resident complained of left hip pain but was unable to give a complete description of what happened to cause the pain, and while an X-ray was being completed, the resident stated she had a fall but could not provide details of how it occurred. On 3/9/2026, an IDT progress note documented X-ray findings of an acute complete femoral neck fracture with partial displacement of the left hip, and the physician ordered transfer to a general acute care hospital for further evaluation and treatment. In an interview, RN 1 stated that on 3/6/2026 the resident was alert and oriented to name only and unable to explain how the fall occurred, and that details such as when or where the fall occurred were unknown. In a concurrent interview and record review, the DON stated the fall was unwitnessed, the details were unknown, and the resident was unable to explain the circumstances. The facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and to state officials, including the state licensing/certification agency. The DON acknowledged that failure to report this injury of unknown origin delayed investigation by CDPH and placed residents’ safety at risk.
Failure to Maintain Accurate and Updated Fall Risk Assessment After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate and up-to-date fall risk assessment for a resident with dementia and moderate cognitive impairment. The resident was admitted with diagnoses including dementia, HTN, and hyperlipidemia, and a History and Physical documented that the resident lacked capacity to understand or make medical decisions. An MDS assessment showed moderate cognitive impairment and a need for setup or cleanup assistance with eating, toileting, and personal hygiene. However, the resident’s Fall Risk Assessment dated 2/2/2026 documented the mental status as alert and oriented x3. During interviews, RN 1 and the DON both stated that the resident was only oriented to name with periods of confusion and that the assessment should have indicated intermittent confusion. Physician progress notes dated 2/15/2026 also documented periods of confusion, which were not reflected in the fall risk assessment. The report further describes that the resident experienced a fall on 3/6/2026, documented on an SBAR communication form, which noted the resident was unable to provide a detailed description of how the fall occurred. RN 1 stated that nurses were responsible for completing an updated fall risk assessment after a fall, but no updated assessment was completed following this incident. The DON confirmed that the fall risk assessment was not updated after the fall and acknowledged that the assessment should reflect the resident’s mental status and be updated to ensure appropriate interventions for fall prevention. The facility’s fall risk assessment policy indicated that staff, with physician support, would evaluate functional and psychological factors that may increase fall risk, including cognition, but there was no specific policy for required documentation after a fall.
Failure to Follow Care Plan for Monitoring Paranoid Delusions Leading to Aggressive Incident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow a resident’s care plan interventions for monitoring paranoid delusions. The resident, who had diagnoses including major depressive disorder, HTN, and CKD, was assessed on the MDS as having moderate cognitive impairment and needing staff assistance with toileting, eating supervision, and personal hygiene. The resident’s care plan dated 3/12/2026 documented episodes of paranoid behavior, including claims that the mafia was trying to kill him, and included an intervention to monitor episodes of paranoid delusions every shift. However, review of the medical record showed there was no physician order for behavior monitoring of paranoid delusions, and no behavior monitoring tasks were created in the MAR, where such monitoring was supposed to be documented when an order existed. During an interview, the resident reported that on 3/2/2026, while eating dinner in the dining hall, he believed another resident was talking about him on the phone after reading the other resident’s lips, and he responded by walking up and punching the other resident in the face. RN 1 stated that monitoring the resident’s paranoid delusions every shift was important to ensure the effectiveness of the medication regimen and to determine the need for physician reassessment, and acknowledged that monitoring tasks are generated only when there is an order. The DON stated that following the care plan is important to prevent unaddressed aggressive behaviors and to keep residents and staff safe, and that monitoring paranoid delusions allows evaluation of the effectiveness of the current plan of care and the need for physician reassessment or medication adjustment. The facility’s comprehensive, person-centered care plan policy indicated that services outlined in the care plan are to be provided by qualified persons to help attain or maintain the resident’s highest practicable well-being.
Failure to Notify MD, Complete Ordered UA, Monitor for Dehydration, and Report Delayed Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received treatment and care in accordance with professional standards of practice during multiple changes of condition. The resident, who had diagnoses including metabolic encephalopathy and oropharyngeal dysphagia and was assessed as having severe cognitive impairment and dependence in ADLs and mobility, experienced a change of condition on 12/18/2025 when she refused breakfast and lunch and allowed food to fall from her mouth. A family member reported this pattern occurred when the resident developed a UTI and requested a urinalysis (UA), which the MD ordered. However, the change of condition documentation and progress notes did not show that the MD was informed of the resident’s refusal to eat or the food falling from her mouth. On 12/18/2025, the resident’s care plan was updated with a problem of decreased or inability to eat/drink adequate amounts related to refusing meals and allowing food to fall from her mouth, with an intervention to assess the resident for dehydration. Review of the clinical record from that date showed no documentation that the resident was monitored or assessed for dehydration as care-planned. Additionally, although progress notes on 12/19/2025 indicated a urine specimen was collected, the lab report dated 12/22/2025 did not contain a UA result, and later information from the contracted lab indicated no urine specimen had been collected on 12/18/2025. The DON acknowledged there was no UA result in the record and that the specimen may not have been collected, despite the MD’s order. On 12/22/2025, the resident had another change of condition with poor meal intake, pocketing food, and abnormal lab results, and the MD ordered transfer to a general acute care hospital (GACH) for evaluation. Progress notes documented that the GACH had no available bed and later that the GACH ED could not admit the resident due to saturated admissions, and subsequent notes into the early morning of 12/23/2025 indicated the resident was still waiting for transfer. There was no documentation that the MD was notified of the delay in transfer or that additional orders were obtained while the resident remained in the facility. During interviews, the LVN and DON confirmed there was no documented evidence of MD notification regarding the 12/18/2025 change of condition, no documentation of dehydration assessment as care-planned, no UA result due to lack of specimen collection, and no MD notification when the hospital could not accept the resident as ordered.
Failure to Develop and Implement Care Plan for Sleep Apnea and BiPAP Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's diagnosis of sleep apnea and the prescribed use of a BiPAP machine. The resident was admitted with diagnoses including diabetes mellitus and hypertension, and was assessed as having intact cognition and requiring moderate assistance with activities of daily living. The resident's physician had ordered nightly use of a BiPAP machine for sleep apnea, and the resident confirmed regular use of the device. However, upon review of the resident's clinical records and active care plans, it was found that no care plan had been created or initiated to address either the sleep apnea diagnosis or the use of the BiPAP machine. The Assistant Director of Nursing confirmed that care planning serves as a communication tool among staff to ensure consistent implementation of goals and interventions, including monitoring BiPAP use, resident education, and evaluation of tolerance. The absence of a care plan meant that staff lacked guidance on providing necessary care and services related to the resident's sleep apnea and BiPAP use. This deficiency was identified through observation, interview, and record review, and was found to be inconsistent with the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timelines.
Unsecured Medications Found at Bedside Without Self-Administration Authorization
Penalty
Summary
Facility staff failed to ensure the safe storage of medications for one resident. During an observation in the resident's room, four prescription medications were found unsecured inside the nightstand, within reach of the resident. The medication bottles were not labeled for self-administration and were not stored in a locked medication cart or secured drawer. The resident reported taking the medications independently, without supervision. Review of the resident's records indicated that the resident had intact cognition, required moderate assistance with activities of daily living, and had diagnoses including diabetes mellitus and hypertension. There was no completed self-administration assessment or physician order permitting the resident to self-administer medications. The Assistant Director of Nursing confirmed that facility policy did not allow residents to keep medications at their bedside or self-administer medications without proper assessment and documentation. The presence of multiple medications at the resident's bedside and the resident's unsupervised administration were acknowledged as unacceptable and not in accordance with facility policy. Review of facility policies indicated that all medications and biologicals were to be stored in locked compartments, accessible only to authorized personnel, and administered only by licensed or permitted staff.
Failure to Ensure CNA Competency in Immediate BLS Response
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to demonstrate the necessary competencies and skills to provide immediate Basic Life Support (BLS) to a resident who was found unresponsive in bed. The resident, who had a history of hypertension and heart failure and was designated as full code status, was discovered by the CNA during routine care. Instead of assessing the resident for breathing and pulse or initiating CPR as trained, the CNA left the resident to notify a Registered Nurse (RN). The CNA did not check for vital signs or begin resuscitation efforts, despite having received BLS training two months prior, and was unable to verbalize the correct process for initiating CPR during an interview. Upon notification, the RN immediately assessed the resident, found them unresponsive, not breathing, and pulseless, and began CPR while instructing another staff member to call 911. Facility policy required all staff trained in BLS to initiate CPR immediately upon finding an unresponsive individual, following American Heart Association guidelines. The failure of the CNA to act according to training and facility policy resulted in a delay in the initiation of life-saving measures for the resident.
Failure to Timely Repair Broken Window Compromises Resident Comfort and Safety
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident by not replacing a broken window in the resident's room in a timely manner. Observation revealed that the window was covered with a wooden panel, leaving a gap through which cold air entered the room. The maintenance supervisor confirmed that the window had been broken for four days and that the replacement frame was ready to be installed on the day it broke, but the installation was not completed. The maintenance assistant stated that the repair was delayed due to being occupied with other tasks, despite maintenance staff being available on weekends for emergencies. Both the maintenance supervisor and assistant acknowledged that the window should have been repaired promptly to maintain the resident's comfort and safety. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, atrial fibrillation, and schizoaffective disorder, and was dependent on staff for activities of daily living. The resident also had severe cognitive impairment and was unable to make medical decisions. Facility policy required the maintenance department to keep the building in good repair and provide a safe, comfortable, and homelike environment. Interviews with the Director of Nursing and review of facility policies confirmed that the window repair should have been prioritized to ensure the resident's well-being.
Failure to Notify Physician and Conservator After Abuse Allegation
Penalty
Summary
The facility failed to notify both the attending physician and the resident's conservator after a resident made an allegation of abuse. The resident, who had a history of nontraumatic chronic subdural hemorrhage, schizophrenia, and depression, and was assessed as lacking the mental capacity to make decisions, reported to a nurse that he had been hit by staff and claimed to have scratches and bruises on his arm. The nurse assessed the resident and found no evidence of injury, and subsequently documented the incident in the progress notes but did not inform the physician or the conservator. The nurse determined that the allegation was not credible based on the resident's history of fabricating stories and did not consider it a change in condition. The Director of Nursing confirmed that the facility's policy required notification of the physician and the resident's representative in the event of an abuse allegation or change in condition. The failure to notify the physician delayed any potential medical or psychiatric evaluation, and the conservator was not made aware of the resident's well-being. Facility policies and performance improvement plans reviewed indicated that such notifications were required, but these procedures were not followed in this instance.
Failure to Timely Report Resident Abuse Allegation to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse made by a resident to the State Agency, the ombudsman, and local law enforcement as required. The incident involved a resident with a history of cognitive impairment, schizophrenia, and depression, who stated to an LVN that he was hit by staff when being assisted. The LVN assessed the resident for injuries and found none, and subsequently did not report the allegation to the Administrator or the required authorities, as she did not believe the claim was true due to the absence of physical evidence and her own observations. The facility's policy and recent in-service training required all staff to report any abuse allegations immediately, regardless of their personal belief in the validity of the claim or the presence of physical evidence. The LVN had received this training but failed to follow the protocol, resulting in the Administrator and DON not being informed of the allegation. The DON and Administrator both confirmed during interviews that the LVN was responsible for reporting the allegation so that an investigation could be initiated. The failure to report the abuse allegation led to a delay in notification to the appropriate authorities and a delay in the initiation of an onsite inspection. The facility's own performance improvement plan identified communication breakdowns as a root cause for such incidents, emphasizing the need for prompt reporting of all abuse allegations to ensure proper investigation and resident safety.
Failure to Develop Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop a person-centered care plan after a resident reported an abuse allegation to an LVN. The resident, who had a history of nontraumatic chronic subdural hemorrhage, schizophrenia, and depression, was assessed as having moderately impaired cognitive skills and lacking the mental capacity to make decisions. Despite the resident informing the LVN that staff had hit him and complained of scratches and bruises, the LVN assessed the resident and found no physical injuries. The LVN documented the incident in the progress notes but did not update or develop a care plan addressing the abuse allegation. The care plans reviewed for the resident did not include any interventions or guidance related to the reported abuse incident. The DON confirmed that care plans serve as a guideline for staff and should include immediate and ongoing interventions following an abuse allegation. The absence of a care plan meant there were no documented approaches or interventions for staff to follow in response to the resident's report, as required by the facility's policy on comprehensive, person-centered care planning.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the reporting process for such incidents, as required by regulations. The report indicates that there was a delay or failure in notifying the appropriate authorities about the suspected event and in communicating the outcome of the internal investigation.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Ensure Safe Medication Administration and Monitoring
Penalty
Summary
A deficiency occurred when a resident with diagnoses of paranoid schizophrenia and anxiety disorder, who had moderately impaired cognition and a history of hallucinations and delusions, was found in possession of two medications—Klonopin and Risperdal—without staff knowledge. The resident was observed in the hallway holding a green pill (Risperdal) and a yellow pill (Klonopin), which matched the medications prescribed to him. The resident admitted to keeping the medications after they fell to the floor on an unknown date and requested that staff not be informed. Review of the Medication Administration Record indicated that both medications were scheduled to be administered in the morning, but the resident had not received the full dose as intended due to pocketing the pills. Interviews with nursing staff revealed that the resident had a known tendency to pocket medications rather than swallow them, and that staff were responsible for ensuring the resident swallowed each pill before moving on. The Director of Nursing confirmed that failure to observe the resident swallowing the medications resulted in the resident not receiving the correct dose, and that this practice was not in accordance with the facility's policy for safe medication administration. The incident also created the potential for other residents to access medications not prescribed to them.
Failure to Implement Abuse Reporting Protocols Following Repeat Deficiency
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) Committee implemented action plans to correct previously identified abuse allegation deficiencies. Despite in-service training and a performance improvement plan that required immediate reporting of abuse allegations to the California Department of Public Health (CDPH), the ombudsman, and law enforcement, staff did not follow these protocols. Specifically, when a resident reported to Social Services that a Certified Nursing Aide (CNA) was rough while shaving him, the Director of Staff Development (DSD) was notified and interviewed the CNA but did not suspect abuse and did not report the allegation as required. The Director of Nursing (DON) and the Administrator (ADM) were not informed of the allegation until several days later, contrary to the facility's established procedures. The review of grievance and complaint forms revealed that incidents were not promptly communicated to the appropriate authorities or facility leadership. The DON confirmed that she was not made aware of the resident's allegation until weeks after the incident, and that the required reporting to CDPH, the ombudsman, and law enforcement did not occur prior to the internal investigation. This failure to follow the facility's abuse reporting protocols represents a repeat deficiency and demonstrates a breakdown in communication and adherence to established procedures for handling abuse allegations.
Failure to Notify Physician of Responsible Party's Declined CT Scan
Penalty
Summary
The facility failed to notify a resident's physician after the resident's responsible party declined a recommended head CT scan following the discovery of discoloration on the resident's forehead. The resident, who had diagnoses including metabolic encephalopathy, depression, and generalized muscle weakness, was assessed as having severely impaired cognitive skills and lacked capacity to make decisions. After a certified nursing assistant reported the discoloration, the physician was initially notified and ordered monitoring and for the responsible party to be consulted regarding the CT scan. The responsible party was contacted and ultimately declined the CT scan. However, the licensed vocational nurse who received the responsible party's decision did not inform the physician of this outcome. Both the nurse and the director of nursing acknowledged that the physician should have been notified to allow for further recommendations or interventions. The facility's policy required prompt notification of the physician regarding changes in a resident's condition or status, but this was not followed, resulting in the physician being unaware of the responsible party's decision and no further interventions being ordered.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH), the ombudsman, and local law enforcement as required. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy and depression, who was found to have discoloration on the right side of the forehead. The injury was first observed by a CNA and reported to an LVN, who acknowledged not knowing the cause and could not recall if the Director of Nursing (DON) or Administrator (ADM) were informed at the time. Interviews with staff confirmed that the discoloration was considered an injury of unknown origin and should have triggered immediate notification to facility leadership and external agencies. Both the LVN and RN interviewed stated that such injuries must be reported to the DON and ADM, who are then responsible for notifying the appropriate authorities and initiating an investigation. The DON confirmed that reporting injuries of unknown origin is essential for resident safety and that the incident was not reported because the possibility of abuse was not considered at the time. The ADM stated that injuries of unknown origin are to be reported to CDPH, the ombudsman, and the police, but did not recall being informed of the incident when it occurred. Upon seeing the resident several days later and not observing any discoloration, the ADM did not report the incident. Review of the facility's policy confirmed the requirement for immediate reporting of all alleged violations involving abuse, neglect, or injuries of unknown source to multiple agencies and individuals.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with discoloration on the right side of the forehead. The resident had a history of metabolic encephalopathy, depression, and generalized muscle weakness, and was assessed as having severely impaired cognitive skills and lacking capacity to make decisions. When the discoloration was discovered by a CNA and reported to an LVN, the LVN did not recall informing the DON or the Administrator. The LVN acknowledged that such an injury should have been reported to allow for a proper investigation. Interviews with nursing staff and facility leadership revealed that, although some staff were aware of the injury, a comprehensive investigation was not conducted. The DON interviewed nurses about possible falls or combativeness but did not explore other potential causes, such as being struck by another resident or staff member. The Administrator did not recall being informed at the time and did not initiate a formal investigation, only making informal inquiries with nurses. The facility's policy required thorough investigation of all injuries of unknown origin, but this was not followed, resulting in the facility being unaware of the cause of the resident's injury.
Failure to Complete Post-Fall Assessments and Documentation
Penalty
Summary
A resident with a history of metabolic encephalopathy, depression, and generalized muscle weakness, and who was assessed as having severely impaired cognitive skills and high risk for falls, experienced a fall after attempting to stand from a wheelchair. Following this incident, the facility failed to complete the required 72-hour neurological checks as indicated in the resident's care plan. Multiple entries on the neuro check list were left blank, and both the LVN and DON confirmed that these missed assessments could have resulted in undetected neurological changes. Additionally, the facility did not complete a post-fall fall risk assessment for the resident after the incident. The LVN stated that such an assessment is necessary to identify ongoing risks and to inform the interdisciplinary team (IDT) in developing appropriate interventions. The DON confirmed that the absence of this assessment meant the resident's risk factors were not re-evaluated after the fall. The documentation for the IDT meeting held after the fall was also incomplete. While the progress note listed staff participants, it did not include post-fall recommendations or a documented plan of care. The DON acknowledged that without this documentation, the discussed interventions would not be implemented as part of the resident's care plan.
Expired Medications Found in Medication Cart and Storage Room
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from both a medication cart and a medication room. Specifically, one bottle of expired cetirizine hydrochloride 5 mg was found inside the Main St Medication Cart, with an expiration date of 3/2025. A Licensed Vocational Nurse (LVN) confirmed during the observation that the medication was expired and should not have been present in the cart. The LVN also stated that registered nurses were responsible for auditing the medication carts for expired medications. Additionally, a bottle of expired haloperidol decanoate, labeled as expired since 1/2025, was found stored in the refrigerator of Medication Room Nursing Station 2. Another LVN confirmed that the expired medication should have been disposed of before its expiration date and that licensed nurses assigned to the station were responsible for monthly checks for expired medications. The Director of Nursing (DON) stated that expired medications should not be present in storage areas and that administering expired medication would be considered a medication error. Facility policy indicated that outdated non-controlled drugs should be stored in a secured area until picked up by pharmaceutical waste disposal or pharmacy personnel.
Deficient Food Storage and Labeling Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and preparation practices. Two personal food containers belonging to a dietary staff member were found stored inside a designated kitchen refrigerator, which was acknowledged by the dietary aide as inappropriate. Additionally, in the walk-in refrigerator, several opened food items—including a bottle of chocolate syrup, a bottle of caramel drizzle, a can of whipped cream, and a container of chopped onions—were found unlabeled. An opened carton of ice cream was also found unlabeled in the walk-in freezer. The dietary aide confirmed that all opened food items should have been labeled with the date they were opened and stored. The dietary supervisor further stated that all opened and prepared foods must be labeled with the date of opening or preparation and the date of storage, and that personal food items should not be stored in facility refrigerators. The facility's policy and procedure on sanitation and infection control requires that no outside food be stored in the food and nutrition services department, and that leftover and frozen foods be properly covered, labeled, and dated. These deficiencies were observed in a facility serving 99 residents, 95 of whom were medically compromised and received food from the kitchen.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure safe medication administration for two residents, resulting in missed doses and improper documentation. For one resident with severe cognitive impairment and multiple health conditions, including metabolic encephalopathy and kidney failure, an order for oyster shell calcium 500 mg twice daily was present in the electronic health record but was not transcribed onto the Medication Administration Record (MAR). As a result, 40 consecutive doses were not administered over a 20-day period. The nurse responsible for medication administration confirmed that the omission was due to the order not appearing on the MAR and acknowledged that the weekly review of active orders had not yet been completed for that week. For another resident with schizophrenia, depression, and low back pain, there were discrepancies in the administration and documentation of controlled medications, including tramadol HCl, lorazepam, and hydrocodone-acetaminophen. The MAR indicated that these medications were administered, but the Narcotic Count Sheet (NCS) and bubble packs showed missing signatures and discrepancies in pill counts. The nurse involved stated that she was too busy to sign the NCS after administering the medications, resulting in missing documentation for multiple doses across different medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires immediate documentation of medication administration on the NCS and that the nurse receiving new orders is responsible for ensuring they are added to the MAR. The lack of proper transcription and documentation was acknowledged as a medication error by both the nursing staff and the Director of Nursing. Facility policies reviewed also supported the requirement for accurate and timely documentation of medication administration.
Resident Room Over-Occupancy Exceeds Regulatory Limits
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents, as required by regulation. Observations and census review revealed that Rooms A, B, C, and D each housed six residents, exceeding the maximum occupancy limit. Measurements of these rooms indicated they were between 478.33 and 487.44 square feet, and the rooms were observed to have sufficient space for beds and dressers. However, the number of residents per room did not comply with the regulatory standard. Throughout the survey period, there were no documented adverse effects related to space, nursing care, comfort, or privacy for the residents in these rooms. The DON confirmed that these rooms were occupied by six residents each and acknowledged the facility's ongoing request for a waiver to allow this arrangement, citing the facility's typical admission of residents with behavioral and psychological needs.
Failure to Honor Resident's Smoking Preferences and Choices
Penalty
Summary
The facility failed to honor a resident's right to make choices about his daily routine and preferences, specifically regarding his request for additional smoke breaks. The resident, who had a history of chronic obstructive pulmonary disease (COPD), alcohol abuse, hypertension, bipolar disorder, and depression, was assessed as having the capacity to make medical decisions and was noted to have moderately impaired cognition. His care plan documented his enjoyment of smoke breaks and indicated that staff should respect his preferences and rights. Despite these documented preferences, the resident reported that he was only permitted to participate in two scheduled smoke breaks per day, although he preferred at least one additional break in the evening. The resident stated that his requests for an extra smoke break were repeatedly ignored by nursing staff, and when he asked the Activities Department, they deferred the request to the Social Services Director without follow-up. Staff interviews confirmed that additional smoke breaks required approval and that residents often became anxious when not allowed to smoke as desired. It was also noted that the facility previously allowed an additional evening smoke break, which had a calming effect on residents. The Director of Nursing acknowledged that residents could be accommodated for additional smoke breaks to honor their preferences and that arrangements could be made as long as safety was maintained. The facility's policy on dignity emphasized supporting resident choices and preferences, yet the resident's requests were not consistently communicated or honored, resulting in the resident feeling ignored and his choices unmet.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from two residents prior to administering psychotropic medications. For one resident with dementia and anxiety, the clinical record showed that Quetiapine Fumarate was started without any documentation that the resident received education about the risks and benefits of the medication before initiation. The Director of Nursing (DON) confirmed that there was no evidence of informed consent being obtained prior to starting the medication. For another resident with dementia and behavioral disturbances, orders were in place for Depakote, Risperdal, and Seroquel. The Medication Administration Record indicated that these medications were administered, but the informed consent forms were incomplete. The forms had the physician's signature but did not specify from whom consent was obtained or the date. The registered nurse could not recall why the forms were incomplete and acknowledged that consent may not have been obtained or documented at the time of readmission. Interviews with the DON confirmed that, due to the lack of completed informed consent forms, the resident was not given the opportunity to make an informed decision regarding the prescribed psychotropic medications. Review of facility policy indicated that residents have the right to provide informed consent before treatment with psychotherapeutic drugs, which was not followed in these cases.
Call Light Accessibility Deficiency
Penalty
Summary
A deficiency occurred when a resident was found lying in bed, awake and alert, with their call light device hanging from a hook on the wall out of reach. The resident reported being unable to reach the call light and stated that it had not worked for months. The resident had a history of bilateral osteoarthritis of the hip, difficulty walking, lack of coordination, asthma, dysphagia, and schizoaffective disorder. The resident's care plan indicated impaired cognition, incontinence, and a need for assistance with activities of daily living (ADLs), with specific interventions to keep the call light within reach and encourage its use for requesting assistance. During the observation, a CNA confirmed that the call light was not within the resident's reach and acknowledged responsibility for ensuring it was accessible. The DON stated that nursing staff are expected to check call lights for proper function and accessibility at every shift change. Facility policy requires that calls for assistance be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately. The failure to keep the call light within reach resulted in the resident being unable to summon staff for assistance in a timely manner.
Failure to Provide Required Discharge Notice to Resident and Ombudsman
Penalty
Summary
The facility failed to provide a required written notice of discharge to both the Ombudsman and a resident prior to the resident's discharge. Record review showed that the resident, who had diagnoses including generalized muscle weakness, dementia, and diabetes mellitus, was discharged to a lower level of care. The resident's Minimum Data Set indicated mild cognitive impairment and a need for varying levels of assistance with daily activities. Upon review of the closed record, there was no documentation of a discharge notice for the resident, nor evidence that the Ombudsman was notified. Interviews with the Medical Records Director and the DON confirmed that the notice of discharge was not present in the resident's record and had not been sent to the Ombudsman. Facility policy requires that residents and their representatives receive written notification of discharge, including specific information about the discharge, appeal rights, bed-hold policies, and contact information for advocacy agencies. The policy also mandates that a copy of the notice be sent to the Ombudsman at the same time as the resident and representative are notified. The absence of this documentation indicated noncompliance with facility policy and regulatory requirements.
Failure to Complete Timely MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessment for a significant change in status within the required timeframe for one resident. The resident was initially admitted with multiple diagnoses, including dementia, metabolic encephalopathy, diabetes mellitus, and had a gastrostomy feeding tube. Upon readmission, there was a recognized change in condition, specifically the presence of a gastrostomy feeding tube, but the required MDS change of condition assessment was not completed within 14 days as mandated. Record review showed that no MDS assessments addressing the change in condition were available between early February and early May, despite the resident's readmission and altered clinical status. The MDS nurse confirmed during interview and record review that the assessment should have been completed within the specified timeframe but was not. Facility policy required a comprehensive assessment for significant changes in a resident's condition, in accordance with OBRA regulations, but this was not followed in this instance.
Failure to Accurately Document Active Diagnosis of Depression in MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by omitting depression as an active diagnosis in Section I, despite documentation in the medical record and ongoing treatment for depression. The resident's admission record and physician orders indicated a diagnosis of depression, and the resident was prescribed Trazadone for depression manifested by self-isolation. The MDS assessment, however, did not reflect depression as an active diagnosis, even though the resident was receiving antidepressant medication. During an interview and record review, the MDS nurse confirmed that the MDS was inaccurate and acknowledged that the resident had a diagnosis of depression based on the medical record. The facility's policy required healthcare professionals to certify the accuracy of the MDS, but this was not followed in this instance, resulting in an incomplete assessment for the resident.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with significant medical and psychosocial needs. For one resident with diagnoses including anxiety, depression, atrial fibrillation, and schizoaffective disorder, there was no care plan addressing vitamin D deficiency or the administration of oyster shell calcium, Trazodone, and Buspirone. The resident was severely cognitively impaired and dependent on staff for activities of daily living. Interviews with the MDS nurse and DON confirmed that care plans for these diagnoses and medications were missing, and that such plans are necessary to guide staff in providing appropriate care and monitoring for side effects. Another resident with diagnoses of depression, Alzheimer's disease, dementia, and diabetes mellitus was prescribed Trazodone for depression manifested by self-isolation. Despite severe cognitive impairment and dependence on staff for daily activities, there was no care plan addressing the resident's depression. The MDS nurse and DON both acknowledged the absence of a care plan for depression and emphasized that care plans are essential for communicating resident needs and ensuring quality care. A third resident with pulmonary embolism, COPD, dementia, and pleural effusion had a care plan instructing staff to provide oxygen as ordered and to educate about the risks of excessive oxygen for COPD. However, observations revealed that the resident was receiving continuous oxygen at a rate of 4.5 LPM, contrary to the physician's order of 2 LPM as needed. Staff interviews confirmed that the care plan was not followed, and the DON acknowledged that this deviation placed the resident at risk. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, which were not implemented in these cases.
Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via gastrostomy tube was not maintained with the head of the bed elevated to the required 30-45 degrees during feeding, as ordered by the physician and outlined in facility policy. The resident, who had diagnoses including gastrostomy status, dementia, and gastro-esophageal reflux disease, was observed with the bed elevated to only approximately 20 degrees while receiving tube feeding. The order summary specifically required the head of bed to be elevated during and for one hour after feeding. During staff rounds, an LVN did not adjust the bed elevation while the feeding was ongoing and acknowledged that the bed positioning was not acceptable. The DON confirmed that all residents on tube feedings should have the head of bed elevated to 45 degrees to prevent complications. Facility policy also required head of bed elevation to 30-45 degrees during feeding unless medically contraindicated. The failure to follow these orders and policies led to the deficiency.
Failure to Provide and Document Physician-Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with physician orders and professional standards for a resident with multiple respiratory diagnoses, including COPD and pulmonary embolism. The resident was observed receiving continuous oxygen at a flow rate of 4.5 liters per minute (LPM), which exceeded the physician's order of 2 LPM as needed. Both a CNA and an LVN confirmed that the resident had been on continuous oxygen at this higher rate, and the LVN acknowledged that this did not align with the physician's order. The DON and RN also confirmed that the administration of oxygen at this rate and frequency was not appropriate for the resident's condition and could lead to adverse outcomes. Additionally, the resident was observed on the facility patio without supplemental oxygen, exhibiting increased respiratory rate and signs of respiratory distress. The CNA responsible for the resident stated that the resident refused oxygen and was taken outside without notifying the LVN. The LVN was not aware of the resident's refusal or removal of oxygen until after the fact, and upon assessment, found the resident's oxygen saturation to be below normal. The DON stated that the expectation was for the CNA to immediately notify the LVN of the refusal so that appropriate monitoring and interventions could be implemented. Documentation of the resident's oxygen flow rate was also lacking, as there was no record of the amount of oxygen administered from 4/29/2025 to 5/20/2025. The LVN admitted to forgetting to check and document the flow rate, and the DON confirmed that documentation of oxygen administration was expected each shift. The facility's policy required proper flow of oxygen, documentation of the rate, and notification of supervisors in the event of refusal, none of which were consistently followed in this case.
Failure to Monitor and Document Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to ensure that two residents were properly monitored for medication side effects and efficacy, resulting in a deficiency. For one resident with severe cognitive impairment and multiple diagnoses including atrial fibrillation, depression, and anxiety, physician orders required monitoring for signs and symptoms of bleeding due to anticoagulant therapy (Eliquis), monitoring of sleep hours for Trazadone, and documentation of episodes of physical restlessness for Buspar. These monitoring orders were not transcribed onto the Medication Administration Record (MAR) by the responsible RN, and as a result, no monitoring or documentation was completed for the specified period. The LVN confirmed the absence of required monitoring documentation, and the RN acknowledged missing the transcription of these orders, which prevented nursing staff from implementing the necessary monitoring protocols. Another resident, also with severe cognitive impairment and multiple medical conditions including atrial fibrillation and heart failure, was prescribed Apixaban, an anticoagulant. The resident's care plan included interventions to monitor for side effects and effectiveness of the medication, with instructions to document and report any adverse reactions. However, the MAR showed no documentation of monitoring for anticoagulant side effects during the specified period. The LVN responsible for the resident stated that she did not monitor for side effects because she believed it was only necessary if symptoms appeared, and she was unaware of the care plan's requirement for ongoing monitoring and documentation. The DON confirmed that daily monitoring and documentation for anticoagulant side effects should have been completed as per the care plan and facility policy. Facility policies reviewed indicated that nurses are responsible for carrying out physician orders, including transcribing them onto medication or treatment records and ensuring communication to relevant staff. The policies also required assessment and documentation of anticoagulant therapy, including monitoring for adverse drug reactions. The failure to transcribe, implement, and document physician-ordered monitoring for these residents resulted in a lack of oversight for potential medication side effects and effectiveness, as required by both physician orders and facility policy.
Failure to Provide Physician-Ordered Therapeutic Diet Supplement
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral infarction, dysphagia, and depression, and who was assessed as having severely impaired cognition and requiring moderate assistance with activities of daily living, did not receive a physician-ordered therapeutic diet supplement. The resident was prescribed a fortified pureed diet with honey thick liquids and Magic Cup twice daily as a supplement, as documented in the order summary and medication administration record. On the observed date, the resident's lunch tray, which was supposed to include Magic Cup according to the meal ticket, was missing the supplement. This was confirmed by a certified nurse assistant during meal assistance. The dietary supervisor acknowledged awareness of the omission and stated that both the dietary aide and the nurse responsible for tray checks should have ensured the supplement was provided. The director of nursing confirmed that trays are checked by both dietary and nursing staff against diet orders. The facility's policy requires that food trays be inspected to ensure correct meals are provided to each resident.
Failure to Maintain Catheter Drainage Bag Off Floor
Penalty
Summary
Surveyors observed that a resident's urinary catheter drainage bag was repeatedly found touching the floor during two separate observations on the same day while the resident was lying in bed. The resident had a history of chronic kidney disease and dementia, with moderate cognitive impairment and required assistance with daily activities. The care plan for the resident specified the goal of preventing urinary infections, and the facility's policy required that catheter tubing and drainage bags be kept off the floor. Interviews with staff, including a Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that the drainage bag should not be on the floor due to infection control concerns. Both staff members acknowledged that the improper placement of the drainage bag was inappropriate and contrary to facility policy, and that all staff were responsible for ensuring proper catheter care. Review of the facility's policy and procedure further supported that catheter drainage bags must be kept off the floor.
Nonfunctional Call System in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that the call system was functional and accessible for two of eight sampled residents. For one resident, the call light device was observed hanging on the wall, out of reach, and when tested, neither the light inside the room nor the indicator outside the door activated, and there was no audible alert. Nursing staff were observed walking in the hallway without responding to the call light, and a CNA confirmed that the device was not working and not within the resident's reach. The resident's care plans specifically required the call light to be within reach and encouraged its use for assistance, and the resident was assessed as having impaired cognition, limited mobility, and a moderate risk for falls. Another resident's call light was also found to be nonfunctional during multiple observations, with the indicator outside the room not lighting up when pressed. A CNA confirmed that the call light did not activate the indicator on the switchboard at the nurses' station, and acknowledged that the resident's needs could go unmet due to the malfunction. This resident had severe cognitive impairment, required assistance with activities of daily living, and was at risk for falls, with care plans instructing staff to keep the call light within easy reach and encourage its use. Interviews with the DON confirmed that staff are expected to check call lights for proper function and accessibility at every shift change, and that a nonfunctioning call light could delay care and services, especially in emergencies. The facility's policy required that the call system remain functional at all times, be routinely maintained and tested, and that calls for assistance be answered promptly.
Deficiency: Resident Room Size Below Regulatory Requirement
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. A review of the facility's Room Waiver Request letter revealed that several two-person rooms were below the regulatory requirement, with each room measuring between 139.18 and 141.31 square feet, resulting in less than 80 square feet per resident. Observations made during the survey period confirmed that these rooms were in use and did not meet the space requirement. During an interview, the DON acknowledged that the rooms were slightly under the required size but stated that care and safety would not be compromised.
Failure to Maintain Required Bed Hold and Notification for Hospitalized Residents
Penalty
Summary
The facility failed to maintain a seven-day bed hold for two residents who were transferred to a General Acute Care Hospital (GACH), resulting in a violation of their rights to return to their assigned beds. For one resident with severe cognitive impairment and multiple diagnoses, the bed was assigned to another individual just one day after transfer, despite the requirement to hold the bed for seven days. Staff interviews confirmed that the bed hold was not honored, and there was no clear explanation for this action. The resident's need for continuity and comfort in returning to the same room was acknowledged by staff, but not upheld in practice. For another resident, also with severe cognitive impairment and significant medical conditions, the bed hold process was not properly followed. Although the resident was placed on bed hold status, the bed was not available upon readmission, and the resident was placed in a different bed. Additionally, the required Bed Hold Informed Consent form was not completed, meaning the responsible party was not properly informed of the resident's rights. Facility policy requires written notification of bed hold rights prior to transfer, but this was not consistently implemented, leading to the deficiency.
Call Light Not Maintained Within Reach for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found on the floor behind the head of her bed, making it inaccessible while she was lying in bed. The resident had a history of falls, generalized muscle weakness, osteoarthritis in both hips, dementia, lack of coordination, and difficulty walking, as documented in her admission record and Minimum Data Set (MDS). The care plan for this resident specifically required staff to keep the call light within her reach as a fall prevention intervention. During interviews, both a CNA and an LVN confirmed that the call light should be within the resident's reach to prevent falls and allow the resident to call for assistance. Facility policy also required that each resident be provided with a means to call staff directly for assistance from their bed. The failure to maintain the call light within reach was observed and acknowledged by staff, and it was not in accordance with the resident's care plan or facility policy.
Failure to Develop and Implement Comprehensive Care Plan After Choking Incidents
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan with measurable interventions after two documented choking episodes involving a resident with dysphagia, Parkinson's Disease, and moderate cognitive impairment. Despite clear evidence from assessments and physician orders indicating the resident's high risk for choking and aspiration, the care plans created after the incidents on 1/6/2025 and 1/15/2025 were incomplete, lacking specific goals and interventions to prevent recurrence. The resident's care plan for dysphagia and choking risk included general interventions, but did not address the specific circumstances of the choking episodes, such as the need for supervision during all meals or the resident's tendency to eat quickly or take food from others. The resident was only placed on a Restorative Nursing Assistant (RNA) feeding program for breakfast and lunch, despite physician and policy indications that such supervision should have been provided for all meals due to the resident's risk factors. Staff failed to update the care plan to reflect the need for RNA supervision at dinner, even after repeated choking incidents. The care plans initiated after the choking events were not completed, and the Director of Nursing confirmed that they lacked necessary goals and interventions. As a result of these deficiencies, the resident was left unsupervised during dinner, which led to a fatal choking incident on 3/5/2025. Emergency personnel were unable to clear the resident's airway, and the resident was pronounced dead following cardiac arrest. The facility's own policies required comprehensive assessment and timely revision of care plans when problems were identified or outcomes were not met, but these procedures were not followed in this case.
Failure to Reassess Respiratory Status After Oxygen Administration
Penalty
Summary
The facility failed to reassess the respiratory status of a resident who had an oxygen saturation of 86%, which is below the normal range. The resident, who had a history of metabolic encephalopathy, dysphagia, Parkinson's Disease, and acute respiratory failure, experienced a seizure and was found to have low blood pressure and low oxygen saturation. Oxygen was administered, but the amount was not specified, and there was no documentation of a reassessment of the resident's oxygen saturation or vital signs after the intervention. Following the initial event, the resident became unresponsive, aspirated, and turned blue, prompting staff to call emergency services. The documentation did not indicate whether a complete assessment was performed or if vital signs were rechecked after suctioning the resident. Staff interviews confirmed that the oxygen tank initially used was not functioning, and the resident only received oxygen after being returned to their room. Staff could not confirm the amount of oxygen administered, and there was no record of the effectiveness of the intervention being evaluated. Facility policy required a comprehensive assessment and evaluation of interventions following a significant change in a resident's condition. However, the records and staff interviews revealed that these steps were not documented or performed, as indicated by the lack of reassessment and incomplete documentation of the resident's status and care provided during the emergency.
Failure to Provide Adequate Supervision During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident with a history of dysphagia, Parkinson's Disease, and moderate cognitive impairment, who had previously experienced two choking incidents. The resident was on a controlled carbohydrate, pureed diet with honey thick liquids and had physician orders for a Restorative Nursing Assistant (RNA) feeding program for breakfast and lunch, but not for dinner. Despite documented risks and care plan interventions requiring supervision and assistance during meals, the resident was left unsupervised during dinner. On the evening in question, the resident was observed feeding himself in the dining room without RNA supervision. Shortly after, he experienced a seizure, became unresponsive, and was found with food particles and mucous in his mouth, indicating aspiration. Staff attempted to clear the airway and perform suctioning, but were unsuccessful. Emergency services were called, but the resident was pronounced dead after becoming pulseless. Interviews with facility staff, including the DON, CNA, SLP, LVN, and MD, revealed that the RNA feeding program should have been implemented for all meals due to the resident's high risk for choking and impulsive eating behaviors. Facility policies required supervision and individualized interventions to prevent accidents, but these were not fully implemented or monitored for effectiveness, resulting in the resident being unsupervised during a high-risk activity.
Failure to Implement Contact Precautions for Resident with CRE
Penalty
Summary
The facility failed to implement appropriate contact precautions for a resident who was admitted with a known history of Carbapenem-Resistant Enterobacterales (CRE). Upon admission, the resident's records from a general acute care hospital indicated a prior CRE infection, and physician orders specified the need for contact isolation. However, the admitting staff did not review all the documents that accompanied the resident, resulting in the omission of necessary contact precautions for two days following admission. During this period, the resident was not placed on contact isolation, and staff were not notified to use the required personal protective equipment (PPE) when providing care. Interviews with nursing staff and the Director of Nursing revealed that the facility was unaware of the resident's CRE status until two days after admission, despite the information being present in the admission records. The facility's policies and procedures required the implementation of enhanced barrier and transmission-based precautions for such cases, including the use of gowns and gloves for all contact with the resident or their environment. The failure to review the resident's hospital records and implement contact precautions as ordered by the physician led to a lapse in infection prevention and control practices.
Failure to Implement Timely Scabies Precautions and Treatment
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for scabies, affecting six residents. Resident 1, diagnosed with scabies at a general acute care hospital, returned to the facility without being placed on Contact Precautions immediately. This delay in implementing precautions occurred despite Resident 1's diagnosis and treatment for scabies being documented in the hospital records. The facility only placed Resident 1 and the other five residents on Contact Precautions two days after Resident 1's return. Additionally, the facility did not provide immediate prophylactic treatment to Residents 2, 3, 4, 5, and 6, who were exposed to Resident 1. These residents were only treated with Elimite cream two days after Resident 1's return, despite the known contagious nature of scabies. The delay in treatment and precautions increased the risk of scabies transmission among residents, staff, and visitors. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) revealed lapses in communication and responsibility. The IPN stated that it was not her responsibility to check Resident 1's hospital records, while the DON admitted to not reviewing the records due to Resident 1's return on a Sunday. The facility's policy required immediate treatment and precautions for scabies, which were not followed, leading to the deficiency.
Failure to Manage Elopement Risk Leads to Resident's Disappearance
Penalty
Summary
The facility failed to adequately assess and manage the elopement risk for a resident who had a history of wandering and attempted elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar type, and anxiety disorder, was assessed as having wandering behaviors on the Minimum Data Set (MDS). Despite this, the facility did not conduct an elopement risk assessment or hold an Interdisciplinary Team (IDT) meeting after the resident's elopement attempts on two occasions. The care plan for the resident included monitoring whereabouts and assessing elopement risk, but these interventions were not effectively implemented. The resident attempted to elope from the facility on two occasions, once being found outside the facility and another time attempting to climb over a fence. Despite these incidents, the facility did not revise the care plan to include non-pharmacological interventions or conduct an IDT meeting to address the resident's specific needs. The resident's care plan was updated to include medication adjustments, but it lacked individualized interventions to prevent further elopement attempts. Ultimately, the resident successfully eloped from the facility by breaking a window and climbing out, leading to the declaration of an Immediate Jeopardy situation. The facility's failure to assess the resident as high risk for elopement and to conduct IDT meetings after each elopement attempt contributed to the resident's successful elopement and subsequent disappearance.
Failure to Notify Residents and Responsible Parties of Care Conferences
Penalty
Summary
The facility failed to notify the responsible parties of two residents about their rights to participate in care conferences, which is a violation of their rights to be active participants in their care. Resident 1, who was admitted with multiple diagnoses including dementia and schizoaffective disorder, had severely impaired cognitive skills and lacked the capacity to make decisions. Despite this, there was no documented notification to Resident 1's responsible party for several care conferences, and the resident attended these conferences without the responsible party's involvement. Interviews with the Director of Rehabilitation, Social Service Director, and Director of Nursing confirmed the lack of communication and documentation regarding the responsible party's involvement. Similarly, Resident 2, who also had severely impaired cognitive skills, was not notified about care conferences, nor was there documentation of the resident's participation. Resident 2, diagnosed with conditions such as Type 2 diabetes and osteoarthritis, stated he was unaware of his plan of care and had not attended any care conferences. The Social Service Director and Director of Nursing acknowledged the importance of involving residents and their responsible parties in care planning and confirmed the absence of proper notification and documentation. The facility's policies on resident rights and interdisciplinary team care planning emphasize the importance of notifying residents and their representatives about care conferences. However, the facility failed to adhere to these policies, resulting in a lack of participation from the residents and their responsible parties in care planning. This deficiency highlights a failure to respect and honor the residents' rights to be involved in their care decisions.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, identified as Resident 1, which was observed through a review of records and interviews. Resident 1, who was admitted with diagnoses including anemia, dementia, and generalized muscle weakness, experienced a five-pound weight loss between May and June 2024, and a further nine-pound loss by August 2024. Despite these significant changes, there was no documentation indicating that the attending physician was notified, as required by the facility's policy and procedure for changes in condition. The Director of Nursing confirmed the lack of notification and documentation during a review of Resident 1's records, acknowledging the importance of informing the physician to assess the need for new orders or care plan adjustments. The attending physician, MD 1, also stated that he was not informed of the weight loss, which he considered a change of condition requiring further evaluation. The facility's policy mandates that licensed nurses promptly notify the attending physician of significant changes in a resident's physical status, and document all attempts to notify in the medical record, which was not adhered to in this case.
Failure to Revise Nutritional Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to revise the nutritional care plan for a resident following significant weight loss. The resident experienced a five-pound weight loss between May and June 2024, and a further nine-pound weight loss by August 2024. Despite these changes, the care plan was not updated to address the resident's nutritional needs, and the dietary staff did not attend the care conference where these issues could have been discussed. The resident, who was admitted with conditions including anemia, dementia, and generalized muscle weakness, had severely impaired cognition and required assistance while eating. The facility's records showed a consistent decline in the resident's weight, yet the care plan remained unchanged. The Registered Dietician made recommendations for care plan revisions, but these were not implemented. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, revealed awareness of the resident's weight loss but no action was taken to revise the care plan. The facility's policy required updates to care plans following changes in a resident's condition, but this was not adhered to, leaving the resident at risk of further weight loss.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to refer a resident to the Nutrition Weight Variance Committee after experiencing significant weight loss. The resident, who had diagnoses including anemia, dementia, and generalized muscle weakness, lost five pounds between May and June 2024, and an additional nine pounds by August 2024. Despite these losses, the resident was not referred to the committee until August 21, 2024, and was not monitored for the initial five-pound loss. The facility's policy indicated that a five-pound loss in one month was significant and required referral to the committee, which did not occur in a timely manner. The resident, who had severely impaired cognition and required assistance with eating, was observed to sometimes eat less than half of her meals or refuse them entirely. The Registered Dietician did not address the resident's weight loss until mid-August, and the attending physician was not informed of the unplanned weight loss, which required further evaluation and adjustments to the care plan. The delay in referral and intervention placed the resident at risk for continued unplanned weight loss.
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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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