Coral Cove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 1730 Grand Ave, Long Beach, California 90804
- CMS Provider Number
- 055077
- Inspections on file
- 82
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Coral Cove Post Acute during CMS and state inspections, most recent first.
The facility did not follow its abuse prevention policy requiring immediate reporting of suspected abuse when an allegation arose that one resident used a cane to strike another resident who required substantial assistance with care. A nurse was informed of the allegation by a COTA, assessed both residents, and notified an RN supervisor, who then separated the residents and removed the cane. The administrator later confirmed that, instead of reporting to CDPH, law enforcement, and the Ombudsman within two hours as required, facility administration first conducted its own investigation and submitted the SOC341 report approximately seven hours after the alleged incident.
Dietary staff did not consistently wear proper hair and beard nets while preparing food, with some staff having uncovered hair or beards and beard nets unavailable for several days. This resulted in food being prepared for a large number of residents without adherence to infection control policies requiring hair restraints.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing a gown or performing hand hygiene while providing high-contact care, including a dressing change and feeding tube disconnection, for a resident with a tracheostomy and G-tube. The resident was severely cognitively impaired and dependent on staff, and EBP orders were in place requiring PPE and hand hygiene for such tasks.
Two residents with mental health diagnoses engaged in a verbally aggressive altercation on the patio, which was witnessed by staff. Despite facility policy requiring immediate reporting of all abuse allegations, including verbal aggression, the incident was not reported to the state agency or investigated as abuse. This failure delayed state inspection and potentially placed other residents at risk.
Two residents with intact cognition and psychiatric diagnoses engaged in a verbally aggressive altercation on the smoking patio, including the use of derogatory language. An LPN witnessed and reported the incident as verbal aggression, but it was not investigated as verbal abuse by facility administration, contrary to facility policy requiring immediate investigation of all abuse allegations.
A resident with severe cognitive impairment and multiple medical conditions was not re-admitted to the facility after being cleared for return by an LTAC hospital. Although the facility initially cited no available beds, census records confirmed that open female beds were present on several dates. Facility staff could not explain why the resident was not re-admitted, despite policy requiring the first available bed to be offered.
A resident with paraplegia and hydronephrosis was not readmitted to the facility after a hospital transfer, despite being medically ready and having at least one available male bed for several days. The resident remained in the hospital due to the facility's claim of no available beds, contrary to census records and facility policy.
A resident with a history of encephalopathy, schizophrenia, and bipolar disorder was readmitted after a hospital transfer for aggressive behavior, but the care plan was not reviewed or revised upon return. This omission led to the resident exhibiting further behavioral issues, including throwing a book at another resident, despite staff and documentation noting ongoing emotional instability and poor impulse control.
Two CNAs were assigned to the Subacute Unit without receiving the necessary training or orientation, as confirmed by their own statements and facility leadership interviews. Staffing records showed at least one CNA was assigned to the unit without prior preparation, and there was no documentation of required training. Facility leaders acknowledged that additional training is needed for staff working with residents requiring more intensive care, including those with ventilators.
A CNA was permitted to work without an active certificate after presenting exam results, but their certification was not yet listed on the state registry. The ADON allowed the CNA to begin work without verifying active status, and both the DSD and DON later confirmed the lack of proper certification verification.
A CNA worked ten shifts with an expired certification, as confirmed by state certification records and facility assignment sheets. The CNA was aware of the expiration but continued to perform CNA duties. Facility leadership acknowledged that certification tracking is the responsibility of the DSD and that a valid certification is required for CNA duties.
A resident with schizoaffective disorder and a history of aggressive behavior repeatedly refused prescribed psychotropic medications, but staff did not consistently document behavioral episodes or notify the psychiatrist as required. Nursing staff confirmed that behavioral monitoring was sometimes incomplete and that the psychiatrist was not informed of the refusals, despite facility policy mandating timely documentation and notification for such changes in condition.
Two residents with significant mobility impairments were found to have nonfunctional or inaccessible call lights, resulting in prolonged waits for assistance and increased frustration. Staff confirmed the issues, and observations showed call lights either did not work or were placed out of reach, contrary to facility policy.
A resident with a history of wandering and multiple mental health conditions eloped from a facility due to an inactive front door alarm and incorrect elopement assessment. The resident was found miles away, confused, after the facility failed to develop a care plan or interventions for her elopement risk. Staff interviews revealed non-functional cameras and unmonitored alarms, contributing to the incident.
The facility failed to address concerns raised by the resident council about delayed call light response times during the 11pm-7am shift. A resident with intact cognition and significant medical history reported these delays, which were documented in council meetings without any action plan developed. The Director of Staff Development did not provide necessary oversight during this shift, focusing instead on paperwork, and the facility's policies requiring response to council concerns were not followed.
A resident with intact cognition was involved in an altercation with another resident who has severe cognitive impairment. The incident, witnessed by an MDS nurse, was not reported to the resident's physician by RN 1, leading to a delay in necessary assessments and services. The facility's policy requires notifying the physician of significant changes in condition, which was not followed in this case.
A facility failed to report a physical altercation between two residents to CDPH within the required two-hour timeframe. The incident involved a resident with intact cognition protecting himself from another resident with severely impaired cognition. The MDS nurse witnessed the event and informed an RN, who did not report it, believing it was not abuse due to the lack of injuries. This oversight delayed necessary assessments and services, violating federal regulations and facility policy.
A facility failed to create a comprehensive care plan for a resident after an altercation with another resident. The incident involved one resident trying to protect himself from being hit by another resident with severe cognitive impairment. Despite the incident, no care plan was developed, and no interdisciplinary team meeting was held to address the concerns, resulting in a delay in care and services for the resident.
The facility did not post accurate daily staffing information, as required, at the entrance. Observations and interviews revealed that only projected hours were posted, not the actual number of staff or hours worked. This failure was contrary to the facility's policy, which mandates posting the total number and actual hours worked by nursing staff per shift.
A resident with respiratory failure and intact cognition, dependent on staff for ADLs, was not provided incontinence care due to insufficient staffing. On a night shift, only two CNAs were present instead of the scheduled four, with one CNA responsible for 82 residents. This led to the resident calling the police for assistance, highlighting a failure to treat the resident with dignity and respect.
The facility failed to implement its water management plan effectively, leading to potential risks of Legionella bacteria growth. The water management team did not meet regularly, and there was no documentation of control measures being monitored. The resignation of the full-time IPN led to confusion in infection control duties, further exacerbating the issue. The Maintenance Supervisor did not maintain logs, and there was no communication regarding a Legionella concern from the Department of Health.
The facility failed to appoint a full-time IPN, leading to inadequate oversight of the infection prevention and control program. The RNC assumed IPN duties without clear documentation or role delineation, sharing responsibilities with the DSD. This resulted in missed water management meetings and unaddressed infection control risks, increasing the potential for waterborne pathogen outbreaks.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician or responsible party, assess the resident's condition, or document the incident. The resident, with a history of serious health conditions and on medications increasing bleeding risk, was found on the floor by a CNA. The LVN did not perform a full assessment or communicate the incident to the oncoming shift, leading to a delay in care. The resident was later transferred to a hospital with multiple injuries.
A resident with multiple medical conditions was found with skin tears, which were not reported to the CDPH in a timely manner. The injuries were attributed to a rough towel used by a CNA, but the LVN and DON failed to report them as required. The facility's policy mandates prompt reporting of such incidents to prevent potential mistreatment.
A resident with a history of falls and high fall risk was not provided a one-on-one sitter as ordered by the physician. Despite the resident's need for constant supervision due to conditions like metabolic encephalopathy and Parkinsonism, staff failed to consistently assign a sitter, leaving the resident unsupervised and at risk for further falls. The facility's fall management policy was not effectively implemented, resulting in this deficiency.
A resident's bed was cluttered with dirty blankets, limiting comfort and mobility. Despite the resident's cognitive ability and need for assistance, CNA 1, who had a poor relationship with the resident, was repeatedly assigned to them. The DON confirmed the lack of bed space, and the DSD admitted to ineffective communication of staff assignments, contributing to the issue.
The facility did not follow LBDHHS guidelines during a CPO outbreak by posting incorrect isolation signs on 8 out of 12 rooms in the SAU. Instead of contact isolation precautions, Enhanced Barrier Precautions were used, which do not align with the guidelines for residents who tested positive for CPO. The error was acknowledged by the DSD and IPN, and the DON confirmed receipt of the guidelines but could not explain the oversight.
A resident with a history of anxiety and depression was verbally and physically abused by a CNA who entered the bathroom without waiting, despite the resident's request for privacy. The CNA yelled and threw a urinal and water bottle at the resident, causing emotional distress. The facility's abuse prevention policy was not followed, as confirmed by staff interviews and documentation.
A resident in an LTC facility experienced an alleged abuse incident when another resident pulled her beanie and hair. The incident was reported to a CNA, who informed an LVN. However, the LVN failed to report it to the Administrator due to workload, resulting in a delay in notifying the CDPH within the required two-hour timeframe. The facility's policy requires immediate reporting of abuse allegations to ensure resident safety.
A facility failed to submit a five-day investigative report for an alleged abuse incident where a resident with cognitive impairment pulled another resident's beanie and hair. The incident was reported to an LVN by a CNA, but the LVN did not inform the Administrator due to workload. The facility's policy requires such incidents to be reported and investigated within five days, which was not done, leading to an incomplete investigation.
A resident at high risk for falls, due to legal blindness and cognitive impairment, sustained multiple fractures after the facility failed to follow her care plan. The plan required the bed to be in the lowest position with floor mats on both sides, but the resident was found on the floor with the bed in a high position and no mats present. Staff interviews confirmed the care plan was not consistently implemented, leading to the resident's injuries.
A resident's bed was improperly arranged against a wall with pillows tucked under the sheet, restricting movement and acting as a physical restraint. This setup lacked a physician's order or consent, violating the facility's policy on restraints.
The facility failed to ensure informed consent was obtained by prescribers for antipsychotic medications for two residents. One resident was prescribed quetiapine for schizophrenia without the prescriber obtaining consent, and another resident's consent documentation listed a psychiatrist instead of the prescribing physician. The facility's administrator confirmed the deficiency in obtaining proper consents.
A facility failed to ensure consistent diagnoses for a resident's antipsychotic medication use. The resident had various diagnoses, including bipolar disorder and generalized anxiety disorder, but physician orders for quetiapine cited different diagnoses like schizophrenia and schizoaffective disorder without supporting evidence. This inconsistency was confirmed by the facility administrator, highlighting a deficiency in medication management practices.
A resident was denied re-admission to a facility after hospitalization for pneumonia and infections, despite being deemed appropriate for transfer back. The facility had an available bed but cited a lack of isolation beds as the reason for denial. The resident's social worker attempted multiple times to coordinate the return, but the facility did not respond. The facility's policy requires readmission to the first available bed, even with an outstanding balance.
A resident with mental health conditions inappropriately touched two other residents on separate occasions while unsupervised on the facility's patio. Despite a care plan to monitor and supervise the resident after the first incident, the facility failed to implement these measures, leading to a second incident. Staff interviews confirmed the expectation of close monitoring, which was not fulfilled, resulting in residents feeling unprotected and disrespected.
A resident with mental health conditions in an LTC facility inappropriately touched two female residents on consecutive days due to inadequate supervision. Despite a care plan to monitor and prevent further incidents, the facility failed to implement effective measures, resulting in repeated inappropriate behavior. Staff interviews highlighted the lack of consistent monitoring, contrary to the facility's safety and abuse prevention policies.
A resident with a history of mood disorder, schizophrenia, and depression was not readmitted to the facility after being medically cleared following a transfer to a hospital's ER for inappropriate behavior. Despite being cleared for return, the facility did not allow the resident back, citing potential emotional triggers for other residents and pending charges. This resulted in the resident's extended stay in the hospital, contrary to the facility's bed hold and transfer policies.
A resident with multiple diagnoses, including quadriplegia and osteoarthritis, experienced delays in receiving necessary orthopedic consultations following hospitalizations for right shoulder pain and left hip dislocation. Despite discharge summaries indicating the need for follow-up, the consults were not completed until months later, resulting in delayed care. The facility's policies on timely and person-centered care were not followed.
A resident with multiple diagnoses, including rheumatoid arthritis and osteoporosis, did not receive their prescribed Oxycodone for pain management due to an expired prescription. The LVN failed to follow up with the physician for a new prescription, despite contacting the pharmacy multiple times. The facility's policy requires medications to be reordered five days in advance, but this was not adhered to, resulting in the deficiency.
A resident with schizophrenia and bipolar disorder was administered quetiapine without informed consent on two occasions. The facility's policy requires informed consent before administering psychotropic medications, but it was obtained only after the medication was given. Interviews with the DSD and DON confirmed the oversight.
A resident with a history of diabetes and glaucoma experienced vision loss and eventual blindness due to the facility's failure to ensure timely follow-up care. Despite recommendations from an optometrist to see a retina and glaucoma specialist, the facility delayed scheduling these appointments, leading to a significant decline in the resident's eyesight. The resident's care plan lacked a comprehensive approach to address potential vision impairment, and staff failed to communicate necessary information to the primary physician, resulting in the resident's increased dependency and depression.
A resident with diabetes and impaired vision was admitted to an LTC facility without a comprehensive care plan addressing his vision needs. Despite requests for an optometrist consultation and indications of moderate cognitive and vision impairment, the facility delayed creating a vision care plan for five months. This resulted in a lack of necessary referrals and monitoring, leading to a decline in the resident's right eye vision.
A resident experienced vision loss and blindness in the right eye due to the facility's failure to follow an optometrist's recommendations for specialist consultations. Despite a history of eye-related health issues, the resident's appointments with a retina and glaucoma specialist were delayed by several months, leading to significant deterioration in vision. The lack of timely communication and follow-up by the facility staff contributed to the resident's condition worsening.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with schizophrenia and other mental health diagnoses. Despite the resident's inability to make medical decisions, the facility administered Quetiapine Fumarate, Lithium Carbonate, and Risperidone without consent until August. Staff interviews confirmed the oversight, and the facility's policy required written consent for such medications.
A facility failed to provide an adaptive call light system for a quadriplegic resident who was completely dependent on staff for daily activities. The resident's call light was found on the floor, and the type provided was unsuitable for their needs. An LVN confirmed the resident required a call pad due to limited use of extremities. Facility policies indicated the need for adaptive call systems based on resident needs, but this was not adhered to, placing the resident at risk of being unable to communicate their needs.
A resident with multiple medical conditions expressed a desire to change his primary care physician (PCP) from PCP 2 to PCP 1, but the facility failed to facilitate this change. Despite the resident's ability to communicate his needs, the social services director did not act on the request, and there was no documentation of the request. Interviews with staff confirmed the facility's inaction, and the Director of Nursing acknowledged the resident's right to choose his physician was not honored, leading to the resident's distress.
A facility failed to follow its restraint policy for a resident by not specifying the duration of a right-hand mitten restraint and not documenting assessments of circulation, sensation, movement, and skin integrity. The resident, with severe medical conditions, was observed with the restraint in place, and the Director of Nursing acknowledged the lack of compliance with the facility's policy.
A resident with moderate cognitive impairment and dependency on staff was observed receiving oxygen at 2.5 liters per minute, contrary to a physician's order for 4 liters per minute. This discrepancy was confirmed by facility staff, including an LVN, RN, and the DON, who acknowledged the potential risks of under-oxygenation. The facility's policy required adherence to physician orders, which was not followed in this case.
The facility failed to properly store and dispose of medications, including a controlled substance, Hydrocodone and Acetaminophen, which was improperly sealed instead of disposed of. A bottle of Docusate Sodium was found in regular trash, and the medication room was left unsecured, contrary to facility policy, posing risks of drug diversion and accidental consumption.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an allegation of physical abuse between two residents to the California Department of Public Health (CDPH) within two hours of the occurrence. One resident, admitted with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, osteoarthritis, and schizophrenia, required substantial/maximal assistance with care per the Minimum Data Set (MDS). The other resident, admitted with chronic kidney disease, type 2 diabetes mellitus, heart disease, and gout, had documented capacity to understand and make decisions and required moderate assistance for bed mobility and transfers. An occupational therapy assistant reported that the second resident allegedly hit the first resident on the head with a cane while the first resident was lying on his side and coughing. Following the allegation, the LVN assessed both residents and informed the registered nurse supervisor (RNS), who then took steps such as relocating the first resident and removing the second resident’s cane and notifying the physician. The administrator stated that, per facility policy and the abuse prevention and management procedure dated 1/1/2026, law enforcement must be notified immediately or as soon as practicably possible, and a written SOC341 report must be sent to the Ombudsman, law enforcement, and CDPH immediately, but not later than two hours after forming the suspicion if the events result in serious bodily injury. However, the administrator acknowledged that administration conducted its own investigation first, and the SOC341 was faxed to CDPH and the Ombudsman approximately seven hours after the allegation, exceeding the required two-hour reporting timeframe.
Failure to Ensure Dietary Staff Wore Required Hair and Beard Nets During Food Preparation
Penalty
Summary
Dietary staff in the facility failed to consistently wear appropriate hair and beard nets while preparing or handling food in the kitchen. During observations, one cook was seen with a hair net that did not fully cover the back and sides of her head, and another staff member with a beard was not wearing a beard net in the food preparation area. The Dietary Supervisor confirmed these lapses and stated that the requirement is for all hair, including beards, to be covered while in the kitchen to prevent hair from contaminating food. Additionally, it was noted that beard nets had not been available for three days prior to the observation, resulting in multiple dietary staff with beards not wearing the required protective equipment during food preparation for a significant portion of the resident population. The Director of Nursing confirmed that the facility's infection control practices require dietary staff to wear hair and beard nets in the kitchen to prevent hair shedding and potential food-borne illness. Review of the facility's policy indicated that personal cleanliness and effective hair restraints are mandatory in all kitchen and food storage areas. At the time of the deficiency, 104 residents were in the facility, with 73 receiving meals prepared in the kitchen where these lapses occurred.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during care of a resident who was on EBP due to a tracheostomy and gastrostomy tube. The LVN performed a dressing change at the tracheostomy site and disconnected a feeding tube without donning a gown or performing hand hygiene prior to these high-contact tasks. The LVN acknowledged not following the required infection control practices, despite the presence of signage indicating EBP requirements and her awareness of the necessity for gown use and hand hygiene. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene and device care. Facility records confirmed that EBP precautions were ordered for the resident, and the infection prevention nurse and director of nursing both stated that staff are required to use gowns and perform hand hygiene for high-contact care tasks under EBP. The facility's policy specified that PPE, including gowns and gloves, must be donned before each high-contact task and that adherence to infection prevention practices should be periodically monitored.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for two residents who were involved in a verbally aggressive incident. Both residents had intact cognition and were diagnosed with mental health conditions such as bipolar disorder, depression, and schizophrenia. The incident occurred on the facility's patio, where one resident made inappropriate and aggressive comments towards the other, resulting in a verbal altercation that included cursing and shouting. Staff members, including a Licensed Vocational Nurse and a Social Service Assistant, witnessed or were made aware of the incident and acknowledged that all abuse allegations, including verbal aggression, should be reported immediately to supervisors and the administrator. Despite the facility's policy requiring immediate reporting of all abuse allegations, including verbal abuse, to the administrator and appropriate authorities, the incident was not reported to the state agency. The Director of Nurses confirmed that the incident was not reported, and the administrator stated that the event was not investigated as abuse because it was perceived as only verbal aggression. Multiple staff interviews indicated awareness of the incident, but no formal report or investigation was initiated as required by facility policy and state regulations. The failure to report the incident resulted in a delay in an onsite inspection by the state agency and had the potential to place other residents at risk for unaddressed abuse and unsafe interactions. The facility's own policy defined abuse to include verbal aggression and mandated reporting to law enforcement and the state agency within two hours of an initial report, which was not followed in this case.
Failure to Investigate Alleged Verbal Abuse Between Residents
Penalty
Summary
The facility failed to investigate an incident of verbal abuse involving two residents. Resident 1, who had diagnoses including bipolar disorder, depression, schizoaffective disorder, and diabetes, was observed on the smoking patio when Resident 2, diagnosed with schizophrenia and bipolar disorder, spoke to her in a loud tone. Resident 1 responded by standing up, but there was no physical contact. Documentation indicated that Resident 1 exhibited verbal aggression, including cursing and screaming, while Resident 2 was noted to have made inappropriate comments and shown increased aggression toward another resident. Both residents were assessed as having intact cognition and required minimal assistance with daily activities. During interviews, Resident 1 reported being called a derogatory name by Resident 2 after refusing to give him cigarettes. An LVN confirmed witnessing verbal aggression between the two residents and reported the incident to a supervisor, but did not consider it verbal abuse. The administrator acknowledged being notified of the incident but did not initiate an investigation, as he was only aware of verbal aggression and not abuse. The facility's policy required immediate investigation of all abuse allegations, but this was not followed in this case.
Failure to Re-Admit Resident Despite Bed Availability
Penalty
Summary
The facility failed to re-admit a resident after the resident was cleared for return by a Long-Term Acute Care (LTAC) hospital. The resident, who had been living at the facility for two years and had diagnoses including anoxic brain injury, chronic respiratory failure, and atrial fibrillation, was transferred to a General Acute Care Hospital for generalized body swelling. After treatment, the LTAC facility issued a discharge order for the resident to return. Despite communication from the LTAC case manager to the facility's admission coordinator, the resident was not re-admitted, with the initial explanation being a lack of available beds. However, facility census records reviewed with the Director of Nursing and Administrator showed that there were open female beds available on multiple dates following the discharge order. Interviews with facility staff, including the Director of Business Development and the Administrator, revealed uncertainty and lack of clear communication regarding why the resident was not re-admitted despite bed availability. The facility's own bed hold policy indicated that the resident should have been offered the first available bed upon return, but this did not occur, and staff could not provide a reason for the failure to re-admit.
Failure to Readmit Resident Despite Available Bed
Penalty
Summary
The facility failed to readmit a resident after transfer to a General Acute Care Hospital (GACH) for evaluation of a distended abdomen with pain. The resident, who had diagnoses including paraplegia and hydronephrosis and was cognitively intact, was initially admitted and later readmitted to the facility. After the hospital transfer, the resident was determined to be ready for discharge back to a skilled nursing facility, and the discharge order remained active for several days. Despite this, the facility informed the hospital case manager that there were no available male beds, and the resident remained at the hospital awaiting placement. A review of the facility's census and bed assignments revealed that there was at least one available male bed for 11 consecutive days during the period the resident was waiting for readmission. The Director of Nursing confirmed that a bed was available and stated that the resident should have been readmitted. The facility's policy indicated that residents eligible for Medi-Cal/Medicaid should be readmitted to their previous room or the first available bed. The failure to readmit the resident resulted in a prolonged hospital stay and frustration for the resident, who considered the facility his home.
Failure to Revise Care Plan After Readmission Leads to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was readmitted after a transfer to a General Acute Care Hospital (GACH) due to aggressive behavior. Upon readmission, the resident, who had diagnoses including encephalopathy, schizophrenia, and bipolar disorder, did not require 1:1 supervision according to staff, and the behavior care plans were not updated. The Minimum Data Set Coordinator (MDSC) acknowledged that the care plan should have been reviewed and revised upon the resident's return, but this was not done. As a result of the lack of care plan revision, the resident exhibited further behavioral issues, including throwing a book at another resident. Documentation indicated the resident was anxious, irritable, emotionally labile, and demonstrated poor impulse control and unpredictable behavior. The Director of Nursing (DON) confirmed that care plans need to be updated upon readmission to prevent gaps or delays in care, and the facility's policy required comprehensive care planning to be reviewed and revised as needed.
CNAs Assigned to Subacute Unit Without Required Training or Orientation
Penalty
Summary
Two Certified Nursing Assistants (CNAs) were assigned to work in the Subacute Unit without receiving the necessary training or orientation specific to that unit. Both CNAs reported in interviews that they had not been trained prior to floating to the Subacute Unit and expressed feeling unsafe and unprepared to care for residents requiring more intensive care, including those with ventilators. Review of staffing records confirmed that at least one CNA was assigned to the Subacute Unit on a specific date without prior training. Interviews with facility leadership, including the Registered Nurse Supervisor, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that CNAs should receive additional training and orientation before working in the Subacute Unit due to the specialized needs of the residents. The DSD and DON acknowledged there was no documentation of training or orientation for the CNAs in question, and the DSD's job description indicated responsibility for coordinating ongoing in-service training for all employees. The lack of training and documentation had the potential to result in inadequate care for residents in the Subacute Unit.
Plan Of Correction
Competent Nursing Staff How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 05/22/2025, CNA 1 was provided training and orientation to work in the Subacute Unit. Competencies were completed and filed on the employee's file. On 05/22/2025, CNA 2 was provided training and orientation to work in the Subacute Unit. Competencies were completed and filed on the employee's file. On 05/22/2025, The Administrator/ DON provided a 1 on 1 education to the new DSD and DSD Assistant on ensuring that all licensed and certified staff assigned to the Subacute Unit shall receive orientation, training and competencies prior to any assignment on the floor and a retraining shall be provided as needed. On 05/22/2025, residents identified to be under the care of CNA 1 in the Subacute Unit on 05/09/2025 were assessed and no negative findings were noted. On 05/22/2025, residents identified to be under the care of CNA 2 in the Subacute Unit on 05/09/2025 were assessed and no negative findings were noted. 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 05/22/2025 and 05/23/2025, DON/DSD/Designee reviewed the employee files of licensed and certified staff assigned to work for the Subacute Unit in the past 30 days and found no other licensed or certified staff were scheduled without orientation, training and competencies for the unit; hence, 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 recur: On 05/22/2025, The Administrator/ DON provided a 1 on 1 education to the new DSD and DSD Assistant on ensuring that all licensed and certified staff assigned to the Subacute Unit shall receive orientation, training and competencies prior to any assignment on the floor and retraining shall be provided as needed. On 05/22/2025 and 05/23/2025, Administrator, DON/Designee initiated an in-service education to Licensed Nurses, Certified Nursing Assistants, and Restorative Nursing Assistants on assuring that they receive the necessary orientation, training and competency to ensure that residents under their care will receive the appropriate care. A tracking log was created to ensure that all staff orientation, training, re- training and competencies are documented and filed in each respective employee file. This file will be kept by the DSD and will be updated accordingly. All licensed and certified staff members who do not have any documented Subacute orientation, training, retraining or competencies will not be scheduled in the Subacute Unit. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/Designee will conduct an audit of the DSD's tracking log for 4 weeks then bi- weekly for 3 months, to ensure that staff assigned to the Subacute Unit have the proper orientation, training, retraining and competencies needed prior to being assigned in the unit. Any issues identified will be addressed immediately. The Administrator will present the results of the above reviews to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for 3 months then quarterly thereafter. The plan will be reevaluated monthly by the QA Committee and make necessary changes as warranted to ensure that safety of the residents. Completion Date: 05/30/2025 F 726
CNA Worked Without Active Certification
Penalty
Summary
A Certified Nursing Assistant (CNA 1) was allowed to work without an active certification. Review of the California Department of Public Health (CDPH) License and Certification Verification Detail Page showed that CNA 1 did not have an active certificate. Although CNA 1 had passed both the skills and knowledge portions of the California Nurse Aide Assessment Program (NNAAP) examination, the results indicated that certification would only be granted and appear on the registry up to 60 days after submission. At the time CNA 1 began working, their certification was not yet active or verifiable on the registry. The Assistant Director of Nursing (ADON) permitted CNA 1 to work after being shown the exam results, relying on personal experience rather than verifying active certification status on the registry. The Director of Staff Development (DSD) and Director of Nursing (DON) both confirmed that CNA 1's certification was not active and that proper verification procedures were not followed prior to CNA 1 starting work. The facility's job description for CNAs also required an active license, which was not met in this instance.
CNA Worked Shifts with Expired Certification
Penalty
Summary
A Certified Nursing Assistant (CNA) worked ten shifts with an expired certification, as confirmed by a review of the California Department of Public Health License and Certification Verification Detail Page and the facility's Nursing Staff Assignment Sheets. The CNA was aware that her certification had expired but continued to perform CNA duties during this period. The facility's Director of Staff Development (DSD) acknowledged that the CNA functioned in her role with an expired certification and was only reassigned to non-clinical duties after the expiration was discovered. Interviews with facility leadership revealed that the DSD is responsible for tracking CNA certifications, and the Director of Nursing (DON) stated that employees should notify the DSD if they encounter issues with renewal. The facility's job description for CNAs requires a valid certification, and both the DSD and DON confirmed that working with an expired certification is not permitted. The deficiency was identified through interviews and record reviews, with no mention of corrective actions taken at the time of the incident.
Failure to Monitor and Report Psychotropic Medication Refusals and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of targeted behaviors for a resident prescribed psychotropic medications, and did not notify psychiatry when the resident refused these medications. The resident in question had diagnoses including schizoaffective disorder, violent behavior, and delusional disorder, and was prescribed Depakote and Invega Sustenna to manage symptoms such as sudden mood changes and aggressive behavior. Physician orders required staff to monitor and document behavioral episodes and to indicate the use and effectiveness of nonpharmacological interventions. Record reviews revealed that the resident refused the prescribed medications multiple times over the course of two months, with documentation showing frequent refusals and several episodes of behavioral disturbances. Despite these refusals and behavioral episodes, there was inconsistent documentation of the behaviors, and staff did not consistently notify the attending physician or psychiatrist as required by facility policy. Interviews with nursing staff confirmed that the psychiatrist was not informed of the medication refusals, and that documentation of behavioral monitoring was sometimes inaccurate or incomplete. Facility policies required that occurrences of behaviors for which psychoactive medications are used be documented on the medication administration record every shift, and that significant changes in a resident's condition, including medication refusals, be promptly reported to the physician and family. However, the report found that these procedures were not consistently followed, resulting in a lack of timely notification to the medical team and incomplete behavioral monitoring for the resident.
Failure to Provide Functioning and Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were functioning and accessible for two of six sampled residents. For one resident with hemiplegia, hemiparesis, contractures, and cognitive communication deficits, the call light was observed to be nonfunctional, with no response when pressed. The resident reported waiting for two hours for assistance and expressed frustration. Staff confirmed the call light was not working and acknowledged that the resident had to call out for help. Additionally, the call light was placed on the side of the bed that the resident could not reach due to a dislocated shoulder, further limiting access to assistance. Another resident with contractures, hemiplegia, hemiparesis, and generalized muscle weakness also experienced issues with the call light system. The resident reported that pressing the call light did not result in staff response and was unaware of the call light's location, which was observed to be on the floor and out of reach. Staff interviews confirmed the importance of accessible and functioning call lights for resident safety and indicated that nonfunctional call lights would be reported to maintenance. Facility policy requires call lights to be within reach and operational to allow residents to request assistance.
Resident Elopement Due to Inactive Door Alarm and Inadequate Assessment
Penalty
Summary
The facility failed to ensure the front door was alarmed, which led to a resident under conservatorship eloping from the facility. The resident, who had a history of wandering and was assessed incorrectly during an elopement evaluation, was not provided with a care plan or interventions to address her elopement risk. This oversight resulted in the resident leaving the facility unsupervised and being found approximately four miles away, confused and incoherent. The resident's medical history included schizophrenia, brief psychotic disorder, generalized anxiety disorder, dementia, and aphasia, with moderately impaired cognition requiring supervision for walking. Despite these conditions, the resident's elopement evaluation was inaccurately completed, indicating no history of elopement or wandering, which contradicted previous assessments. The facility's staff, including the Registered Nurse Supervisor and Certified Nursing Assistant, acknowledged the resident's frequent hallway walking but did not perceive it as wandering or a risk for elopement. Interviews revealed that the facility's cameras were non-functional, and the front door alarm was not activated at the time of the incident. The Administrator admitted that the alarm should have been on, and the Maintenance Supervisor confirmed that alarm checks were not conducted on weekends or after hours. The Director of Nursing acknowledged the resident's elopement risk and the need for a care plan, which was not developed, leading to the resident's unsupervised departure from the facility.
Failure to Address Resident Council Concerns and Provide Adequate Staff Oversight
Penalty
Summary
The facility failed to uphold residents' rights by not addressing concerns raised by the resident council regarding delayed call light response times during the 11pm-7am shift. Resident 1, who has intact cognition and a medical history including type 2 diabetes and a traumatic partial amputation, reported that the staffing during this shift is very short, leading to significant delays in response times when residents call for assistance. These concerns were documented in resident council meetings held on two occasions, but no action plan was developed or implemented to address these issues. The Director of Staff Development (DSD) did not provide appropriate oversight during the 11pm-7am shift, as required by the facility's job description. The DSD was aware of the residents' concerns but did not conduct rounds or check in with the staff during her presence at the facility. Instead, she focused on paperwork in her office, missing the opportunity to address the staffing issues and delayed response times. The Assistant Director of Nursing (ADON) emphasized that it is the responsibility of department heads, including the DSD, to ensure that residents' call lights are answered promptly and that residents' rights are upheld. The facility's policies and procedures require that concerns raised by the resident council be addressed by the responsible department, with a response form used to track issues and resolutions. However, the minutes from the resident council meetings did not indicate any actions taken to resolve the identified issues. The Administrator acknowledged the staffing shortage and the need for department heads to conduct rounds and provide oversight, but the lack of documented action plans in response to the resident council's concerns highlights a failure to uphold residents' rights and dignity.
Failure to Notify Physician of Resident Altercation
Penalty
Summary
The facility failed to maintain resident rights by not notifying a resident's physician about a change in condition following an altercation. Resident 1, who has intact cognition and a history of type 2 diabetes, muscle weakness, and traumatic partial amputation, was involved in an incident where Resident 2 attempted to hit him. Resident 2, who has severe cognitive impairment and a history of type 2 diabetes and metabolic encephalopathy, was noted to have behavioral symptoms and attempted to strike peers, including Resident 1. The incident was witnessed by the MDS nurse, who reported it to RN 1. However, RN 1 did not notify the administrator or Resident 1's physician, as she did not consider the incident to be abuse since no physical harm occurred. This oversight resulted in a delay in necessary assessments and services for Resident 1, as the physician was unaware of the altercation and its potential impact on Resident 1's health. The facility's policy requires prompt notification of the resident's physician and legal representative in the event of a significant change in condition. The failure to adhere to this policy led to a delay in addressing Resident 1's needs, as the physician was not informed of the incident, which could have warranted further medical assessment and intervention.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report a physical altercation between two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved Resident 1, who was attempting to protect himself from being hit by Resident 2. The altercation was witnessed by the Minimum Data Set (MDS) nurse, who reported it to Registered Nurse (RN) 1. However, RN 1 did not report the incident to the Administrator or the appropriate authorities, as she did not consider it abuse since no injuries were observed. Resident 1, who has intact cognition, reported feeling threatened by Resident 2, who has severely impaired cognition and a history of behavioral symptoms. The MDS nurse witnessed the incident and redirected Resident 2 but assumed RN 1 would report it. RN 1 acknowledged her mistake in not reporting the incident, which placed Resident 1 at risk for further harm and delayed necessary assessments and services. The facility's policy requires all allegations and suspected abuse incidents to be reported immediately to the Administrator, police, ombudsman, and CDPH. The Administrator was unaware of the incident until informed by the ombudsman over two months later, at which point the incident was reported to CDPH. This delay violated federal regulations and the facility's policy, potentially delaying CDPH's investigation and leaving other abuse allegations unreported.
Failure to Develop Comprehensive Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for Resident 1 after an incident involving Resident 2. On December 3, 2024, the MDS nurse witnessed Resident 1 holding Resident 2's hands and was informed by Resident 1 that he was trying to protect himself from being hit by Resident 2. Despite this incident, no care plan was created for Resident 1, and there was no interdisciplinary team meeting to address Resident 1's concerns or to develop a plan of care. This oversight resulted in a delay in care and services for Resident 1, placing him at risk for a decline in mental and psychosocial well-being. Resident 1 was initially admitted to the facility with diagnoses including type 2 diabetes, muscle weakness, and traumatic partial amputation of the right foot. His cognition was intact, and he was able to understand and be understood by others. In contrast, Resident 2, who was involved in the incident, had severe cognitive impairment and was sometimes understood by others. The facility's policy required a comprehensive care plan to be reviewed and revised at the onset of new problems or changes in condition, but this was not done for Resident 1 following the altercation with Resident 2.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure that accurate daily staffing information was posted and readily available to residents and visitors. During an observation at the facility entrance, it was noted that there was no visible daily staffing information, including the total number of staff and actual hours worked, at the receptionist desk. Interviews with the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) revealed that the hours posted were only projected hours and did not reflect the actual number of staff hours or the number of staff working. The ADON and the Administrator (ADM) acknowledged that the purpose of posting staffing hours was to ensure compliance with staffing requirements and to demonstrate that the facility was staffed at or above the required number. The facility's policy and procedure, dated July 2018, indicated that the facility should post the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. However, this was not being adhered to, resulting in residents and visitors not having access to accurate daily staffing numbers.
Inadequate Staffing Leads to Resident's Call to Police for Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect due to insufficient staffing, resulting in inadequate incontinence care. A resident, who was admitted with respiratory failure and had intact cognition, was dependent on staff for activities of daily living, including toileting. On a specific night, the facility had only two CNAs working the night shift instead of the scheduled four, with one CNA assigned to care for 82 residents. This staffing shortage led to the resident not receiving necessary incontinence care, prompting the resident to call the police for assistance. The facility's records indicated discrepancies in staffing, with timecards showing only two CNAs clocked in and out, despite the schedule indicating four were assigned. Interviews with staff confirmed the shortage, with one CNA assigned as a sitter for two residents, leaving the other CNA responsible for the remaining 82 residents. The facility's policy on resident rights emphasized treating residents with kindness, respect, and dignity, which was not upheld in this instance due to the staffing issue.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement its water management plan effectively, which is crucial for preventing the growth and spread of Legionella bacteria. The water management plan team, responsible for overseeing and implementing the plan, did not meet regularly to discuss issues related to water management. This lack of regular meetings and discussions led to a failure in recognizing and addressing potential issues within the facility's water system. The facility's water management policy and procedure required regular meetings and documentation, but there was no evidence of such meetings or documentation being maintained. The deficiency was further compounded by the resignation of the full-time Infection Prevention Nurse (IPN) in November 2024, which left the infection prevention duties to be shared between the Regional Management Quality Nurse Consultant (RNC) and the Director of Staff Development (DSD). This arrangement led to confusion and delays in implementing infection control measures, including the water management plan. The Maintenance Supervisor (MS) was aware of the water management plan but did not maintain logs to demonstrate how control measures were monitored and implemented. Additionally, there was no communication or team meetings to discuss a Legionella concern raised by the Department of Health. The facility's Water Management Plan for Legionella Control was not updated to reflect current team members, and the team had not reviewed the facility's water infection control risk assessments. The plan required maintaining logs and documentation for various water-related equipment and systems, but these were not reviewed by the team. The lack of regular meetings and documentation review could lead to undetected water contamination and potential outbreaks, posing a risk to the health of the residents.
Failure to Designate Full-Time Infection Preventionist
Penalty
Summary
The facility failed to designate a full-time infection preventionist nurse (IPN) to oversee the infection prevention and control program, as required by the facility's job description. This deficiency resulted in inadequate oversight of the facility's water management plan team, which is responsible for addressing hazardous conditions in the water system to prevent legionella growth. The absence of a dedicated IPN led to a lack of regular meetings and discussions about water management issues, increasing the risk of infection for residents. The Regional Management Quality Nurse Consultant (RNC) assumed the IPN duties after the previous IPN resigned in November 2024. However, the RNC was unable to provide documentation of the hours spent performing IPN responsibilities and shared these duties with the Director of Staff Development (DSD), who also had other responsibilities. This lack of clear role delineation caused confusion and delays in implementing the infection prevention and control program. Additionally, the RNC was also acting as the Director of Nursing (DON) after the DON resigned, further complicating the situation. The facility's water management policy and procedure required regular meetings of the water management plan team, which included the IPN, DON, Administrator, and Maintenance Director/Supervisor. However, the RNC could not locate any documentation of such meetings, and the team members listed in the plan had resigned or left their roles. Consequently, the team had not reviewed the facility's water infection control risk assessments, potentially leading to the proliferation of waterborne pathogens and an outbreak. The facility's job description for the IPN emphasized the need for a full-time role to oversee infection prevention and control activities, but this requirement was not met.
Failure to Notify and Assess After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care for a resident who experienced an unwitnessed fall, resulting in injuries. The nursing staff did not notify the resident's physician or responsible party following the incident, which occurred during the night shift. The resident, who had a history of atrial fibrillation, cirrhosis of the liver, and other serious health conditions, was on medications that increased the risk of bleeding. Despite these factors, the nursing staff did not assess or monitor the resident's condition adequately after the fall. The resident was found on the floor by a CNA, who informed an LVN of the situation. However, the LVN did not perform a full assessment, check vital signs, or document the incident in the resident's medical record. The LVN also failed to communicate the incident to the oncoming shift, leaving the resident's condition unmonitored and unreported. This lack of communication and documentation resulted in a delay in the resident's care, as the physician and responsible party were not informed until two days later. The resident was eventually transferred to a general acute care hospital, where multiple bruises and skin abrasions were noted. The facility's policy requires that any change in a resident's condition be reported to the physician and family, but this protocol was not followed. The Director of Nursing acknowledged the oversight, emphasizing the importance of timely assessment and communication to prevent delays in treatment and potential complications.
Failure to Report Resident's Injuries of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH) in a timely manner. The resident, who had multiple medical conditions including atrial fibrillation, cirrhosis of the liver, and cancer, was found with multiple skin tears on his body. These injuries were discovered during a review of the resident's records and interviews with staff and the resident's responsible party. The resident reported that the skin tears were caused by a rough towel used by a certified nursing assistant during the night shift. The licensed vocational nurse (LVN) who observed the injuries was not informed about them by the previous shift and found no documentation regarding the change of condition in the resident's medical record. The LVN acknowledged that she should have reported the injuries to the Director of Nursing Services (DON) or the Administrator. The Registered Nurse Supervisor stated that such injuries should be reported to the CDPH within 24 hours to prevent potential mistreatment. The Director of Nursing was not aware of the injuries until two days later and did not report them to the CDPH, believing the explanation of the rough towel was sufficient. The Administrator confirmed that injuries of unknown origin should have been reported, especially given the questionable nature of the injuries. The facility's policy on abuse prevention and management requires prompt reporting of such incidents to the appropriate authorities.
Failure to Provide One-on-One Sitter for High-Risk Resident
Penalty
Summary
The facility failed to provide a one-on-one sitter for a resident with a history of falls, as per the physician's order. The resident, who was admitted with diagnoses including metabolic encephalopathy, Parkinsonism, and epilepsy, was assessed as having a high risk for falls. Despite the physician's order for a one-on-one sitter following an unwitnessed fall, the resident was observed without a sitter on multiple occasions, attempting tasks beyond her capacity due to her condition. The resident's care plan and physician's order both indicated the need for a one-on-one sitter to ensure safety, especially after a recent fall that resulted in pain and injury. However, during observations and interviews, it was noted that the resident was left unsupervised, attempting to reposition herself and reach for items, which posed a risk of further falls. Staff interviews confirmed that the resident was forgetful, unsteady, and required constant supervision, yet no sitter was consistently assigned. The facility's Director of Nursing and other staff members acknowledged the lack of consistent assignment of a sitter for the resident, despite being aware of the physician's order and the resident's high fall risk. The facility's policy on fall management was not effectively implemented, as the interdisciplinary team failed to ensure the resident's care plan was followed, leading to the deficiency in providing appropriate care and supervision.
Deficiency in Bed Maintenance and Staff Assignment
Penalty
Summary
The facility failed to ensure a clean and comfortable bed for a resident, resulting in a deficiency. The resident, who was cognitively intact and required assistance with activities of daily living, was observed with a bed cluttered with dirty blankets, limiting their ability to sit up properly and rest comfortably. The resident expressed dissatisfaction with the care provided by CNA 1, who was repeatedly assigned to them despite the resident's requests for reassignment. CNA 1 believed the resident could make their own bed and acknowledged a poor relationship with the resident. The Director of Nursing confirmed the lack of space in the resident's bed for comfortable rest. The Director of Staff Development admitted to failing to communicate changes in staff assignments effectively, which contributed to the ongoing issue. The facility's policies on resident rights and activities of daily living emphasize the need for accommodating individual needs and providing appropriate support, which was not adhered to in this case.
Failure to Implement Correct Isolation Precautions During CPO Outbreak
Penalty
Summary
The facility failed to adhere to the Long Beach Department of Health and Human Services (LBDHHS) guidelines during an outbreak of Carbapenemase-producing organisms (CPO) by not posting the correct isolation precaution signs on 8 out of 12 rooms in the sub-acute unit (SAU). Instead of using contact isolation precautions, which require staff to don personal protective equipment (PPE) before entering a resident's room, the facility posted Enhanced Barrier Precautions (EBP) signs. EBP requires PPE only during high-contact activities, which is not in line with the LBDHHS guidelines for residents who tested positive for CPO. The issue was identified during observations and interviews conducted on the SAU. The Director of Staffing (DSD) and the Infection Preventionist Nurse (IPN) both acknowledged the error, noting that the correct contact isolation signs were not posted despite the guidelines being communicated to staff. The Director of Nurses (DON) also confirmed that the LBDHHS guidelines were received but could not explain why the incorrect signs were used. The facility's policy and procedure for infectious disease management indicated adherence to CDC and local health department recommendations, which were not followed in this instance.
Resident Abused by CNA During Bathroom Incident
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA 1). The incident involved CNA 1 yelling at the resident and throwing a urinal and a bottle of water towards the resident. This occurred when CNA 1 entered the bathroom while the resident was using it, despite the resident's request for privacy. The resident reported feeling emotionally distressed and disrespected due to this interaction. The resident, who was admitted with diagnoses including muscle weakness, anxiety, major depressive disorder, and schizophrenia, had intact cognitive abilities and required supervision for various activities of daily living. The resident's care plan highlighted a risk for psychosocial well-being problems related to disagreements with CNA 1. On the day of the incident, the resident reported the altercation to the nursing staff, stating that CNA 1 had entered the bathroom without waiting and had thrown a drinking cup towards him. Interviews with staff and the resident confirmed the events, with CNA 1 admitting to entering the bathroom without waiting and responding with attitude when the resident requested privacy. The facility's policy on abuse prevention and reporting was not adhered to, as CNA 1's actions constituted verbal abuse and a violation of the resident's dignity and respect. The incident was documented in various notes, including the resident's care plan, nurse's progress notes, and interdisciplinary team discussions.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. This incident involved two residents, where one resident pulled the beanie off another resident's head and pulled her hair. The affected resident, who was independent in decision-making, reported the incident to the Administrator the following day. However, the Certified Nursing Assistant (CNA) who witnessed the event reported it to the Licensed Vocational Nurse (LVN), who then failed to report it to the Administrator due to being overwhelmed with work. The LVN acknowledged the oversight, recognizing the obligation to report any allegations of abuse to ensure safety and prevent further incidents. The facility's policy mandates that any abuse allegations be reported to law enforcement and CDPH within two hours. The Administrator confirmed that the incident was not reported to him and emphasized the importance of reporting and investigating all abuse allegations to maintain a safe environment for residents.
Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not submitting a five-day investigative report for an alleged abuse incident involving two residents. Resident 1, who was independent in decision-making, reported that Resident 2, who had moderate cognitive impairment, pulled her beanie off and pulled her hair while on the smoking patio. This incident was reported to the Administrator the following day by Resident 1. However, the Licensed Vocational Nurse (LVN) who was informed of the incident by a Certified Nursing Assistant (CNA) failed to report it to the Administrator due to being overwhelmed with work. The facility's policy requires that all allegations of abuse be investigated and reported to the Administrator within five working days. Despite this requirement, the LVN admitted to forgetting to report the incident, acknowledging his obligation as a mandated reporter to ensure resident safety. The Administrator confirmed that all abuse allegations should be investigated and reported within the specified timeframe. The failure to submit the investigative report resulted in an incomplete investigation and conclusion of the alleged abuse incident.
Failure to Implement Fall Prevention Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a care plan designed to minimize falls and decrease significant injuries for a resident, resulting in a serious incident. The care plan, dated March 20, 2022, specified that the resident's bed should be kept in the lowest position with floor mats on both sides. However, the resident was found kneeling on the floor beside her bed, which was in a high position, and there were no floor mats present. This oversight led to the resident sustaining multiple fractures, including to her thoracic spine and right leg. The resident, who was legally blind and had a history of cognitive impairment, was at high risk for falls as indicated by a Fall Risk Assessment score of 15. Despite this, the care plan interventions were not consistently followed. The resident's responsible party reported that the bed was often in a high position without floor mats, and the resident had previously fallen at the facility. On the night of the incident, the resident attempted to retrieve a fallen pillow, resulting in her fall and subsequent injuries. Interviews with facility staff revealed a lack of adherence to the care plan. A Certified Nursing Assistant noted the absence of floor mats for some time, and a Licensed Vocational Nurse confirmed that the bed was not in the lowest position during the incident. The Assistant Director of Nursing Services acknowledged that staff were expected to implement fall precautions as outlined in the care plan. The facility's policies emphasized the importance of providing a safe environment and implementing person-centered care plans, which were not adhered to in this case.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the arrangement of the resident's bed. The right side of the bed was pushed against a wall, and pillows were tucked under the left side of the bed sheet, which prevented the resident from getting up or moving in bed. This setup was observed during a survey, and it was noted that there was no restraint assessment conducted, nor was there a physician's order for the use of restraints on the resident. The resident, who was admitted with diagnoses including delirium and a recent fall, was dependent on staff for activities of daily living and did not use any form of restraints according to her Minimum Data Set. Interviews with facility staff, including a CNA, LVN, and the Administrator, confirmed that the bed arrangement was intended to prevent falls but inadvertently restrained the resident's movements. The facility's policy requires a physician's order and informed consent for restraints, which were not obtained in this case.
Failure to Obtain Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement a policy to verify that prescribers of antipsychotic medications obtained informed consent from residents before administration. This deficiency was identified during a review of records and interviews, affecting two of the three sampled residents. Resident 1, who was admitted with diagnoses including urinary tract infection, psychosis, and diabetes, was prescribed quetiapine for schizophrenia without the prescriber obtaining informed consent. The facility's policy required written informed consent for psychotherapeutic drugs, but the consent was obtained by a psychiatrist, not the attending physician who prescribed the medication. Similarly, Resident 3 was prescribed quetiapine for schizophrenia with auditory hallucinations, and the informed consent documentation indicated a psychiatrist as the medical provider, not the prescribing physician. Interviews with the facility's administrator confirmed that the prescribers did not obtain the necessary consents from the residents, highlighting a failure in the facility's process to ensure informed consent was properly documented and obtained by the prescribers themselves.
Inconsistent Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the diagnosis for the use of an antipsychotic medication was consistent for a resident. The resident was admitted with diagnoses including urinary tract infection, psychosis, and diabetes. Psychiatric evaluations later assessed the resident with bipolar disorder and generalized anxiety disorder. However, physician orders for quetiapine, an antipsychotic medication, were inconsistent, citing different diagnoses such as bipolar disorder, schizophrenia, and schizoaffective disorder without supporting evidence for these changes. The inconsistency in diagnoses was confirmed by the facility administrator during a review of the resident's health records. The facility's policy on Behavior/Psychoactive Medication Management states that antipsychotic medications should only be used to treat specific mental health diagnoses. The lack of consistent and supported diagnoses for the antipsychotic medication orders indicates a deficiency in the facility's medication management practices.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after hospitalization, which exceeded the bed-hold policy. The resident, who had been originally admitted to the facility with diagnoses including Alzheimer's disease, depression, and anxiety disorder, was transferred to a general acute care hospital (GACH) due to low oxygen levels and pneumonia. Despite being deemed appropriate for transfer back to the facility, the resident was denied readmission, resulting in the resident remaining at the GACH beyond the bed-hold period. The resident's social worker at the GACH attempted to coordinate the resident's return to the facility, contacting the facility's admissions department multiple times without receiving a response. The facility had an available male bed that could have accommodated the resident. However, the facility's marketer stated that the resident was not readmitted due to a lack of isolation beds, as the resident required isolation for infections including MRSA, pseudomonas, and ESBL E. coli, which were not cleared until a later date. The facility's administrator acknowledged that residents have the right to return to the facility, as it is considered their home. However, the Director of Nursing (DON) was not aware of the resident's discharge orders to return. The facility's policy indicated that residents eligible for Medi-Cal/Medicaid must be readmitted to the first available bed, even if they have an outstanding balance. Guidance from the California Department of Public Health stated that facilities should not deny admission based on multi-drug resistant organism infections.
Failure to Protect Residents from Inappropriate Touching
Penalty
Summary
The facility failed to protect two residents from inappropriate touching by another resident, leading to a deficiency in ensuring resident safety and dignity. Resident 3, who was admitted with diagnoses including unspecified mood disorder, schizophrenia, and depression, was involved in inappropriate sexual behavior with Resident 1 and Resident 2. On 10/1/2024, Resident 1 reported that Resident 3 touched her inappropriately on her buttocks twice while they were left unattended on the facility's patio. Despite this incident, Resident 3 was not closely monitored, which led to another incident the following day. On 10/2/2024, Resident 2 reported that Resident 3 touched her left thigh and breast while they were alone on the patio. Resident 2 felt uncomfortable and reported the incident to a charge nurse and a certified nursing assistant. The facility's care plan for Resident 3, following the first incident, included monitoring for inappropriate sexual behavior and providing one-on-one supervision, but these interventions were not effectively implemented, allowing the second incident to occur. Interviews with staff, including LVN 1, LVN 2, and the Director of Nursing Services, revealed that the nursing staff was expected to monitor Resident 3 closely after the first incident to prevent further inappropriate behavior. However, the lack of consistent supervision and failure to implement the care plan interventions resulted in repeated incidents of inappropriate touching, leaving the residents feeling unprotected and disrespected. The facility's policy on abuse prevention clearly states that any form of resident abuse, including sexual abuse, is not condoned, yet the policy was not effectively enforced in this case.
Inadequate Supervision Leads to Inappropriate Resident Interaction
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident, leading to inappropriate touching incidents involving two female residents. Resident 3, who was admitted with diagnoses including unspecified mood disorder, schizophrenia, and depression, was reported to have inappropriately touched Resident 1 on October 1, 2024. Despite this report, the facility did not implement sufficient measures to prevent further incidents, as evidenced by another inappropriate touching incident involving Resident 2 on October 2, 2024. The facility's care plan for Resident 3, following the first incident, included goals to prevent further inappropriate behavior and interventions such as monitoring Resident 3's behavior, notifying the primary physician, and encouraging participation in daily activities. However, these measures were not effectively implemented, as Resident 3 was able to inappropriately touch Resident 2 the following day. Interviews with staff revealed that there was an expectation for close monitoring of Resident 3, which was not adequately fulfilled. The facility's policies on resident safety and abuse prevention were not adhered to, as staff interviews indicated a lack of consistent monitoring and supervision of Resident 3. The Director of Nursing Services acknowledged the responsibility of the nursing staff to implement care plans and abuse prevention protocols to ensure resident safety. The facility's policy required resident checks every two hours or more frequently as needed, which was not effectively carried out in this case, leading to the deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after they were transferred to a General Acute Care Hospital's emergency room for evaluation following two incidents of inappropriate touching of female residents. The resident, who had a history of unspecified mood disorder, schizophrenia, and depression, was deemed appropriate for transfer back to the facility after medical clearance. However, the facility did not allow the resident to return, resulting in an unnecessary and extended stay in the hospital's emergency room for 17 days. The facility's social services informed the family member of one of the female residents that the resident in question was not welcome back due to the potential emotional triggers for the other residents. Additionally, the facility's Director of Nurses stated that the resident would be readmitted if there was no pending case against him, but the social services assistant mentioned that charges were being filed by one of the female residents. The facility's policy on bed hold and transfer/discharge was not followed, as the resident was not provided with a Notice of Transfer and Discharge, and the facility did not adhere to the bed hold policy, which allows for a seven-day hold if elected by the resident or their representative.
Delayed Orthopedic Consultations for Resident
Penalty
Summary
The facility failed to ensure timely completion of orthopedic consultations for a resident who experienced right shoulder pain and left hip dislocation following hospitalizations. The resident, who was admitted with multiple diagnoses including inflammatory spondylopathy, quadriplegia, and osteoarthritis, was supposed to have an orthopedic consult for a torn right shoulder tendon identified in January and another for a left hip dislocation identified in June. However, the outpatient orthopedic consult was not completed until late September, resulting in a delay of care. Interviews and record reviews revealed that the resident's discharge summaries from hospitalizations in January and June indicated the need for follow-up orthopedic consultations. The Quality Assurance Nurse and the Director of Nursing acknowledged that the consults should have been scheduled shortly after the hospitalizations to address the resident's chronic pain and treatment needs. The facility's policies on resident rights and referrals to outside services emphasize the importance of timely and person-centered care, which was not adhered to in this case.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed Oxycodone, a strong pain medication, was available for administration when needed. The resident, who had intact cognition and required assistance with daily activities, was admitted with multiple diagnoses including rheumatoid arthritis, ulcers, muscle spasms, osteoporosis, and a history of traumatic fracture. The resident reported that the Oxycodone had been unavailable for about seven days, which was confirmed by the Licensed Vocational Nurse (LVN) who stated that the pharmacy had been contacted multiple times. However, the prescription had expired, and the LVN did not follow up with the physician to obtain a new prescription. The Director of Nursing acknowledged that prescribed pain medication should be in stock to manage residents' pain effectively. A review of the facility's policy indicated that medications should be reordered five days in advance to ensure an adequate supply. Despite this policy, the resident's Individual Narcotic Record showed that the Oxycodone ran out, and the necessary steps to renew the prescription were not taken, leading to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medication to a resident on two occasions. The resident, who had a history of schizophrenia, bipolar disorder, and other medical conditions, was given quetiapine without informed consent on two separate dates. The medication was prescribed for schizophrenia and bipolar disorder, with specific behavioral manifestations noted in the physician's orders. However, the informed consent documentation was only completed after the medication had already been administered. Interviews with the Director of Staff Development and the Director of Nursing confirmed that informed consent is required before administering psychotropic medications. Both acknowledged that the medication was given without obtaining the necessary consent, which is against the facility's policy. The facility's policy clearly states that informed consent must be obtained and documented before administering the first dose or increasing the dose of psychoactive medications.
Failure to Provide Timely Eye Care Leads to Resident's Blindness
Penalty
Summary
The facility failed to ensure timely and appropriate follow-up care for a resident with intact right eyesight, leading to vision loss and eventual blindness. The resident, who had a history of type 2 diabetes, proliferative diabetic retinopathy, and primary open-angle glaucoma, was admitted to the facility with normal vision in the right eye. On 3/22/2024, an optometrist recommended that the resident see a retina and glaucoma specialist due to blurred vision in the right eye. However, the facility did not act on these recommendations promptly, resulting in a delay of 132 days before the resident was seen by a retina specialist and 158 days before seeing a glaucoma specialist. The facility's staff, including the Social Services Director, Case Management, and licensed nurses, failed to inform the resident's primary physician of the optometrist's recommendations. Consequently, no orders were obtained, and appointments with the necessary specialists were not scheduled in a timely manner. The resident's care plan did not include a comprehensive plan for the potential of impaired vision in the right eye, despite the diagnosis of advanced diabetic retinopathy. This lack of action and communication led to the resident's right eye vision deteriorating, resulting in blindness. The resident expressed frustration and concern about the worsening eyesight to multiple facility staff members, but these concerns were not adequately addressed until much later. The resident's condition worsened, leading to increased dependency on staff for activities of daily living and a decline in mental health, including depression. The facility's failure to act on the optometrist's recommendations and ensure timely specialist consultations directly contributed to the resident's vision loss.
Failure to Develop Timely Vision Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with impaired vision upon admission. The resident, who was admitted with a diagnosis of type 2 diabetes, proliferative diabetic retinopathy, blindness in the left eye, and primary open-angle glaucoma, did not have a care plan addressing his vision needs until five months after admission. This oversight resulted in a delay of services, including necessary referrals to an eye specialist and monitoring for potential decline in eyesight. The resident had requested an optometrist consultation upon admission, but the facility did not arrange for this or include it in the care plan. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and moderately impaired vision, highlighting the importance of a vision care plan to ensure the resident attended necessary eye appointments and received appropriate care. Despite these indicators, the facility did not initiate a vision care plan until several months later. Interviews with facility staff, including the MDS Nurse and Director of Nursing, confirmed that a vision care plan should have been in place from the time of admission. The facility's policies and procedures also required the interdisciplinary team to address the resident's diabetes and vision care needs in the care plan. The lack of a timely care plan led to the resident experiencing a decline in right eye vision, which could have been mitigated with proper care and monitoring.
Failure to Follow Optometrist's Recommendations Leads to Resident's Vision Loss
Penalty
Summary
The facility failed to ensure timely follow-up on an optometrist's recommendations for a resident, leading to the deterioration of the resident's right eye vision and eventual blindness. The optometrist recommended that the resident see a retina specialist and a glaucoma specialist, but these appointments were not scheduled until several months later. The resident was not seen by the retina specialist until 132 days after the recommendation and by the glaucoma specialist 158 days later. This delay in care resulted in the resident's right eye vision loss and subsequent blindness. The resident, who had a history of schizoaffective disorder, type 2 diabetes with proliferative diabetic retinopathy, and primary open-angle glaucoma, expressed concerns about his vision upon admission to the facility. Despite a physician's order for an eye health and vision consult, the facility did not act promptly on the optometrist's recommendations. The resident's care plan, which included goals to prevent acute eye problems and maintain visual function, was not effectively implemented, as the necessary specialist consultations were not arranged in a timely manner. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's eye care needs. The Social Services Director and case management did not ensure that the optometrist's recommendations were relayed to the resident's primary physician, nor did they obtain the necessary orders and arrange the specialist appointments. The Director of Nursing acknowledged that there were no orders placed for the specialist consultations after the optometrist's visit, and the facility's policy to document follow-ups was not adhered to. As a result, the resident experienced significant vision loss, leading to depression and a loss of independence in daily activities.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to Resident 16, who was admitted with diagnoses including schizophrenia, altered mental status, and paranoid personality disorder. Despite the resident's intact cognition, the History and Physical indicated that Resident 16 could not make medical decisions. The facility administered Quetiapine Fumarate, Lithium Carbonate, and Risperidone to Resident 16 from June to August 2024 without obtaining informed consent until August 8, 2024. Interviews with the Medical Records Assistant and Registered Nurse 1 confirmed that no consent was documented before August 8, 2024, and that licensed nurses should have verified consent prior to medication administration. The Director of Nursing acknowledged the importance of obtaining consent to ensure the responsible party was informed about the medications' side effects. The facility's policy required written informed consent for psychotherapeutic drugs, which was not followed in this case.
Failure to Provide Adaptive Call Light System for Quadriplegic Resident
Penalty
Summary
The facility failed to provide an adaptive call light system for a resident who was quadriplegic and completely dependent on staff for activities of daily living. This deficiency was identified during a review of the resident's admission record, which noted the resident's conditions, including quadriplegia, muscle weakness, and muscle wasting. The Minimum Data Set (MDS) indicated that the resident's cognition was impaired, and they were dependent on staff for all daily activities. Despite this, the resident's call light was found on the floor, and the type of call light provided was not suitable for the resident's needs. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that the call light was not appropriate for the resident, who required a call pad due to limited use of extremities and hands. The facility's policy and procedure documents stated that an adaptive call bell should be provided according to the resident's needs and that residents should be cared for in a manner that promotes quality of life and dignity. The failure to provide an appropriate call light system placed the resident at risk of being unable to communicate their needs, potentially leading to harm.
Failure to Honor Resident's Right to Choose PCP
Penalty
Summary
The facility failed to honor Resident 318's right to choose a primary care physician (PCP) of his choice, which is a violation of resident rights. Resident 318, who has multiple medical conditions including pneumonia, pulmonary edema, type 2 diabetes, and major depressive disorder, expressed a desire to change his PCP from PCP 2 to PCP 1. Despite being able to communicate his needs and understand others, the facility did not facilitate this change, leading to Resident 318's agitation and distress. During interviews and record reviews, it was revealed that Resident 318 had repeatedly informed the social services director (SSD) of his wish to change his PCP, citing dissatisfaction with PCP 2. The SSD acknowledged Resident 318's right to choose his PCP but failed to act on his request, attributing the inaction to a lack of further complaints from the resident. Additionally, there was no documentation of the request for a PCP change, and the care plan inaccurately labeled Resident 318's concerns as delusional thoughts. Further interviews with staff, including an LVN and the Director of Nursing (DON), confirmed that the facility did not follow through with Resident 318's request to change his PCP. Although an attempt was made to contact PCP 3, Resident 318 was not informed of this, and PCP 2 continued to provide care. The DON acknowledged that the resident's doctor should have been changed, as residents have the right to choose their physician, and the failure to do so contributed to Resident 318's upset and outbursts.
Failure to Follow Restraint Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the use of physical restraints for a resident, identified as Resident 52. The deficiency involved the use of a right-hand mitten restraint without specifying a duration of use, as required by the facility's policy. The resident, who was admitted with severe medical conditions including a tracheostomy, functional quadriplegia, and traumatic subdural hemorrhage, was observed with the restraint in place. The facility's order summary for the restraint did not include an end date or a discontinued date, and there was no order to assess or monitor the resident's circulation, sensation, movement, and skin integrity, which are critical components of the facility's restraint policy. Additionally, the facility failed to document assessments of the resident's circulation, movement, sensation, and skin integrity during the period the restraint was in use, as evidenced by a review of the Medication Administration Record (MAR) from May 2023 to August 2024. During an interview, the Director of Nursing (DON) acknowledged that the restraint order lacked a specified duration and that the MAR did not reflect the necessary documentation of assessments every two hours, as required by the facility's policy. This oversight had the potential to result in the unnecessary use of the restraint and unmonitored skin breakdown or loss of circulation and sensation for the resident.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a physician's order for oxygen administration for one resident, identified as Resident 48. The resident, who was moderately cognitively impaired and dependent on staff for various activities, was observed receiving oxygen at a rate of 2.5 liters per minute, despite a physician's order specifying 4 liters per minute. This discrepancy was noted during multiple observations on different dates, indicating a consistent failure to provide the prescribed level of oxygen. Interviews with facility staff, including a Licensed Vocational Nurse (LVN 4), a Registered Nurse (RN 1), and the Director of Nursing (DON), confirmed the oversight. Each staff member acknowledged the physician's order and the potential risks associated with administering oxygen at a lower rate than prescribed. The facility's policy and procedures for oxygen therapy, which were reviewed, also indicated that oxygen should be administered per physician orders, highlighting the facility's failure to comply with its own guidelines.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and disposal of both controlled and non-controlled medications, leading to potential risks of medication errors and drug diversion. During an inspection, it was observed that a bubble pack of Hydrocodone and Acetaminophen, a controlled medication, was improperly sealed with paper tape instead of being disposed of as per the facility's policy. This medication should have been wasted to prevent drug diversion or accidental administration. Additionally, a bottle of Docusate Sodium, a non-controlled medication, was found in a regular trash can instead of the designated medication disposal bin, increasing the risk of accidental consumption or misuse. Furthermore, the facility did not secure the medication room properly, as the door was found unlocked and unsecured on multiple occasions. This oversight was acknowledged by a registered nurse, who noted that the door might not have been closed completely by the licensed nurses. The facility's policy mandates that medication rooms be locked to prevent unauthorized access and potential drug diversion. These deficiencies highlight lapses in adherence to the facility's policies regarding medication storage and disposal, posing risks to resident safety.
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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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