Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 2335 S. Mountain Ave, Duarte, California 91010
- CMS Provider Number
- 05A109
- Inspections on file
- 62
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Community Care Center during CMS and state inspections, most recent first.
The facility did not provide necessary behavioral health care and services to residents, as required. Survey findings showed that residents did not receive the behavioral health interventions and supports needed to address their conditions.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
For the past nineteen months, non-controlled medication destruction was performed by only one nurse instead of two, as required by facility policy. Disposition logs showed only a single nurse's signature, with the witness section left blank, and the DON confirmed this practice had been ongoing for all non-controlled medication disposals involving multiple residents.
A medication cart was found unattended and unlocked outside a medication room in a nursing station, where non-nursing staff such as CNAs had access. The DON confirmed the cart was not secured, which was contrary to facility policy requiring medications to be stored safely and only accessible to licensed personnel.
Surveyors found an unsealed, unlabeled, and undated bag of dehydrated milk in the dry food storage area. The Dietary Supervisor confirmed the deficiency, noting that the product should have been sealed, labeled, and dated according to facility policy to prevent contamination.
A resident with schizoaffective disorder and PTSD, prescribed Clozaril for auditory hallucinations, did not have required monthly Clozaril serum levels obtained for two months. The DON confirmed the missing lab results, and facility policy did not address monitoring of Clozaril levels.
A resident with mental health diagnoses was transferred to a hospital for psychiatric evaluation due to physical aggression, but staff failed to obtain a physician's discharge order and did not complete the required discharge summary. Communication lapses between the social services assistant, LVN, and case manager led to missing documentation and lack of a bed hold notice, contrary to facility policy.
A resident's care plan was found to be incomplete, lacking coverage of all identified needs and missing measurable timetables and specific actions, as observed by surveyors.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
A resident's cabinet was found without a functioning lock, leaving it unable to be securely closed. Staff interviews revealed that the missing lock had been verbally reported to maintenance weeks earlier, but no follow-up or documentation occurred, and the issue remained unresolved. Facility policy requires maintenance to keep equipment in safe, operable condition, but this was not met in this instance.
Ten resident rooms were found to be below the required 80 square feet per resident, with some rooms providing as little as 66 to 72 square feet per resident. The Administrator had not submitted a waiver or variance for these rooms. Despite the deficiency, observations showed that residents had adequate space for movement, care, and privacy, and no concerns were raised by residents during the survey.
A resident with Type 1 diabetes and cognitive impairment did not have their physician notified when blood sugar levels dropped below the ordered threshold, and there was no evidence that blood sugar was monitored after insulin administration as required. The care plan lacked specific interventions for hypoglycemia management, and facility policies for prompt notification and hypoglycemia were not followed.
Two residents with behavioral and cognitive impairments, both on line of sight (LOS) monitoring for safety, were left unsupervised when staff failed to maintain required visual contact. This lapse allowed one resident to enter a shared bathroom and physically assault another resident, contrary to facility policy and physician orders requiring continuous supervision.
During a COVID-19 outbreak, several staff members, including LVNs, CNAs, and a Program Counselor, failed to consistently wear N95 respirator masks as required by the facility's infection control policy and public health recommendations. Observations showed staff either wearing surgical masks or no masks at all, despite the Infection Prevention Nurse's confirmation that N95 masks were mandatory. Reasons given included forgetting, not seeing masks available, or discarding them prematurely, potentially increasing the spread of infection.
A facility failed to provide sufficient staff to monitor residents, resulting in one resident with a history of aggression hitting another. On the day of the incident, only one MHW was assigned to monitor four hallways, which was insufficient. Resident 3, with schizophrenia and a history of hitting peers, was on a 15-minute monitoring schedule, but the lack of continuous supervision allowed him to assault Resident 4, who also had schizophrenia. Staff interviews confirmed inadequate staffing due to call-offs, contrary to facility policy requiring sufficient supervision for safety.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to an incident where he entered another resident's room and engaged in non-consensual contact. Despite previous incidents, the resident was not under special monitoring, allowing him to act without detection. The facility's failure to implement effective supervision and precautionary measures resulted in this deficiency.
A resident with schizoaffective disorder and PTSD reported a threatening sexual comment and gesture from a roommate. The facility failed to report the alleged abuse to authorities within the required two-hour timeframe, as mandated by their policy. The Administrator acknowledged the oversight, admitting the report was delayed by three days.
The facility failed to protect residents from physical abuse, resulting in incidents where residents were assaulted by peers. Despite known histories of aggression and behavioral issues, the facility did not adequately monitor or separate residents, leading to multiple altercations. Staff interviews revealed lapses in supervision and delayed responses to aggressive behaviors.
The facility failed to maintain safe food handling and hygiene practices. Dietary staff did not wash hands or change gloves when handling dishes, and some did not wear hair nets while preparing food. Additionally, a serving spoon placed in a sink was reused, risking food contamination. These actions were against the facility's policies and could lead to cross-contamination.
The facility failed to promptly notify primary physicians and the local health department about a disease outbreak affecting several residents, delaying intervention. Additionally, three staff members worked while symptomatic, increasing the risk of disease transmission. These actions violated the facility's infection control policies, which require timely reporting and prevention of symptomatic staff from working.
The facility failed to maintain the low-temperature dishwasher at the recommended temperature range, with observed temperatures fluctuating between 105 F and 118 F. A dietary aide logged an incorrect temperature and did not report the issue due to the absence of the dietary supervisor and maintenance staff. The Maintenance Supervisor found a booster tank was not functioning due to a power outlet issue, which had not been checked for a long time.
A resident with mild intellectual disabilities and ADHD eloped from a facility by climbing onto a roof and exiting through an unfenced area. The resident was not assessed for elopement risk upon admission, and despite participating in activities without incident, he left after being denied a community break. Staff initiated a Code Green but could not stop him. The facility's policy on safety and supervision was not effectively implemented, as a gap in the security fence allowed the escape.
A resident with a history of mental health disorders exhibited physical aggression due to hearing voices, but the care plan failed to specify the content of these voices. Facility staff, including an LVN and RN, noted the importance of this information for preventing future incidents. The Administrator acknowledged the need for a comprehensive, person-centered care plan, as per the facility's policy.
A resident with paranoid schizophrenia and anxiety was inappropriately touched by another resident with a history of inappropriate behavior in the dining room hallway. Despite being on every 15-minute monitoring, the incident occurred due to a lack of staff supervision at the time, as required by the facility's policy.
A resident with a history of sexually inappropriate behavior was inadequately monitored and managed, leading to repeated incidents of inappropriate touching of female staff and peers. Despite having a care plan, the facility failed to update interventions or provide specific monitoring instructions, resulting in an incident where the resident inappropriately touched another resident who was unable to consent.
A resident with schizoaffective disorder repeatedly refused medications, including Zyprexa and Valproic acid, over several days without the physician being notified, contrary to facility policy. The resident's psychiatric condition was declining, and staff interviews revealed that the facility's protocol for handling medication non-compliance was not followed, leading to a lack of monitoring and an incident of aggression.
A resident with cognitive impairments was physically restrained by a Program Counselor inappropriately, contrary to the facility's policy requiring at least two staff members for such actions. The incident, involving an altercation with another resident, was not reported until nearly eight hours later, despite multiple staff members being aware. This failure to adhere to reporting protocols violated the residents' rights and posed a risk of injury.
A resident with known hypersexual behavior was inadequately monitored, leading to inappropriate touching incidents involving another resident. Despite care plans requiring frequent monitoring and Line of Sight supervision, these measures were not consistently implemented, compromising the safety and well-being of the affected resident.
A resident with schizophrenia reported feeling unsafe and alleged sexual abuse by unknown men in her room. Despite these reports, facility staff failed to report the incidents to authorities or conduct a thorough investigation as required by policy. The staff dismissed the claims without proper investigation, leaving the resident and others potentially vulnerable.
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies in managing transmission-based precautions (TBP) for two residents with lice infestations. A CNA entered a resident's room without the required PPE due to a lack of TBP signage, and there was no appropriate notification near the room entrances of the affected residents. This oversight led to confusion among staff regarding the isolation status of the residents.
A resident with mood and developmental disorders was physically abused by a Program Counselor (PC) after the resident began punching the PC. A CNA witnessed the PC retaliate by punching the resident in the face, causing a nosebleed. The facility's Program Director confirmed the incident, noting that staff are instructed to walk away from escalating situations. The facility's policy emphasizes residents' right to be free from abuse.
A resident with cognitive impairments was allegedly punched by a staff member, resulting in a nosebleed. The LVN did not report the incident to authorities, believing the staff member's claim that the injury was self-inflicted. The Program Director later questioned this account, noting the resident's history did not support self-harm. The facility's policy requires immediate reporting of abuse, which was not followed.
A resident with cognitive impairments and at risk for elopement left the facility unsupervised during a kitchen delivery. The gates were left open without proper supervision, allowing the resident to exit. Staff interviews revealed a lack of communication and adherence to the facility's policy on supervising at-risk residents.
A facility failed to monitor and document mood instability in a resident receiving psychotropic medications, leading to an incident of physical aggression towards a roommate. Despite known triggers for the resident's aggression, staff did not document these episodes, violating the facility's policy on antipsychotic medication use. This lack of documentation could result in inappropriate medication management and increased risk to others.
A lack of staff supervision in a hallway led to an altercation between two residents, both with paranoid schizophrenia, resulting in one resident being hit. Interviews confirmed no staff were present during the incident, despite facility policy requiring supervision.
The facility failed to maintain a safe and comfortable environment, with non-functional paper towel dispensers, a damaged ceiling in the Dining Room, and high temperatures in the Big Dining/Activity room. A resident expressed discomfort due to the lack of paper towels, and staff confirmed the issues, highlighting deficiencies in maintenance and environmental conditions.
The facility failed to follow its food storage policy, leading to unlabeled and expired food items in the kitchen. Observations included unlabeled fruits and lettuce, and expired cinnamon rolls. Interviews with the DSS, DA, and DON confirmed the importance of labeling and discarding expired food to prevent contamination and foodborne illnesses.
The facility failed to properly dispose of garbage and refuse, leaving two dumpsters uncovered and old mattresses and a broken sofa near the garbage area. Staff, including the Dietary Service Supervisor and Director of Nurses, expressed concerns about potential pest infestations and health risks. Facility policies require garbage containers to be covered to prevent vermin access.
The facility failed to conduct water testing for legionella, as required by its infection control policy. The Infection Preventionist and Maintenance Supervisor admitted that the water system was not tested, putting residents at risk. The Administrator confirmed that tests were only conducted when there was suspicion, and no recent tests had been done. The facility's policy and federal guidelines require regular testing and documentation.
The facility failed to ensure bed safety by not checking the compatibility and size of bed frames, mattresses, and bedrails, leading to entrapment risks for several residents. Observations revealed significant gaps between mattresses and footboards, posing a danger of entrapment. Maintenance staff were aware of the issue but did not recognize the safety risk, and the facility's policy on bed safety was not followed.
The facility failed to maintain a sanitary environment, as evidenced by the presence of flies in several residents' rooms and a stained pillow used by a resident. Flies were observed in the rooms of three residents, with staff acknowledging their presence and attributing them to food brought into the rooms. Additionally, a resident was found using a pillow with brown and red stains, which had not been cleaned since admission. Another resident's room had numerous flying insects due to food remnants, posing a risk of infection.
The facility failed to implement its smoking policy, resulting in an unsafe environment for five residents who were smokers. Metal containers with self-closing covers were not provided, and residents were not adequately monitored, leading to improper disposal of cigarette butts. Residents with cognitive impairments required supervision while smoking, but the facility did not adhere to its policy, posing a fire hazard.
A resident with cognitive impairments and mental health diagnoses was observed walking naked in the hallway of an LTC facility, compromising his dignity and the comfort of others. Staff interviews revealed that the resident approached female residents while unclothed, and the facility's monitoring policies failed to prevent the incident. The resident's care plan included safety monitoring, but it was insufficient to uphold privacy and dignity standards.
A resident with schizophrenia and schizoaffective disorder experienced multiple falls due to inadequate care planning. Despite being at high risk for falls, the facility failed to develop a comprehensive care plan addressing the resident's behavior of walking or running fast, contributing to falls during smoke breaks and showering. Staff interviews revealed a lack of awareness and monitoring for fall risks, and the facility's policies for timely care plan development were not followed.
A resident with a superficial arm scratch did not receive proper wound care as per physician's orders, leaving the wound uncovered for five days. The LVN failed to read the order fully, leading to this oversight. The DON acknowledged the importance of following physician orders to prevent infection risks.
The facility failed to post accurate nurse staffing information daily, as required by its policy. Observations revealed incomplete NHPPD forms and missing postings at nursing stations. Interviews confirmed that the actual hours were not completed and posted within the required timeframe, resulting in residents not having access to direct care staffing numbers.
A medication administration error occurred when an LVN documented the administration of MiraLAX to a resident without actually administering it. The resident, with a history of schizophrenia and depression, was supposed to receive the medication for constipation. The facility's policy requires documentation after administration, but this was not followed, leading to a significant medication error.
A resident with paranoid schizophrenia returned from an Out-on-Pass with a cigarette lighter, which was not detected due to inadequate screening by the facility's staff. The resident used the lighter to ignite a magazine, triggering a smoke alarm and necessitating fire department intervention. This incident exposed residents and staff to smoke and potential injury.
The facility failed to revise the care plans for two residents to include interventions to prevent further abuse. One resident, with schizoaffective disorder, was a victim of physical abuse twice in one month, and the care plan was not updated. Another resident, also with schizoaffective disorder, exhibited multiple instances of socially inappropriate behavior, and the behavior contract was not updated to address these incidents.
A resident with a history of schizophrenia and swallowing difficulties choked and was not immediately assisted with the Heimlich maneuver or CPR, leading to their death. Staff failed to follow emergency procedures, delaying critical intervention. The facility lacked an AED, and no Code Blue was announced. Interviews revealed a lack of CPR certification among some staff and procedural failures in handling the emergency.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly noted during the survey, indicating that the facility did not meet the regulatory requirement to address residents' behavioral health needs.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Non-Controlled Medication Dispositions Not Witnessed by Two Nurses
Penalty
Summary
The facility failed to ensure that non-controlled medication dispositions were performed in accordance with its own policy, which requires the presence of two licensed nurses during the destruction of such medications. Over a period of nineteen months, disposition logs for non-controlled medications consistently showed that only one registered nurse signed off on the destruction, with the witness column left blank. This practice was confirmed during interviews and record reviews with the Director of Nursing (DON), who acknowledged that the process had not involved two nurses as required by the facility's policy since January 2024. The deficiency was identified during a review of medication disposition records and concurrent interviews with the DON. The most recent medication disposition involved 25 residents' non-controlled medications, all documented with only one nurse's signature. The DON confirmed that this had been the standard practice for at least nineteen months, and that the facility's written policy, which mandates two licensed nurses for non-controlled medication destruction, had not been followed during this period.
Unattended and Unlocked Medication Cart in Nursing Station
Penalty
Summary
A medication cart labeled 'AM med cart' was observed unattended and unlocked outside the medication room in Nursing Station 1. The area could be accessed by non-nursing staff, including CNAs, who had key access to the nursing station. During the observation, the DON confirmed that the medication cart was not locked and acknowledged that it should have been secured. Facility policy requires that medications be stored safely and securely, accessible only to licensed nursing or pharmacy personnel. The failure to lock the medication cart when unattended constituted a breach of this policy.
Failure to Properly Store and Label Dehydrated Milk in Food Storage Area
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and professional standards regarding food storage, preparation, distribution, and serving. During an inspection of the dry food storage area, an opened plastic container was found containing an unsealed bag of dehydrated milk. The bag was not labeled or dated to indicate when it was opened or its expiration date. The Dietary Supervisor confirmed the presence of the unsealed, unlabeled, and undated bag during the observation and interview. A review of the facility's policy and procedures on Food Receiving and Storage, revised in November 2022, indicated that dry foods stored in bins should be removed from their original packaging, labeled, and dated with a use-by date. The Dietary Supervisor acknowledged that the bag of dehydrated milk should have been sealed, labeled, and dated to prevent contamination and spoilage, and stated that the product needed to be discarded due to the risk of contamination.
Failure to Monitor Clozaril Serum Levels as Ordered
Penalty
Summary
The facility failed to follow a physician's order to obtain monthly Clozaril (clozapine) serum levels for a resident diagnosed with schizoaffective disorder and post-traumatic stress disorder. The resident had an active order for Clozaril 400 mg at bedtime to address auditory hallucinations, with a corresponding order to monitor Clozaril blood levels monthly. However, the facility did not obtain or have records of the required Clozaril serum levels for two out of five months reviewed. Interviews with the Director of Nursing confirmed the absence of Clozaril blood level results for the specified months. Additionally, a review of the facility's policy on antipsychotic medications revealed that it did not address the monitoring of Clozaril serum levels or outline a process for adequate monitoring of antipsychotic usage.
Failure to Obtain Physician Order and Complete Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to follow its policy and procedure for discharge planning and documentation for one resident who was transferred to a general acute care hospital for psychiatric evaluation. The resident, who had diagnoses including schizophrenia and anxiety disorder, was transferred due to physical aggression. Upon review, it was found that there was no physician's order for discharge and no discharge summary completed in the resident's medical record. The Social Services Assistant (SSA) initiated the discharge notification but did not provide a bed hold notice, based on communication from the case manager indicating the resident would not return. The Licensed Vocational Nurse Supervisor (LVNS) did not obtain a discharge order or complete the discharge summary, stating she was unaware of the discharge decision and was occupied with other duties. Interviews with facility staff confirmed that the required discharge documentation was not completed, and there was a lack of communication between the SSA, LVNS, and the case manager regarding the resident's discharge status. The administrator acknowledged that the nurse should have obtained a physician's discharge order and completed the discharge summary to ensure proper and safe discharge. Review of the facility's policy indicated that a discharge summary and post-discharge plan should be developed when a resident's discharge is anticipated, but this was not done in this case.
Incomplete Care Plan Implementation
Penalty
Summary
A deficiency was identified regarding the development and implementation of a complete care plan for a resident. The care plan did not address all of the resident's needs, and it lacked measurable timetables and specific actions. This failure resulted from incomplete assessment and planning, as the care plan did not comprehensively cover the resident's requirements as observed by surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Secure Storage for Resident Belongings
Penalty
Summary
A deficiency was identified when a cabinet in a shared resident room was found to be missing a dead bolt, leaving the cabinet unable to be securely closed. During an observation, the cabinet belonging to a resident was open, and it was confirmed that the locking mechanism was missing. The Infection Prevention Nurse (IPN) acknowledged that all cabinets should have functioning locks to provide residents with a secure space for their personal belongings. The IPN also stated that staff are responsible for reporting maintenance issues, but in this case, the issue had not been properly addressed. Further investigation revealed that a counselor had verbally reported the missing lock to the Maintenance Department several weeks prior, but the maintenance supervisor to whom it was reported was no longer employed at the facility. The counselor was unaware of the need to document maintenance issues in a log and had not followed up after the initial report. The facility's administrator stated that maintenance staff and department heads are expected to conduct daily checks of rooms to ensure safety and functionality, and that the lock should have been repaired when first reported. Review of facility policy confirmed that maintenance is responsible for keeping equipment in safe and operable condition at all times.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms, as specified by regulations. Ten out of 62 resident rooms were identified as not meeting this standard, with room sizes ranging from 66 to 72 square feet per resident. These rooms were observed to have two beds each, and in some cases, only one resident was occupying the room. The deficiency was identified through observation, interviews, and review of the facility's Client Accommodations Analysis, which documented the square footage and occupancy of each room. During the survey, the Administrator confirmed that no room waiver application had been submitted and declined to request room variances prior to the survey. Despite the deficiency, observations during the survey period indicated that residents had sufficient space for movement, nursing care, privacy, and use of care equipment. No concerns regarding room space were raised by residents during the Resident Council meeting, and no adverse effects on residents' personal space, nursing care, or comfort were noted at the time of the survey.
Failure to Notify Physician and Monitor Blood Sugar per Orders in Diabetic Residents
Penalty
Summary
The facility failed to follow physician orders and established protocols in the management of diabetes for two residents. For one resident with a diagnosis of Type 1 diabetes mellitus and moderate cognitive impairment, the facility did not notify the resident’s physician when blood sugar (BS) levels fell below 85, as required by the physician’s orders. Multiple instances were documented where the resident’s BS was below 85, but there was no evidence in the progress notes or other records that the physician was informed of these low readings. Additionally, the facility did not adequately monitor the resident’s BS after administering Humalog Kwikpen insulin following breakfast and dinner, as ordered. The medication administration records showed that insulin was given as scheduled, but there was no documentation that BS was checked at the appropriate times or that the physician was notified when BS was below the specified threshold. The Director of Nursing confirmed that the orders for sliding scale insulin did not include additional BS checks at the times when Humalog Kwikpen was administered, and that this discrepancy was not clarified with the physician. Furthermore, the care plan for diabetes management did not include comprehensive interventions or protocols for hypoglycemia management specific to the resident’s orders. The care plan only stated a general goal to avoid signs and symptoms of hypoglycemia, without detailing actions to be taken for low BS readings or after insulin administration. Facility policies required prompt notification of changes in a resident’s condition and outlined procedures for hypoglycemia management, but these were not followed in practice for the residents involved.
Failure to Maintain Line of Sight Supervision Results in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision for two residents who were both on line of sight (LOS) monitoring due to their behavioral and cognitive conditions. Resident 1 had diagnoses including schizoaffective disorder, intermittent explosive disorder, and insomnia, with a physician order and care plan requiring LOS monitoring for safety due to physical aggression. Resident 2 had diagnoses including unspecified mood disorder, autistic disorder, and mild intellectual disabilities, also with a physician order and care plan for LOS monitoring due to a history of physical aggression and being a victim of aggression. Both residents had moderately impaired cognition as documented in their Minimum Data Set assessments. On the day of the incident, staff assigned to LOS monitoring were not maintaining direct visual supervision as required by facility policy and physician orders. CNA 1 was observed sitting outside Resident 1's room with the door closed, unable to see the resident, despite acknowledging that LOS required direct focus and visual contact. Similarly, the program counselor assigned to Resident 2 stated she could only see the entrance to the bathroom and not the resident himself, as the bathroom door was closed. Staff interviews confirmed that LOS monitoring was not being properly implemented, with room and bathroom doors closed, preventing staff from maintaining the required visual supervision. As a result of this lack of supervision, Resident 1 entered a shared bathroom where Resident 2 was present and punched Resident 2 in the face. The incident was confirmed through resident and staff interviews, as well as review of the facility's abuse investigation. Facility policies reviewed indicated that LOS and one-to-one monitoring require staff to maintain visual contact with the resident at all times, including keeping doors ajar during bathroom use, which was not followed in this case.
Inadequate Use of PPE During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of COVID-19 during an outbreak. Observations and interviews revealed that several staff members, including LVNs, CNAs, and a Program Counselor, did not consistently wear N95 respirator masks as required by the facility's infection prevention and control policy and public health recommendations. Specifically, LVN 1, CNAs 1 and 2, and PC 1 were observed either wearing surgical masks instead of N95 masks or not wearing any mask at all while in the facility. LVN 2 was observed administering medications without a mask, and CNA 2 mentioned not seeing any N95 masks available onsite. The Infection Prevention Nurse confirmed that all staff should be wearing N95 masks during the outbreak, as per the recommendations from a Public Health Nurse. The facility's policy, dated May 2023, required universal use of PPE, including N95 masks, during a COVID-19 outbreak. Despite these guidelines, staff members cited reasons such as forgetting to wear the mask, not seeing any available, or discarding the mask prematurely. These actions and inactions had the potential to increase the spread of infection among residents, staff, and visitors during the outbreak.
Inadequate Staffing Leads to Resident Assault
Penalty
Summary
The facility failed to provide sufficient staff to monitor and supervise residents, resulting in an incident where one resident was hit by another. On the day of the incident, only one Mental Health Worker (MHW) was assigned to monitor the floor, which was insufficient to cover all four hallways. This lack of adequate staffing led to a situation where the MHW was unable to effectively monitor the residents, contributing to the incident where Resident 3, who had a history of aggressive behavior, struck Resident 4 in the hallway. Resident 3 was admitted to the facility with diagnoses including schizophrenia and hyperlipidemia and had a documented history of behavioral incidents involving hitting peers. Despite being on a 15-minute monitoring schedule due to his aggressive behavior, the monitoring was not continuous, and staff were unable to account for his actions between checks. Resident 4, who also had schizophrenia and hypertension, was the victim of the assault and expressed fear of further incidents, indicating a failure in ensuring her safety. Interviews with staff revealed that the facility's usual practice was to have two to three staff members monitoring the floor, but on the day of the incident, staffing was inadequate due to call-offs and other assignments. The facility's policy emphasized the importance of resident supervision for safety, yet the staffing levels on the day in question did not meet these requirements, leading to the deficiency.
Inadequate Supervision Leads to Non-Consensual Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of sexually inappropriate behavior, leading to an incident where another resident was subjected to non-consensual sexual contact. On the evening of January 31, 2025, a certified nurse assistant (CNA) witnessed Resident 1 in Resident 2's room, engaging in inappropriate behavior. Despite Resident 1's known history of such behavior, the facility did not implement sufficient monitoring measures, allowing Resident 1 to enter Resident 2's room undetected. Resident 1, who has been diagnosed with schizoaffective disorder and intermittent explosive disorder, had a documented history of inappropriate sexual behavior towards female residents. This history included multiple incidents of touching and kissing female residents without consent. Despite these documented behaviors, Resident 1 was not placed under any special monitoring or 1:1 supervision prior to the incident on January 31, 2025. The lack of supervision allowed Resident 1 to enter Resident 2's room, where he kissed her and touched her private area without her consent. The facility's failure to adhere to its own policies regarding supervision and precautions for residents with dangerous behaviors contributed to the incident. Staff members were instructed to monitor Resident 1 closely, but this was not effectively carried out, resulting in Resident 1's unsupervised access to Resident 2. The incident was further complicated by a handwritten consent form that Resident 1 had Resident 2 sign, which was not legitimate and was signed under duress. This lack of proper supervision and failure to implement effective precautionary measures directly led to the deficiency noted in the report.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents to the appropriate authorities within the required two-hour timeframe. Resident 1, who has diagnoses of schizoaffective disorder and post-traumatic stress disorder, reported that his roommate, Resident 2, made a threatening sexual comment and gesture towards him. Despite the seriousness of the allegation, the facility did not notify the long-term care ombudsman, law enforcement, or the California State Department of Public Health (CDPH) as mandated by their policy. The incident occurred on the evening of January 17, 2025, when Resident 1 reported to a staff member that Resident 2 had threatened to rape him while making a sexual gesture. The Program Manager was informed and reported the incident to the Program Director and the charge nurse, who was responsible for notifying the authorities. However, the Administrator, who was ultimately responsible for ensuring the report was made, failed to do so until January 20, 2025, three days after the incident. The facility's policy on abuse prevention and mandated reporting clearly states that any suspected abuse must be reported within two hours to the relevant authorities. The Administrator acknowledged the oversight, admitting that she forgot to report the incident despite being informed about it on the night it occurred. This failure to act in a timely manner placed Resident 1 and potentially other residents at risk for further abuse.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in incidents involving three residents. Resident 7 was physically assaulted by Resident 3, who was supposed to be under line of sight (LOS) supervision due to previous aggressive behavior. Despite the supervision order, Resident 3 managed to approach and hit Resident 7, causing physical harm. The facility's social worker and program director acknowledged that Resident 3 had a history of aggression and was awaiting placement in a higher level of care, but there was a delay in executing the 30-day discharge notice. In another incident, Resident 6 was attacked by Resident 2, who had a history of wandering into other residents' rooms. Despite previous reports of Resident 2's behavior, the facility failed to prevent him from entering Resident 6's room and hitting her. Interviews with staff revealed that Resident 2's behavior had been escalating, and there was a lack of effective monitoring to prevent such incidents. The facility's administrator admitted that more frequent monitoring could have prevented the incident. The third incident involved Resident 4 being assaulted by Resident 1, who had a history of aggression towards both staff and other residents. Despite previous altercations, Resident 1 was not placed on LOS monitoring until after the incident with Resident 4. The facility's administrator acknowledged that Resident 1 should have been monitored more closely following earlier aggressive incidents. The facility's policy on abuse prevention was not effectively implemented, leading to these failures in resident protection.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and handling practices, as observed during a lunch service. Dietary Aide (DA) 3 did not wash his hands or change gloves after returning to the kitchen from serving food, and proceeded to handle both soiled and clean dishes without proper hand hygiene. Similarly, DA 4 assisted in dishwashing without changing gloves or washing hands, leading to potential cross-contamination of clean dishes. Interviews with the kitchen staff confirmed these lapses in hygiene practices, which were against the facility's policy. Additionally, two dietary staff members, including [NAME] 1 and DA 2, were observed not wearing hair nets while preparing and storing food in the kitchen. [NAME] 1 admitted to removing her hair net when she went to the bathroom and failed to put it back on upon returning to the kitchen. DA 2 was seen picking up a hair net from the floor and wearing it, mistakenly believing it was still clean. The facility's policy requires hair nets to be worn at all times in the kitchen to prevent hair from contaminating food and food preparation areas. Furthermore, [NAME] 1 used a serving spoon that had been placed in a sink to mix and scoop cooked macaroni, despite acknowledging that the spoon was dirty and the sink was not clean. This action risked contaminating the food that was to be served to residents. The facility's policies emphasize the importance of maintaining clean and sanitary food service areas and equipment, which was not adhered to in this instance.
Failure in Infection Control and Staff Management
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding the prompt notification of primary physicians and the local health department about a disease outbreak. On December 17, 2024, several residents, identified as Residents 1 through 6, experienced symptoms of nausea, vomiting, and diarrhea. Despite these symptoms being documented in the facility's internal communication log by an LVN, the Infection Preventionist (IP) was not notified until the following day. Consequently, the primary physician and the health department were only informed on December 18, 2024, leading to a delay in intervention. Additionally, the facility did not ensure that symptomatic employees refrained from coming to work, which is a critical component of controlling the spread of communicable diseases. On December 18, 2024, three Program Counselors (PCs) reported to work despite experiencing symptoms such as stomach pain, nausea, and diarrhea. These employees continued to work until they were sent home later in their shifts after reporting their symptoms to their manager. This failure to prevent symptomatic staff from working increased the risk of disease transmission within the facility. The facility's policies, revised in September 2022, clearly state the need for prompt reporting of suspected or confirmed infections to health authorities and the requirement for staff to report symptoms and refrain from working when ill. The inaction in notifying the IP and the failure to prevent symptomatic staff from working represent significant lapses in the facility's infection control practices, potentially exacerbating the spread of the disease among residents, staff, and visitors.
Dishwasher Temperature Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain the low-temperature dishwasher in the kitchen at the manufacturer's recommended temperature range of 120 to 140 degrees Fahrenheit during the washing and rinsing phases. During an observation, the dishwasher's thermometer was recorded at temperatures fluctuating between 105 F and 118 F, never reaching the required 120 F. A dietary aide acknowledged logging a temperature of 120 F despite observing a lower temperature and did not report the issue due to the dietary supervisor being on sick leave and the maintenance staff being unavailable. The Maintenance Supervisor later identified that a booster tank, essential for maintaining the dishwasher's temperature, was not functioning due to a power outlet being shut off, likely caused by a power demand overload in the kitchen. The Maintenance Supervisor admitted that the power outlet had not been checked for a long time and relied on staff to report any issues. The facility's policy indicated that temperatures out of the specified range should be reported to the Nutrition Service Manager, which was not done in this instance.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to maintain a hazard-free environment and provide adequate supervision, resulting in a resident eloping from the premises. The resident, who had been admitted with diagnoses including mild intellectual disabilities and attention-deficit hyperactivity disorder, was not assessed for elopement risk upon admission. Despite having a history of substance abuse, the resident was deemed not at risk for wandering or elopement in an assessment conducted on the day of the incident. On the evening of the elopement, the resident was denied participation in a community break due to a previous incident, after which he climbed onto the roof of Building B and exited the facility through an unfenced area. The facility's investigation revealed that the resident used a wall to climb onto the roof and then proceeded to climb fences to reach the street. Staff initiated a Code Green upon realizing the resident was missing, but were unable to stop him as he was not receptive to their calls to halt. The resident's elopement was unexpected as he had not shown prior signs of wanting to leave the facility, and he had participated in activities throughout the day without incident. The facility staff followed protocol by not chasing the resident to avoid further risks. Interviews with staff and another resident indicated that the elopement was not anticipated, and the resident had not expressed any specific plans to leave. The facility's policy on safety and supervision emphasizes maintaining an environment free from accident hazards, but the gap in the security fence allowed the resident to elope. The facility's policy on elopement precautions states that the grounds are secured with locked fences, which was not the case in the area where the resident escaped.
Inadequate Care Plan for Resident with Aggression
Penalty
Summary
The facility failed to ensure a comprehensive care plan was specific for a resident who exhibited physical aggression toward another resident. The resident, who was diagnosed with bipolar type schizoaffective disorder, paranoid schizophrenia, bipolar disorder, and mild intellectual disabilities, had an incident of physical aggression on 11/7/2024 due to hearing voices. The care plan, revised on 11/8/2024, did not specify what the resident was hearing that led to the aggression, which was crucial for staff to understand and prevent future incidents. Interviews with facility staff, including a Licensed Vocational Nurse and a Registered Nurse, revealed that the care plan lacked specificity regarding the voices the resident was hearing. Both staff members emphasized the importance of knowing the content of the voices to effectively monitor and protect other residents. The facility's Administrator also acknowledged that the care plan needed to be comprehensive and person-centered, indicating that simply noting the resident was hearing voices was insufficient. The facility's policy on care plans, revised in March 2022, requires that care plans include measurable objectives and address underlying sources of problems, not just symptoms or triggers.
Inadequate Supervision Leads to Resident Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents involving two residents, Resident 8 and Resident 9. Resident 8, who was admitted with diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety, was placed on every 15-minute monitoring for safety. Despite these measures, Resident 8 was inappropriately touched by Resident 9 in the dining room hallway, leading to Resident 8 feeling targeted and unsafe. Resident 9, who has a history of socially inappropriate behavior, was also on every 15-minute monitoring and line of sight supervision during certain shifts. The incident occurred when Resident 8 was looking into the kitchen window, and Resident 9 moved behind her, grabbed her hips, and thrusted against her. This inappropriate contact was witnessed by other residents and staff members, who confirmed the lack of supervision in the dining room hallway at the time of the incident. The facility's policy required staff to monitor the dining room lines, but no staff was present in the hallway when the incident occurred. Interviews with staff revealed that the activities aides were responsible for monitoring the dining room lines during weekends, but they were not present at the time of the incident due to other duties. The facility's policy on supervision and precautions indicated that staff should provide daily supervision and monitor hallways on all shifts, but this was not adhered to, resulting in the incident between Resident 8 and Resident 9.
Inadequate Behavioral Health Management and Monitoring
Penalty
Summary
The facility failed to adequately address and manage the behavioral health care needs of a resident, identified as Resident 7, who exhibited socially inappropriate behavior, including sexually inappropriate touching of female staff and peers. Despite having a care plan in place since September 2022, which included interventions such as 1:1 counseling and advising the resident to avoid female peers, the facility did not effectively monitor or revise these interventions following repeated incidents. The care plan was not updated after an incident on November 7, 2024, where Resident 7 attempted to touch a female program manager's buttock, indicating a lack of proactive management of the resident's behavior. The facility's monitoring practices were insufficient, as staff assigned to monitor Resident 7 every 15 minutes were not informed of the specific behaviors to watch for, focusing instead on general inappropriate behaviors. This lack of specificity in monitoring allowed Resident 7 to continue engaging in inappropriate behavior, culminating in an incident on November 13, 2024, where Resident 7 inappropriately touched another resident, identified as Resident 3, who was unable to consent to sexual activities due to severe cognitive impairment. Interviews with staff revealed a lack of awareness and understanding of the specific behaviors that needed monitoring, further contributing to the deficiency. The facility's policies and procedures regarding supervision and behavioral health services were not effectively implemented. Despite having policies in place for 1:1 monitoring and behavioral health services, the facility did not ensure that staff were adequately trained or informed about the specific needs and interventions required for Resident 7. The Director of Nursing and other staff members acknowledged the inadequacy of the interventions and monitoring, yet no significant changes were made to address the escalating behavior of Resident 7, leading to repeated incidents of inappropriate touching.
Failure to Notify Physician of Medication Non-Compliance
Penalty
Summary
The facility failed to notify the physician of a resident's non-compliance with scheduled medications, specifically Zyprexa and Valproic acid, for a period ranging from five to twelve consecutive days. This oversight was contrary to the facility's policy, which required physician notification after two consecutive refusals of medication. The resident, who was admitted with diagnoses including schizoaffective disorder and had a history of medication non-compliance, refused the 9 AM Zyprexa dose 20 times and the 9 PM dose 16 times, with consecutive refusals spanning several days. Additionally, the resident refused the Valproic Acid dose six times, with five consecutive refusals. The resident's psychiatric condition was noted to be declining, and there was no documentation indicating that the physician was informed of the medication refusals. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), LVN Supervisor, and the Director of Nursing (DON), revealed that the facility's protocol for handling medication non-compliance was not followed. The staff acknowledged that the physician should have been notified after three days of medication refusal, and the resident should have been monitored more closely for safety. The facility's Administrator confirmed that the physician should have been notified two days after the medication non-compliance began, and there should have been documentation of this communication. The lack of notification and monitoring potentially contributed to an incident where the resident hit a peer, as the resident was not being closely monitored for aggressive behavior. The facility's policy and procedure titled 'Change in a Resident's Condition or Status' required notification of the physician after two consecutive refusals, which was not adhered to in this case.
Failure to Protect Resident from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Program Counselor (PC) who physically restrained a resident inappropriately. On the morning of October 12, 2024, a resident became upset and aggressive during a group activity, leading to an altercation with another resident. In response, PC 10 grabbed the resident from behind and took them to the ground, which was not in accordance with the facility's policy and procedure for managing dangerous behavior. The facility's policy requires at least two staff members to be involved in restraining an aggressive resident to prevent injury, but PC 10 acted alone. The incident was not reported immediately, as required by the facility's policy. The altercation between the two residents and the subsequent physical restraint by PC 10 occurred around 9 AM, but it was not reported until the resident informed the Program Manager Counselor (PMC) at approximately 4:57 PM, nearly eight hours later. Multiple staff members, including a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA), were aware of the incident but did not report it, assuming others would do so. The facility's policy mandates that any type of abuse should be reported within two hours, but this was not adhered to. The residents involved had cognitive impairments and mental health diagnoses, which may have contributed to the altercation. Resident 1 had a history of mood affective disorder, autistic disorder, and mild intellectual disabilities, while Resident 2 had bipolar disorder, schizophrenia, and major depressive disorder. The failure to follow the facility's policy and procedure for managing aggressive behavior and reporting abuse not only violated the residents' rights to be free from abuse but also posed a risk of injury and recurrence of such incidents.
Failure to Monitor Resident with Hypersexual Behavior
Penalty
Summary
The facility failed to prevent further abuse and mistreatment by not adequately monitoring a resident with known hypersexual behavior, leading to inappropriate touching incidents involving another resident. Resident 5, who has a history of schizoaffective disorder and paranoid schizophrenia, exhibited sexually inappropriate behavior by touching Resident 4's buttocks on two occasions without consent. Despite being on a care plan that required monitoring every 15 minutes and being placed on Line of Sight supervision, there was no documented evidence that these interventions were consistently implemented. Resident 4, who has paranoid schizophrenia and moderate cognitive impairment, expressed feelings of frustration and lack of safety due to these incidents. The care plan for Resident 4 aimed to ensure her safety, but the facility's failure to effectively monitor and manage Resident 5's behavior compromised this goal. Interviews with staff revealed that Resident 5's behavior was known, yet the necessary precautions were not adequately enforced, leading to repeated incidents of inappropriate touching. The facility's policies and procedures emphasize the right of residents to be free from abuse and exploitation, yet the lack of proper supervision and documentation of Resident 5's behavior monitoring indicates a failure to uphold these standards. Staff interviews highlighted the absence of consistent monitoring and the impact on Resident 4's mental and emotional well-being, as well as the potential for further incidents if appropriate measures are not taken.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility staff failed to implement their policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation. Specifically, they did not identify, protect, report, or initiate an investigation immediately following a suspected sexual abuse allegation made by a resident on two separate occasions. The resident, who had a history of schizophrenia, reported feeling unsafe and believed that unknown men were entering her room and touching her inappropriately at night. Despite these allegations, the facility did not report the incidents to the appropriate authorities, including the California Department of Public Health, local law enforcement, the Ombudsman, and Adult Protective Services. The resident's medical records indicated a moderate cognitive impairment and a need for supervision in daily activities. On two occasions, the resident expressed feeling unsafe and attempted to leave the facility, citing the belief that men were entering her room. Despite these reports, the facility staff, including a Licensed Vocational Nurse and a Registered Nurse Supervisor, did not take the allegations seriously. The staff failed to conduct a thorough investigation or report the incidents as required by the facility's policy. The Registered Nurse Supervisor dismissed the claims as false without conducting a proper investigation, relying instead on the police's assessment. Interviews with facility staff revealed a lack of communication and adherence to the facility's policy. The Program Counselor and Program Counselor Manager were aware of the resident's allegations but did not report them to the nursing staff or the Administrator. The Director of Nurses acknowledged that the incidents should have been reported and investigated immediately. The facility's policy required all reports of abuse to be thoroughly investigated and documented, but this was not done, leaving the resident and potentially other residents vulnerable to further abuse.
Inadequate Infection Control and TBP Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as per its policy and procedure, which led to deficiencies in managing transmission-based precautions (TBP) for two residents. Certified Nurse Assistant (CNA) 3 entered the room of Resident 13 without wearing the required gown and gloves, despite the resident being on TBP due to a lice infestation. Additionally, there was no signage indicating that Resident 13 was on TBP, which contributed to the CNA's uncertainty about the resident's isolation status. This oversight was observed during a facility tour and interview with the Infection Preventionist, who confirmed the absence of appropriate signage. Furthermore, the facility did not place appropriate notifications or postings near the room entrances of Residents 13 and 14, who were both on TBP due to live lice. The lack of signage and personal protective equipment (PPE) led to confusion among staff, as evidenced by CNA 4's statement that the absence of signs or PPE would indicate a non-isolation room. The facility's policy required notification on room entrance doors for residents on TBP, but this was not adhered to, as confirmed by a review of the facility's policy and procedure on isolation and transmission-based precautions.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving a resident with unspecified mood disorder, autistic disorder, and mild intellectual disabilities. The resident, who had moderately impaired cognition, was involved in an altercation with a Program Counselor (PC) after the resident began punching the PC. A Certified Nursing Assistant (CNA) witnessed the PC retaliate by punching the resident in the face, causing the resident's nose to bleed. The resident later reported feeling pain in his hand and face and expressed feeling safer after the PC was no longer at the facility. The facility's Program Director (PD) acknowledged the incident, noting that the investigation report initially suggested self-injury, which was inconsistent with the resident's behavior. The PD confirmed that the PC had hit the resident and expressed confusion over the PC's reaction, as staff were instructed to walk away from escalating situations. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse by anyone, including staff, and outlines the administration's responsibility to protect residents from such incidents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner, as required by Federal and State regulatory guidelines. The incident involved a resident with diagnoses including unspecified mood disorder, autistic disorder, and mild intellectual disabilities, who was reported to have been punched in the face by a staff member, resulting in a nosebleed. The staff member involved claimed the resident's injury was self-inflicted, and the Licensed Vocational Nurse (LVN) did not report the incident to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman, as he believed the staff member's account. The Program Director (PD) later reviewed the investigation and expressed doubt about the self-injury claim, noting that the resident would not typically harm himself in such a manner. The facility's policy and procedure require that any suspicion of abuse be reported immediately, defined as within two hours, to the administrator and other officials. The failure to report the incident promptly had the potential to lead to underreporting of abuse allegations and a lack of timely investigation.
Resident Elopement Due to Lack of Supervision During Delivery
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk for elopement, resulting in the resident leaving the premises without authorization. The resident, who had a history of bipolar disorder, oppositional defiant disorder, and ADHD, was identified as having moderately impaired cognition and was assessed to be at risk for elopement. On the day of the incident, the resident was being escorted by a Certified Nursing Assistant (CNA) to a dental appointment within the facility when they noticed an open gate and ran out of the facility. The incident occurred during a kitchen delivery when gates that should have been supervised were left open. The Dietary Supervisor explained that it was the responsibility of the dishwasher attendant or stockperson to supervise the gates during deliveries to prevent residents from leaving. However, during the incident, no staff was present to supervise the gates, allowing the resident to exit the facility. The maintenance assistant confirmed that no kitchen staff was present at the gate when the resident ran out. Interviews with staff revealed a lack of communication and supervision during the delivery process. The Dietary Supervisor was unaware of the exact circumstances as the kitchen staff did not report the details of the incident. The facility's policy on wandering and elopements emphasized the need for identifying at-risk residents and preventing harm, but the lack of supervision during the delivery process led to the resident's unauthorized departure.
Failure to Monitor and Document Mood Instability in Resident on Psychotropic Medication
Penalty
Summary
The facility failed to monitor and document episodes of mood instability for a resident who was receiving psychotropic medications, as required by the care plan and facility policy. This resident, who had a history of verbal aggression towards staff, was involved in an incident where he physically assaulted his roommate. The care plan specified that the resident should be monitored for mood instability every shift, but there was no evidence of such monitoring in the Medication Administration Record (MAR) or clinical records for July and August 2024. Interviews with facility staff, including a Program Counselor, a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), revealed that the resident's aggressive behavior was primarily triggered during shower days. Despite this known trigger, the staff did not document these episodes of aggression, which included shouting and cursing, in the MAR or clinical records. The lack of documentation meant that there was no evaluation of whether the resident's behavior was escalating or if non-pharmacological interventions were effective. The facility's policy on antipsychotic medication use required documentation of the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. However, the facility did not adhere to this policy, as evidenced by the absence of documentation regarding the resident's aggressive behavior and mood instability. This oversight could potentially lead to inappropriate medication management and increased risk of harm to other residents and staff.
Lack of Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure the safety of residents by not providing adequate supervision in the hallway where residents were waiting for lunch. This lack of supervision led to an altercation between two residents, both diagnosed with paranoid schizophrenia, which could have resulted in serious harm. Resident 4, who was admitted with intact cognition, was hit on the face by Resident 5 while looking at the lunch menu. Resident 5, also with intact cognition, claimed to have reacted to a perceived touch by Resident 4. Interviews with both residents confirmed the absence of staff supervision during the incident. The Director of Nursing acknowledged that no staff witnessed the altercation and emphasized the importance of staff presence to prevent such incidents. The facility's policy on supervision, revised in 2022, mandates staff monitoring in hallways and during group activities, which was not adhered to at the time of the incident.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a functional, safe, and clean environment for its residents, as evidenced by several deficiencies observed during the survey. The paper towel dispensers in certain rooms were not in working condition, which was confirmed by the Maintenance Supervisor who stated that they had been fixed after the observation. However, the lack of functioning dispensers had the potential to expose residents to hygiene issues, as they were unable to dry their hands after washing. In the main Dining Room, a water leak had caused damage to the ceiling, which was not promptly repaired. The Maintenance Supervisor acknowledged that a previous leak had been fixed, but subsequent rain caused further damage that was not addressed immediately. This oversight resulted in the dining area being rearranged to avoid the leak, indicating a failure to maintain the environment in good repair and free from hazards. Resident 135 experienced discomfort due to the lack of paper towels in their restroom, which had been ongoing for at least three months. The resident expressed feelings of being upset and dirty due to the inability to dry their hands. The Maintenance Supervisor and Housekeeper both acknowledged the issue, with the Housekeeper noting the dispenser was broken and had not been reported for repair. Additionally, the temperature in the Big Dining/Activity room exceeded the recommended range, causing discomfort for residents who frequented the area. The maintenance assistant and program staff confirmed the room's temperature was too warm, affecting residents' comfort during meals and activities.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure on food storage, which is in accordance with professional standards of practice for food service safety. During an initial kitchen tour, surveyors observed two brown bags of fruits containing approximately 20 oranges and six apples, as well as six heads of lettuce in a clear plastic container, all without labels or used by dates. Additionally, an open box of 15 frozen cinnamon rolls was found in the freezer with an expired used by date. These observations were confirmed through interviews with the Dietary Service Supervisor (DSS) and Dietary Aid (DA) 1, who acknowledged the importance of labeling food to prevent contamination and foodborne illnesses. The Director of Nurses (DON) also confirmed that the kitchen staff should ensure all expired foods are discarded immediately and that all food items should be labeled and dated. The facility's policy and procedure titled 'Labeling and Dating of Foods' requires all food items in storage to be labeled and dated for food safety and product rotation. The Food Code 2022 further supports this requirement by stating that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with a date by which it should be consumed or discarded. The failure to follow these procedures had the potential to result in food contamination and foodborne illnesses for residents.
Improper Garbage Disposal and Potential Pest Infestation
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Two out of three metal dumpsters were left uncovered, and more than 15 old mattresses and a broken sofa were found near the garbage area. This situation was noted during an observation and interview with the Dietary Service Supervisor, who expressed concern about the potential for infestation by rodents, insects, and other pests, which could lead to the spread of infection affecting both staff and residents. Interviews with various staff members, including a Dietary Aid, Maintenance Supervisor, Administrator, and Director of Nurses, revealed a consensus that the garbage area should be maintained properly. The Dietary Aid acknowledged the importance of keeping dumpster lids closed to prevent attracting pests. The Maintenance Supervisor emphasized that maintaining cleanliness in the garbage area is a shared responsibility. The Administrator and Director of Nurses both recognized the potential health risks posed by the improper disposal of garbage and refuse, as outlined in the facility's policies and procedures, which require garbage containers to have tight-fitting lids and be kept covered to prevent access by vermin.
Failure to Conduct Legionella Water Testing
Penalty
Summary
The facility failed to implement its infection control policy by not conducting water testing for legionella, a bacteria that can cause severe pneumonia. During an interview, the Infection Preventionist (IP) admitted that the facility did not test the water system for legionella, although they monitored water temperature and ran water weekly to prevent bacterial growth. The IP acknowledged that without testing, they could not confirm the presence of legionella in the water system, which is crucial for ensuring resident safety. The Maintenance Supervisor (MS) also confirmed that the facility never tested the water system for legionella, which put residents at risk of exposure. The Administrator (ADM) stated that the facility only conducted legionella tests when there was suspicion, and no recent tests had been performed. A review of the facility's Legionella Water Management Program policy indicated that the program should include monitoring control limits and the effectiveness of control measures. Additionally, the Centers for Clinical Standards and Quality/Quality, Safety and Oversight Group (QSO) guidelines require facilities to have water management plans that specify testing protocols and document testing results.
Failure to Ensure Bed Safety and Compatibility
Penalty
Summary
The facility failed to ensure the compatibility and safety of bed frames, mattresses, and bedrails, leading to a significant risk of entrapment for four residents. The deficiency was identified when surveyors observed gaps ranging from 6 to 10 inches between the mattresses and footboards in the beds of Residents 15, 67, 108, and 109. These gaps posed a risk of entrapment, where residents could potentially have their limbs or head trapped, leading to injury or death. The facility's policy required that bed systems leave no gap wide enough to entrap a resident's head or body, but this was not adhered to. Interviews with the Maintenance Supervisor and Maintenance Assistant revealed that the mattresses were too small for the bed frames, creating the dangerous gaps. The Maintenance Supervisor admitted to noticing the issue but was unaware of the safety risk it posed. The Maintenance Assistant also noted that the new mattresses were the same size as the old ones, which were too small, but did not report this to the Administrator, assuming it was normal. The Administrator designee confirmed that the mattresses were indeed too short, measuring about 73 inches instead of the required 80 inches, which contributed to the wide gaps. The facility's policy, revised in August 2022, mandated that bed frames, mattresses, and bedrails be checked for compatibility and size before use, and that maintenance staff routinely inspect all beds to identify risks, including potential entrapment. However, these procedures were not followed, resulting in the identified deficiency. The FDA guidelines also recognize the space between the mattress and footboard as a potential entrapment risk, which was not mitigated in this case.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, as evidenced by the presence of flies in the rooms of several residents. Resident 29's room was observed to have small black flies, which a Certified Nursing Assistant (CNA) identified as fruit flies. The CNA mentioned that these flies had been present since the previous day and speculated that they might have entered the facility with fruits brought into the residents' rooms. Similarly, Resident 100 reported seeing flies in his room daily, which made him uncomfortable and fearful of infection. Resident 80 also noted the presence of flies in various parts of the facility, including residents' rooms and hallways, attributing their presence to food being taken into the rooms. The facility also failed to provide a clean and sanitary environment for Resident 26, who was found to be using a pillow with brown and red stains. During observations, a Licensed Vocational Nurse (LVN) and a CNA acknowledged the stains on the pillow, with the LVN admitting that the pillow had not been washed or cleaned because the resident had not complained. The resident confirmed that the pillow had not been cleaned since his admission and expressed a desire for a clean pillow for comfort. The facility's policy requires staff to provide a clean and comfortable environment, which was not adhered to in this case. Additionally, Resident 108's room was found to have at least twenty small black flying insects, identified as gnats, due to the presence of food remnants like banana peels on the floor. The housekeeper and a CNA noted that Resident 108 frequently brought fruits into his room, which attracted the insects. Despite the facility's policy to maintain a sanitary environment, the presence of these insects posed a risk of infection, especially given Resident 108's existing skin condition. The Director of Nursing acknowledged that flies should not be present in residents' rooms as they could lead to an unsanitary living environment and increase the risk of spreading infection.
Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its smoking policy and procedure, resulting in an unsafe environment for five residents who were smokers. The facility did not provide metal containers with self-closing covers in the smoking areas, and residents were not adequately monitored to ensure cigarette butts were disposed of properly. This oversight was observed during a survey, where cigarette butts were found scattered on the ground and in a plastic trash bin, posing a fire hazard. Resident 104, who was cognitively intact but required supervision for smoking, was among those affected. The resident's care plan indicated a risk for injury related to smoking, necessitating supervision. Similarly, Resident 52, with moderate cognitive impairment, was assessed to smoke independently but with oversight. Residents 69, 6, and 71, all with varying degrees of cognitive impairment, also required supervision while smoking, as they were unable to safely light and extinguish their cigarettes. During observations, it was noted that only one metal smoking bin without a self-closing cover was available, and cigarette butts were improperly disposed of in a regular trash bin and on the ground. Interviews with staff confirmed the lack of appropriate disposal containers and supervision, with more than thirty cigarette butts found scattered in the smoking area. The facility's smoking policy, which required metal containers with self-closing covers and direct supervision for residents with restricted smoking privileges, was not adhered to, leading to the identified deficiencies.
Resident Privacy and Dignity Compromised
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident diagnosed with paranoid schizophrenia and unspecified schizoaffective disorder. The resident, who had moderately impaired cognitive skills and required supervision for daily activities, was observed walking naked in the hallway. This incident was witnessed by a Certified Nurse Assistant and a Patient Counselor, who redirected the resident back to his room. The resident did not recall the incident, which occurred during a time when he typically walked around the hallway. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the resident had approached female residents while naked, causing discomfort. The staff acknowledged that the resident's room was located far from the nursing station, and the hallway monitor should have intervened to prevent the resident from walking unclothed. The facility's policy on privacy and dignity emphasizes the importance of treating residents with respect and ensuring their privacy, which was not upheld in this situation. The resident's care plan included education on safe sex practices and monitoring for safety, but it did not prevent the incident of indecent exposure. The facility's policy on resident monitoring and rounds was intended to ensure resident safety and appropriate care, but the lack of effective monitoring allowed the resident to walk naked in the hallway, compromising his dignity and the comfort of other residents.
Failure to Implement Comprehensive Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident identified as being at risk for falls. The resident, who was admitted with diagnoses including paranoid schizophrenia and schizoaffective disorder, experienced multiple falls during smoke breaks and while showering. Despite these incidents, there was no evidence of a care plan addressing the resident's behavior of walking or running fast, which contributed to the falls. The resident's clinical records showed several fall incidents, including a fall on a cement surface after a smoke break and another in the shower room, both resulting in minor injuries. The interdisciplinary team noted the need for constant reminders to the resident to prevent falls, but there was no documented care plan to address these specific risks. Interviews with staff revealed a lack of awareness and monitoring for the resident's fall risk, indicating a gap in communication and care planning. The facility's policies required a baseline care plan within 48 hours of admission and a comprehensive care plan within 21 days, but these were not adequately developed or updated for the resident. The Director of Nursing acknowledged the absence of a care plan addressing the resident's fall risk behaviors, highlighting a failure to implement necessary interventions to prevent recurrent falls.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to the physician's order for a resident who sustained a superficial scratch on his right arm following an altercation with another resident. The physician's order, dated 06/23/2024, required the wound to be cleaned, treated with A&D ointment, and covered with a dry dressing daily for five days. However, the wound was left uncovered for five days, as observed during an interview with the resident on 06/25/2024, where the scratch was open to air without a dressing. The lapse occurred because the licensed vocational nurse (LVN) did not read the physician's order in its entirety, resulting in the omission of the wound dressing application. The Director of Nursing (DON) confirmed that licensed nurses must follow all physician orders to prevent potential exposure to infections. The facility's policy on medication administration, dated 10/2017, emphasizes that medications and treatments should be administered as prescribed, in accordance with good nursing principles and practices.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information, which is required to be displayed daily in a prominent location accessible to residents and visitors. Observations on June 25, 2024, revealed that the Census and Nursing Hours per Patient Day (NHPPD) forms for June 23 and June 24, 2024, were not properly signed by the Director of Nursing or designee. Additionally, the NHPPD forms were missing from Nursing Stations 1 and 2, and the form for June 24, 2024, was incomplete, lacking actual hours for scheduled total direct care service hours and CNA direct care hours. Interviews with the Director of Staff Development (DSD) and Payroll Coordinator (PRC) confirmed that the actual hours were not completed, visibly posted, and signed by the DON within the required timeframe. The facility's policy, revised in August 2022, mandates that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel directly responsible for resident care must be posted in a clear and readable format. The policy also requires the charge nurse or designee to compute the number of direct staff and complete the Nurse Staffing Information form. However, the DSD and PRC failed to ensure the NHPPD forms were accurately completed and posted, resulting in residents not having access to the direct care daily staffing numbers. The DON stated that the NHPPD forms were reviewed and signed daily, but the deficiency indicates a lapse in adherence to the facility's policy and procedure.
Medication Administration Error Due to Documentation Discrepancy
Penalty
Summary
The facility failed to ensure that licensed nurses administered medications in accordance with the facility's policy and procedure, resulting in a significant medication error for one of the residents. Specifically, a Licensed Vocational Nurse (LVN) was observed omitting the administration of MiraLAX, a medication used to treat constipation, to a resident during a medication pass observation. Despite this omission, the LVN documented on the electronic medication administration record (eMAR) that the medication was administered at the scheduled time. This discrepancy was noted during a medication reconciliation process, where the LVN admitted to not administering the medication but still documenting it as given. The resident involved had a medical history that included schizophrenia and depression, and required supervision with activities of daily living. The facility's policy clearly stated that medication administration should be documented immediately after the medication is given, not before, to prevent errors. The Director of Nursing confirmed that the facility's protocols were not followed in this instance, as the documentation was completed prior to the actual administration of the medication, leading to the potential for medication errors.
Failure to Screen Resident for Contraband Leads to Fire Hazard
Penalty
Summary
The facility failed to maintain a hazard-free environment by not adequately screening a resident who returned from an Out-on-Pass with contraband, specifically a cigarette lighter. This oversight led to the resident using the lighter to ignite a magazine in his room, which triggered the smoke alarm and required intervention from the fire department. The incident exposed all residents and staff to dangerous smoke and potential injuries related to the fire. The resident involved had a history of paranoid schizophrenia and was noted to have severely impaired cognition, requiring supervision for daily activities. Upon returning from a visit to a family member, the resident was not properly screened for contraband by the licensed nurse, as required by the facility's policies. The nurse failed to document the presence of any contraband on the Return from Pass Assessment form, which was a critical step in ensuring the safety of the facility's environment.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plan for Resident 8 to include interventions to prevent further abuse by other patients. Resident 8, who has a diagnosis of schizoaffective disorder and moderately impaired cognitive skills, was admitted to the facility and required supervision for personal hygiene, eating, and oral hygiene. Despite being a victim of alleged physical abuse twice in one month, the care plan initiated on 3/20/24 and revised on 4/26/24 contained the same interventions. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged that the care plan should have been updated to include measures to reduce the risk of resident-to-resident altercations. The facility also failed to revise the care plan and behavior contract for Resident 6 to include interventions to prevent further abuse to staff and other patients. Resident 6, diagnosed with schizoaffective disorder, constipation, and paranoid schizophrenia, exhibited multiple instances of socially inappropriate behavior, including touching female staff and peers inappropriately. Despite these repeated incidents, the behavior contract dated 3/24/24 was not updated to address the ineffectiveness of the current interventions. The Program Manager (PM) and DON both acknowledged that the behavior contract and care plan should have been updated after each incident to include more effective interventions. The facility's policy and procedure titled 'Care Plan, Comprehensive Person-Center,' revised in March 2022, indicated that care plan interventions should be chosen after data gathering and careful consideration of the relationship between the resident's problem areas and their causes. However, the facility did not adhere to this policy, resulting in the failure to provide appropriate care and treatment services for Residents 6 and 8.
Failure to Provide Immediate Emergency Response to Choking Resident
Penalty
Summary
The facility failed to provide immediate and proper emergency response to a resident who was choking, which ultimately led to the resident's death. The incident involved multiple staff members who did not follow the facility's emergency procedures for choking and CPR. The resident, who had a history of schizophrenia, anxiety disorder, and hypertension, was on a mechanical soft diet due to difficulties with chewing and swallowing. Despite showing clear signs of choking, such as holding his neck and gasping for air, the resident was not immediately assisted with the Heimlich maneuver or CPR. The Program Counselors (PCs) who first observed the resident's distress did not perform the Heimlich maneuver or call for immediate help. Instead, they assisted the resident in walking to the nursing station, delaying critical intervention. When the resident reached the nursing station, a CNA attempted the Heimlich maneuver, but the resident lost consciousness and became unresponsive. The Licensed Vocational Nurse (LVN) performed a blind finger sweep, which is against standard practice, and did not immediately initiate chest compressions or provide rescue breaths. The facility lacked an Automated External Defibrillator (AED), and no Code Blue was announced over the facility's call system. Interviews with staff revealed a lack of CPR certification among some personnel and a failure to follow the facility's policies and procedures for emergency situations. The Director of Nursing confirmed that the distance the resident was made to walk while choking was significant and could have been critical. The facility's investigation highlighted multiple procedural failures, including the absence of an AED, lack of immediate CPR, and improper handling of the choking incident, which contributed to the resident's death from cardiac and respiratory arrest due to asphyxia.
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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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