Edgewater Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 2625 East Fourth Street, Long Beach, California 90814
- CMS Provider Number
- 055387
- Inspections on file
- 40
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Edgewater Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with a history of urinary retention and an order to reinsert a Foley catheter if unable to void was unable to urinate and developed increasing groin and abdominal pain. The assigned LVN attempted to follow the order but could not locate catheter supplies, even after seeking help from another nurse and calling the DON, who also did not know the supply location. Because staff had not been oriented to where catheters were stored and the supplies were kept in a locked nursing supply closet, the ordered catheter reinsertion was not performed, and the resident was transferred to a hospital for treatment.
A resident was not adequately prepared for transfer or discharge, and the process did not fully address the resident's needs and preferences, resulting in a deficiency related to safe and appropriate transition of care.
A resident with a history of psychotic disorder and major depressive disorder, who was cognitively intact, was transferred to a hospital without receiving a completed written Bed Hold notification. The required documentation, including the resident's response, date and time of notification, and signatures, was left blank, and there was no record of refusal to sign. The DON confirmed that the notification was not provided as required by facility policy.
A resident with multiple medical conditions was discharged, but a refund owed to the responsible party was not issued within the required timeframe due to errors in account posting and lack of a clear policy for timely refunds. Staff interviews confirmed the absence of a standard procedure, leading to the delay in returning the funds.
The facility failed to address ongoing complaints from residents about delayed call light responses and staff rudeness, particularly during evening and night shifts. Residents reported waiting extended periods for assistance, with one resident waiting 5.5 hours, leading to a 911 call. Despite repeated documentation of these issues in resident council meetings, the facility's attempts to resolve them through staff education were inadequate, and the Director of Nursing was unaware of the full extent of the problems until months later.
The facility failed to implement its Infection Prevention and Control Program, leading to multiple deficiencies. CNAs did not perform hand hygiene or use proper PPE while providing care to residents, including one on Enhanced Barrier Precautions. Other issues included improper management of a nasal cannula, humidifier, and urinal, placing residents at risk for infection.
A resident with type 2 diabetes and other health issues was left in a soiled brief for an hour, despite using the call button for assistance. The resident reported frequent delays in receiving care, leading to feelings of neglect and embarrassment. Facility records showed ongoing issues with call light response times, which were not addressed in subsequent meetings. The DON acknowledged the importance of timely care to prevent health risks, but the facility failed to adhere to its policies on maintaining resident dignity.
A CNA failed to properly implement infection control measures by wearing an N95 mask below her nose and neglecting hand hygiene after caring for a resident with a history of respiratory issues. The Infection Preventionist confirmed the importance of correct mask usage and hand hygiene to prevent the spread of infections like Influenza A.
A resident with severe cognitive impairment fell and was transferred to a GACH, but the resident's representative was not notified until over five hours later. The delay occurred despite instructions from the RNS to the CN to inform the family immediately. The DON acknowledged the failure to adhere to the facility's policy requiring immediate notification of changes in condition.
A resident at high risk for falls, with severe cognitive impairment and communication limitations, experienced multiple falls due to the facility's failure to develop and implement an effective care plan. The care plan did not address the resident's inability to use the call light, and interventions were delayed, compromising the resident's safety. Staff interviews revealed inconsistencies in monitoring practices, highlighting the need for specific time frames for increased monitoring.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall, resulting in head pain. The RN failed to document the incident, including a change of condition note and assessments, as required by facility policy. This omission could lead to confusion and errors in care by other healthcare providers.
The facility failed to obtain informed consents for psychotropic medications for three residents, including one with dementia and another with major depressive disorder. The Director of Nursing acknowledged the importance of informed consents, which were not reobtained every six months as required. Additionally, a resident was administered Trazadone without prior consent, and the indication for Quetiapine was not clarified before administration.
A facility failed to accurately document a resident's discharge status on the MDS, indicating a planned discharge to a hospital instead of the actual discharge to an assisted living facility with hospice care. The error was acknowledged by the MDS Nurse, and the DON stressed the importance of accurate MDS documentation for proper care delivery.
The facility failed to reassess the PASRR for two residents, one with serious mental illness and another with major depressive disorder, leading to a deficiency in providing appropriate care. The PASRR Level II screening for one resident was not completed due to unresponsiveness from staff, while the other resident's PASRR did not reflect their diagnosis. The Director of Nursing acknowledged these oversights.
A facility failed to create a trauma-informed care plan for a resident with a history of significant trauma, including childhood rape and war experiences, leading to difficulty sleeping. Despite being cognitively intact and having diagnoses of major depressive disorder and anxiety disorder, the resident's trauma was not addressed in their care plan. Interviews revealed that the resident's trauma was discussed in IDT meetings, but no individualized plan was developed, contrary to the facility's policies.
A facility failed to update a resident's care plan to include monitoring for newly prescribed medications, Mirtazapine and Trazadone, which were intended for poor meal intake and inability to sleep. The LVN and DON acknowledged the oversight, which was contrary to the facility's policy requiring communication of new psychotropic medication orders to the Social Services department for review with the IDT.
A resident with a history of atherosclerosis and cellulitis did not receive the last dose of Clindamycin as ordered by the physician. The resident returned to the facility and missed the 5:00 p.m. and 9:00 p.m. doses on the last day of the antibiotic course. The Director of Nursing confirmed the oversight, which was against the facility's policy to administer medications as prescribed.
A resident with an indwelling catheter was at risk of infection due to lapses in infection control practices by facility staff. The staff failed to perform hand hygiene and allowed the urine collection bag to touch the floor. Despite the resident's severe cognitive impairment and risk for infection, the CNA did not adhere to enhanced barrier precautions, using the same gloves for multiple tasks. The facility's policies required hand hygiene and PPE use, but these were not followed, as confirmed by the DON.
A resident with Type II Diabetes Mellitus did not receive their prescribed Insulin Glargine Solution on time due to the facility's failure to have the medication available. The resident had an active order for daily insulin administration, but during an observation, it was found that the medication was not on hand, and the LVN stated she would follow up with the pharmacy. The facility's policy requires medications to be reordered at least three days before the last dosage, which was not adhered to in this case.
The facility failed to ensure dietary staff knew proper techniques for thawing frozen food and testing sanitizer concentration, potentially leading to food-borne illnesses. A Dietary Aid used the wrong test strip for sanitizer, and a frozen item was thawed under hot water instead of cold, contrary to facility policy.
The facility was found to have improper food storage and labeling practices, with staff personal belongings in the food storage area and unlabeled or mislabeled food items. These actions, observed by surveyors, violate facility policies and pose a risk for food-borne illnesses.
The facility failed to implement its infection control policy, leading to potential infection risks. A CNA did not perform hand hygiene before entering a resident's room, and an LVN improperly doffed PPE after administering medication to another resident. Both residents had significant medical conditions requiring assistance. The facility's policies emphasize the importance of hand hygiene and proper PPE use to prevent infection spread.
The facility did not meet the required space standards for 15 resident rooms, with some rooms housing two to four residents each, falling short of the mandated 80 square feet per resident. Despite this, observations and interviews indicated no adverse effects on resident care or health, and no complaints were reported by residents or staff.
A facility failed to create a trauma-informed care plan for a resident with a history of significant trauma, including childhood rape, war participation, and a spouse's suicide. Despite the resident's difficulty sleeping and experiencing triggers, staff were unaware of the trauma, and no specific care plan was developed, contrary to facility policy.
The facility's QAA and QAPI committee failed to effectively measure the success of actions addressing Resident Council concerns about call light response delays and inadequate ADL care during specific shifts. Despite efforts to improve, the facility's assessment methods did not directly address these issues, potentially affecting all 73 residents' quality of care.
A facility failed to conduct timely Interdisciplinary Team (IDT) meetings for a resident, leading to a communication breakdown regarding her care plan. The resident, with multiple medical conditions, expressed frustration over unclear communication about her physician appointments and physical therapy goals. Despite her capacity to understand and make decisions, the last IDT meeting was held months ago, and the facility was unaware of her outside therapy appointments. Staff interviews confirmed the lack of regular IDT meetings, contrary to facility policy, resulting in the deficiency.
A resident with limited mobility and a history of stroke was not provided a requested commode, forcing her to use a bedpan, which led to feelings of embarrassment and degradation. Despite being able to communicate her needs and recommendations from the Director of Rehabilitation, the facility did not address her request, failing to adhere to their policy on maintaining residents' ADLs.
A resident with multiple health issues, including a stroke, did not receive necessary psychiatric services as ordered due to insurance coverage issues. Despite having a care plan addressing behavioral concerns, the resident experienced increased depression and anxiety, and the facility failed to facilitate psychiatric consultations, placing the resident at risk for mental health decline.
A resident with severe cognitive impairment did not receive a shower for 28 days and was not dressed in personal clothing, as preferred by her family. Staff were unaware of her shower schedule, and there was no documentation of showers or refusals. The DON confirmed the deficiency in maintaining the resident's dignity and preferences.
A resident with severe cognitive impairment and poor safety awareness was found without a call light button within reach, contrary to her care plan and facility policy. The resident, dependent on staff for daily activities, was unable to call for assistance, as observed by an RN. The DON confirmed that staff should ensure call lights are accessible to residents before leaving their rooms.
A resident with severe cognitive impairment and mobility issues was not repositioned every two hours as required, leading to a deficiency. Observations showed the resident lying on her back for extended periods, and interviews confirmed the care plan was not followed. The facility's policy mandates preventative measures to avoid pressure ulcers.
A resident with a pressure injury did not receive care under Enhanced Barrier Precautions (EBP) as required. The resident, who needed substantial assistance and had multiple health conditions, was not provided with proper infection control measures when a CNA failed to wear an isolation gown during high-contact care activities. Despite the presence of an EBP sign, the CNA did not adhere to the facility's policy, which mandates the use of gowns and gloves to prevent the spread of multidrug-resistant organisms (MDROs).
A resident's RP found three tablets of HIV medication left in a 30-day supply and reported it to the nursing staff, but no action was taken to address the concern or assist in filing a grievance. Interviews revealed that staff were aware of the issue but did not inform the DON or help the RP with the grievance process, contrary to facility policy.
The facility failed to account for eight missing Morphine Sulfate tablets from an emergency medication kit. During a shift change, two LVNs discovered the discrepancy but found no documentation or signatures to explain the removal of the tablets. The DON confirmed missing signatures in the logbooks, indicating a lack of proper documentation and accountability. Facility policies require controlled substances to be inventoried by two licensed nurses at each shift change, but these procedures were not followed.
An LVN failed to document the administration of pain medication for a resident immediately after it was given, as required by professional standards. The resident, with diabetes and neuropathy, had an order for Norco to be administered before wound care. The medication was given, but documentation was delayed by several hours, contrary to facility policy and standard procedures.
A facility failed to conduct an IDT care conference involving a resident and their Responsible Party (RP) before discontinuing the resident's speech therapy. The resident's therapy was stopped due to frequent refusals and aggressive behavior, but the RP was not informed, leading to frustration and distrust. Both the DOR and DON acknowledged the failure to involve the RP, violating the resident's and RP's rights.
A resident with a G-tube experienced two incidents of unintentional dislodgement, requiring hospital transfers for surgical intervention. The facility failed to revise the care plans to prevent future dislodgements and did not investigate the causes of the incidents.
The facility failed to provide required in-service training and skills checklists for abuse and dementia care to two CNAs. The Director of Nursing confirmed the absence of these records, which is against the facility's policy revised in December 2023.
A high-risk resident fell out of bed and sustained injuries due to the facility's failure to follow care plan interventions, including keeping the bed in the lowest position and using floor mats. The resident was left unattended during incontinence care, leading to the fall.
A resident with severe cognitive impairment and high fall risk fell from a bed that was not in the lowest position and without floor mats, as required by the care plan. The resident sustained a non-displaced left intertrochanteric fracture and was transferred to a GACH for further evaluation and treatment.
The facility failed to document the presence of a low air loss mattress on the TAR and did not ensure an order for the mattress was in place for two residents with pressure ulcers. The Licensed Treatment Nurse and MDS Coordinator confirmed the lack of documentation and orders, which could result in poor wound healing.
The facility staff failed to notify the responsible party when a resident experienced a significant weight loss of 12 pounds within a month. Despite the facility's policy requiring notification for any change in condition, there was no record of such notification or a change of condition form being initiated. This oversight was confirmed by multiple staff members, including the Director of Nursing.
Failure to Provide Timely Indwelling Catheter Reinsertion Due to Inaccessible Supplies
Penalty
Summary
The deficiency involved the facility’s failure to ensure timely reinsertion of an indwelling urinary catheter for a resident with a physician’s order to monitor for urinary retention and reinsert the catheter if unable to void. The resident, admitted with diagnoses including myocardial infarction, type 2 diabetes mellitus, and muscle weakness, had an order dated 1/21/2026 to discontinue the Foley catheter and monitor for urinary retention every shift, with instructions to reinsert the catheter if the resident could not urinate. Nursing notes documented that after catheter removal, the resident was being monitored for urinary retention. On the following day, nursing notes indicated the resident was unable to urinate and reported pressure and later pain in the groin and abdomen after multiple attempts to void. The LVN caring for the resident was unable to insert the indwelling catheter as ordered and the resident was subsequently transferred to a general acute care hospital. According to the LVN’s interview, she became aware around 12:30 a.m. that the resident was unable to urinate and was experiencing increasing groin pain, and she knew the physician’s order required catheter reinsertion if the resident could not void. She stated she could not locate the catheter supplies in the facility, asked another nurse for help, and they were still unable to find them. She called the DON for assistance, but the DON did not provide specific instructions on where the supplies were stored, and the LVN reported she had not been oriented to the supply locations. In a separate interview, the DON confirmed receiving a call about the resident’s severe pain and the need for catheter insertion, acknowledged she did not know where the catheter supplies were kept, and stated she later learned they were in a locked nursing supply closet. The facility’s assessment indicated that care for residents requiring intermittent or indwelling urinary catheters was among the commonly provided services, yet the necessary catheter supplies were not accessible or locatable at the time they were needed, resulting in the failure to carry out the physician’s order for timely catheter reinsertion.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being.
Incomplete Bed Hold Notification Upon Resident Transfer
Penalty
Summary
The facility failed to provide a completed written Bed Hold notification to a resident upon transfer to a general acute care hospital. The resident, who had diagnoses including psychotic disorder with hallucinations and major depressive disorder, was cognitively intact and able to make decisions at the time of transfer. Documentation review showed that the Bed Hold Notification form was incomplete, with the section for the resident or representative's response left blank, including the resident's desire for bed hold, date and time of notification, and the facility representative's signature. There was no documentation indicating that the resident refused to sign the form. During an interview and record review, the DON confirmed that staff did not notify the resident of the Bed Hold policy upon transfer and acknowledged the lack of required documentation. The facility's policy required that residents or their representatives be informed in writing of their right to exercise the bed hold provision in the event of a transfer to a hospital or therapeutic leave, but this was not done in this instance.
Delayed Refund Issuance After Resident Discharge
Penalty
Summary
The facility failed to issue a refund of $1,752.00 to the responsible party of a resident within 30 days of the resident's discharge. The resident, who had diagnoses including hemiplegia, hemiparesis, and prostate cancer, was discharged on 2/19/2025. The business office manager (BOM) identified that the resident's share of cost had decreased, resulting in a credit, but the refund was not processed in a timely manner. The BOM explained that the payment for February was incorrectly posted to June, and after an audit, the funds were correctly allocated. However, the refund process was delayed because the BOM overlooked the credit after the books were closed, and the refund was not expedited as required. Interviews with facility staff revealed a lack of a standard policy or timeframe for issuing refunds after discharge. The administrator and director of nursing confirmed that there was no established procedure for timely refunds, and the business office only conducted audits as needed. The responsible party was notified of the refund after the audit, but the delay in processing was attributed to oversight and the absence of a clear policy, resulting in the responsible party not receiving the refund within the required timeframe.
Failure to Address Resident Complaints on Call Light Response and Staff Conduct
Penalty
Summary
The facility failed to address and resolve complaints raised during resident council meetings regarding call lights not being answered, staff rudeness, and untimely or absent care. This deficiency affected five residents, who reported significant delays in receiving assistance, particularly during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. Residents expressed concerns about being left in soiled incontinence briefs for extended periods, with one resident waiting up to 5.5 hours for assistance, leading to a 911 call due to the lack of response from nursing staff. The residents' complaints were documented in the facility's resident council minutes over several months, highlighting ongoing issues with registry staff's behavior and response times. Despite these documented concerns, the facility's Director of Nursing (DON) was unaware of the extent and duration of these issues until November 2024. The DON acknowledged the merit of the residents' complaints and recognized that the ongoing nature of the issues indicated that staff education alone was insufficient to resolve the problems. Interviews with residents and staff revealed that the facility's attempts to address the concerns through in-service education and monitoring were inadequate. The Director of Activities confirmed that the residents' concerns were repeatedly brought up in meetings with department heads, yet the issues persisted. The facility's policy and procedure documents outlined expectations for timely call light responses and addressing resident council concerns, but these were not effectively implemented, resulting in continued resident dissatisfaction and unmet care needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for several residents, leading to multiple deficiencies. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene or use the proper personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). This resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was exposed to potential infection risks when CNA 1 handled contaminated materials improperly and did not follow standard infection control protocols. Another incident involved CNA 2, who also failed to wear proper PPE while providing direct care to the same resident. Additionally, CNA 2 did not discard contaminated gloves before entering another resident's room and turning off the call light, further compromising infection control measures. These actions were contrary to the facility's policies, which emphasize the importance of hand hygiene and the use of PPE to prevent the spread of infections. Further deficiencies were noted with other residents, including the failure to date and change a nasal cannula and humidifier for a resident with respiratory issues, and the improper management of a urinal for another resident, which was not emptied or replaced as required. These oversights in infection control practices placed the residents at risk for infection, highlighting significant lapses in adherence to the facility's infection prevention protocols.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 4, by not providing timely incontinent care. Resident 4, who has diagnoses including type 2 diabetes, muscle weakness, and a major depressive episode, was left to sit in a soiled, wet brief for an hour. This incident occurred despite Resident 4 using the call button to request assistance from a Certified Nurse Aide (CNA). The resident reported frequently waiting over 30 minutes for care and expressed feelings of embarrassment, discomfort, and neglect due to the delays. The facility's Resident Council Minutes from previous months indicated ongoing issues with call lights not being answered promptly and residents expressing a desire for more frequent checks by nursing staff. Despite these documented concerns, there was no evidence that the facility addressed these issues in subsequent meetings. During an interview, the Director of Nursing (DON) acknowledged the importance of accommodating residents' toileting needs promptly and stated that all nursing staff, including CNAs, Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), are responsible for providing incontinent care. The facility's policies and procedures emphasize the importance of maintaining residents' dignity by responding promptly to requests for assistance. However, the failure to provide timely care to Resident 4, as well as the lack of follow-up on previously raised concerns, highlights a deficiency in the facility's adherence to these policies. The DON noted that such delays in care could lead to risks such as urinary tract infections and skin breakdown, further underscoring the importance of timely response to residents' needs.
Infection Control Deficiency Due to Improper Mask Use and Hand Hygiene
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program effectively, as evidenced by the actions of Certified Nurse Assistant (CNA) 4. During an observation, CNA 4 was seen wearing an N95 mask below her nose while interacting with a resident, which is contrary to the proper usage guidelines that require the mask to cover both the nose and mouth. This improper use of the mask was acknowledged by CNA 4, who stated that it was difficult to breathe with the mask properly positioned. Additionally, CNA 4 did not perform hand hygiene after providing care to the resident, failing to use hand sanitizer or wash her hands upon exiting the resident's room. The resident involved, identified as Resident 10, had a medical history that included type 2 diabetes mellitus, acute respiratory failure, and chronic obstructive pulmonary disease. The resident's cognition was intact, and they were able to communicate effectively. The Infection Preventionist confirmed that all staff are required to wear N95 masks correctly and perform hand hygiene before and after resident contact to prevent the spread of infections such as Influenza A. The facility's policy on hand hygiene, which aligns with CDC guidelines, was not followed in this instance, leading to a deficiency in infection control practices.
Delayed Notification of Resident's Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify the resident representative (RR) of a resident's fall and subsequent transfer to a General Acute Care Hospital (GACH) in a timely manner. The resident, who had severe cognitive impairment and required significant assistance for mobility, fell and hit her head on the floor. The incident occurred at 3:20 p.m., but the RR was not informed until 8:45 p.m., over five hours later. This delay in communication violated the RR's right to be informed of the resident's care and services. Interviews and record reviews revealed that the Registered Nurse Supervisor (RNS) had instructed the Charge Nurse (CN) to notify the RR immediately after the fall. However, due to the CN being busy, the notification was delayed. The Director of Nursing (DON) acknowledged that the family should have been informed immediately to prevent worry and frustration. The facility's policy and procedure on change in condition required immediate notification of the resident or their representative, which was not adhered to in this case.
Failure to Implement Effective Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident at high risk for falls, who had a history of falling. The resident, who was non-verbal and unable to use the call light, experienced multiple falls on specific dates. The care plan did not address the resident's inability to communicate needs or use the call light, which contributed to the falls. Additionally, interventions such as moving the resident closer to the nursing station and ordering a perimeter low air loss mattress were delayed, further compromising the resident's safety. The resident was admitted with several diagnoses, including acute respiratory failure, a stage 4 pressure ulcer, aphasia, and cognitive communication deficit. The Minimum Data Set indicated severe cognitive impairment, and the resident was bed-bound and dependent on assistance for all activities of daily living. Despite being identified as a high fall risk, the care plan only included ensuring the call light was within reach, which was ineffective given the resident's communication limitations. Interviews with staff revealed inconsistencies in monitoring practices and a lack of specific time frames for increased monitoring of the resident. The Director of Nursing acknowledged the need for additional interventions in the care plan, such as specific monitoring time frames, to prevent falls. The facility's policies required the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adequately done in this case.
Failure to Document Change in Condition After Resident Fall
Penalty
Summary
The facility failed to document a change in condition for a resident who experienced a fall with injury. The resident, who was admitted with acute respiratory failure, a stage 4 pressure ulcer, aphasia, and cognitive communication deficit, was found on the floor with reported head pain after an unwitnessed fall. Despite the incident, the necessary documentation, including a change of condition note, fall assessment, and pain assessment, was not completed by the registered nurse (RN) responsible for the resident's care. The RN acknowledged forgetting to document the incident, which could lead to confusion and potential errors in care by other healthcare providers. The Director of Nursing emphasized the importance of accurate documentation to reflect the resident's condition and the interventions performed. The facility's policy requires that any change in a resident's condition be assessed and documented in the electronic medical record, which was not adhered to in this case.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free of unnecessary medications by not obtaining informed consents for the use of psychotropic medications. Resident 8, who was diagnosed with dementia, anxiety disorder, and major depressive disorder, did not have the capacity to make decisions. Despite this, informed consents for medications such as Ativan, Duloxetine, and Risperidone were not reobtained every six months as required. The Director of Nursing (DON) acknowledged that informed consents are crucial for ensuring that residents or their representatives are aware of the medication's indication, risks, and the right to refuse. Resident 15, diagnosed with anxiety disorder and major depressive disorder, had the capacity to make decisions. However, the informed consent for Mirtazapine, prescribed for poor meal intake, was not reobtained within the required six-month period. The DON confirmed that psychotropic medications should not be administered without valid consent, emphasizing the importance of informed consents in ensuring residents' rights are respected. Resident 37, with a history of major depressive disorder, type II diabetes, and hypertension, was prescribed Trazadone and Quetiapine Fumarate. The facility failed to clarify the indication for Quetiapine before administration, as there was uncertainty about the resident's schizophrenia diagnosis. The Licensed Vocational Nurse (LVN) noted that the resident did not exhibit the behavior for which Quetiapine was prescribed. Additionally, the informed consent for Trazadone was obtained after the medication had already been administered, which the DON acknowledged as a failure to inform the resident of the medication's risks and benefits before administration.
Inaccurate MDS Documentation of Discharge Status
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's discharge status on the Minimum Data Set (MDS), which is a critical resident assessment tool. Specifically, the MDS for a resident with moderate cognitive impairment and requiring maximal assistance for daily activities inaccurately indicated a planned discharge to a Short-Term General Hospital. However, the resident was actually discharged to an assisted living facility with hospice care. This discrepancy was identified during a review of the resident's records, including the Admission Record and Discharge Summary, which both confirmed the discharge to an assisted living facility. The MDS Nurse acknowledged the error during a concurrent interview and record review, stating that the MDS should have reflected the correct discharge destination. The Director of Nursing emphasized the importance of accurate MDS documentation to ensure appropriate care delivery based on the resident's current status and needs. The facility's policy on Resident Assessment Instrument, last revised in 2019, mandates that assessments must accurately reflect the resident's status and needs, highlighting the deficiency in this case.
Failure to Reassess PASRR for Residents with Special Needs
Penalty
Summary
The facility failed to ensure proper reassessment of the Preadmission Screening and Resident Review (PASRR) for two residents, which is crucial for determining the facility's ability to provide care for their special needs. Resident 5 was initially admitted with diagnoses including unspecified dementia, mood disturbance, anxiety, and psychosis. The PASRR Level I screening indicated a need for a Level II screening due to serious mental illness (SMI), but this was not completed because the facility staff were unresponsive to communication attempts. The Director of Nursing (DON) acknowledged that the facility should have resubmitted the Level I screening to ensure appropriate care for Resident 5. Resident 37 was admitted with diagnoses including major depressive disorder, Type II Diabetes, and hypertension. The PASRR Level I screening incorrectly indicated that Resident 37 did not have an SMI, despite a diagnosis of depression. The DON noted that the PASRR should have been corrected and resubmitted to reflect the resident's actual condition. The facility's policy mandates proper screening using the PASRR specified by the state, but this was not adhered to, leading to the deficiency.
Failure to Develop Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident who reported difficulty sleeping related to previous trauma. The resident, who was admitted with diagnoses of major depressive disorder and anxiety disorder, had a history of significant traumatic events, including being raped as a child, experiencing war, and the suicide of his wife. Despite these factors, the facility did not have a care plan or documentation addressing the resident's trauma, which was confirmed during an interview with a registered nurse who was unaware of the resident's trauma history. The deficiency was further highlighted during interviews with the Social Service Director and the Director of Nursing, who acknowledged that the resident's trauma had been screened and discussed in interdisciplinary team meetings. However, no individualized care plan was developed to address the resident's specific needs and potential triggers. The facility's policies on comprehensive person-centered care planning and behavioral health services emphasize the importance of trauma-informed care, yet these were not implemented for the resident in question.
Failure to Update Care Plans for Medication Changes
Penalty
Summary
The facility failed to review and revise care plans when medication regimens were updated for a resident, identified as Resident 15. This oversight was discovered during a review of the resident's records, which showed that the care plans did not include monitoring for Mirtazapine and Trazadone, despite these medications being prescribed for poor meal intake and inability to sleep, respectively. The Licensed Vocational Nurse (LVN) acknowledged that the care plan should have been updated to reflect these changes. The deficiency was further highlighted during an interview with the Director of Nursing, who confirmed that orders and care plans should be reviewed and revised to accurately reflect the resident's status and medication orders. The facility's policy on psychotropic medications, last revised in February 2024, mandates that new physician's orders for such medications be communicated to the Social Services department for review with the Interdisciplinary Team (IDT) to ensure the resident's psychosocial care plan is updated. This process was not followed, leading to the deficiency.
Failure to Administer Last Dose of Antibiotic
Penalty
Summary
The facility failed to ensure that a resident received the last dose of an antibiotic as per the physician's order. The resident, who was initially admitted on 9/3/2024 and readmitted later, had diagnoses including atherosclerosis of the right leg with ulceration, peripheral venous insufficiency, and heart failure. The resident's Minimum Data Set indicated intact cognitive skills and required maximal assistance for certain activities. The physician had ordered Clindamycin for cellulitis of the right leg, to be administered four times a day for seven days, starting on 11/9/2024 and ending on 11/16/2024. However, a review of the Medication Administration Record for December 2024 revealed that the resident did not receive the 5:00 p.m. and 9:00 p.m. doses on 11/15/2024. The Director of Nursing confirmed that the resident returned to the facility on 11/15/2024 at 6:00 p.m. and did not receive the last dose of the antibiotic, which was supposed to be administered at 9:00 p.m. before the order was discontinued at 10:03 p.m. The facility's policy requires medications to be administered as prescribed by the attending physician, and the failure to administer the last dose could potentially prolong the resident's infection.
Infection Control Lapses in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices during the care of a resident with an indwelling urethral catheter. Specifically, staff did not perform hand hygiene before and after providing catheter care, and the resident's urine collection bag was observed touching the floor, which was covered by a dignity bag. These actions were observed during interactions with the resident, who had a history of severe cognitive impairment and was at risk for infection due to the indwelling catheter. The resident, who had been admitted and readmitted to the facility with diagnoses including infection due to the catheter, kidney stones, and neuromuscular dysfunction of the bladder, was found to have penile edema and scrotal erythema. The facility had active orders for enhanced barrier precautions, including the use of personal protective equipment for high-contact care activities related to the catheter. However, during observations, a CNA failed to adhere to these precautions, neglecting to perform hand hygiene and using the same gloves for multiple tasks, which could lead to the spread of infection. The facility's policies and procedures required staff to perform hand hygiene and use personal protective equipment during catheter care to prevent infection. Despite these guidelines, the CNA did not follow the infection control protocols, as confirmed by the Director of Nursing. The failure to maintain proper hygiene and infection control practices had the potential to result in infection or contamination for the resident.
Failure to Provide Insulin Glargine Solution
Penalty
Summary
The facility failed to ensure that a resident had the required Insulin Glargine Solution available for administration, resulting in the resident not receiving their insulin on time. The resident, who was admitted with diagnoses including Type II Diabetes Mellitus, hypertension, and long-term use of insulin, had an active physician order for Insulin Glargine to be administered daily. However, during an observation and interview, it was noted that the insulin was not available, and the Licensed Vocational Nurse stated that she would follow up with the pharmacy. The facility's policy and procedure require that medications be administered as prescribed by the attending physician and that refills be reordered from the pharmacy at least three days before the last dosage is administered. Despite these policies, the insulin was not on hand, indicating a lapse in following the procedure for medication administration and reorder. The resident's Minimum Data Set indicated mild cognitive impairment and dependency on assistance for various activities, underscoring the importance of timely medication administration for their condition.
Improper Thawing and Sanitizer Testing in Dietary Services
Penalty
Summary
The facility failed to ensure that dietary staff were knowledgeable about the proper techniques for thawing frozen food and testing the concentration of sanitizer, which could potentially lead to food-borne illnesses. During an observation and interview, a Dietary Aid (DA) was found using the wrong test strip to check the sanitizer concentration, resulting in no color change to indicate the concentration level. The Dietary Supervisor (DS) confirmed the error and acknowledged that the DA had used the incorrect test strip. Additionally, a sealed frozen item was observed being thawed under hot water in a strainer in the sink, which was not in accordance with the facility's policy. The DS admitted that the hot water was accidentally turned on, and the proper method required using cold water. The facility's policy indicated that thawing should be done under running water at a temperature of 70 degrees Fahrenheit or lower. These practices were not followed, leading to the potential risk of serving improperly thawed food to residents.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. Personal belongings of staff, including jackets and bags, were found in the dry food storage area, which is against the facility's policy and can lead to cross-contamination. Dietary Aid 1 acknowledged that these items should not be in the food storage area. Additionally, a container of potatoes was found without proper labeling, and a container of green produce in the refrigerator was mislabeled as strawberries and lacked a delivery date. These practices were confirmed by Dietary Aid 3 and the Dietary Supervisor, who emphasized the importance of labeling and dating to prevent food-borne illnesses. The facility's policies and procedures, reviewed during the survey, clearly state that personal items should not be stored in the kitchen area and that all food items should be properly labeled and dated. The lack of adherence to these policies was evident in the observations made by the surveyors, highlighting a potential risk for food-borne illnesses due to improper storage and labeling of food items. The Dietary Supervisor confirmed that the absence of proper labeling and dating could lead to food-borne illnesses, underscoring the importance of following established protocols to ensure food safety.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement its infection control policy for two residents, leading to potential risks of infection transmission. For Resident 130, a Certified Nursing Assistant (CNA) did not perform hand hygiene after exiting another resident's room and before entering Resident 130's room. The CNA believed that hand hygiene was only necessary when providing direct care, not when simply checking on a resident. Resident 130, who was admitted with diagnoses including generalized weakness, cerebrovascular accident, and Parkinson's disease, had intact cognitive skills and required varying levels of assistance for daily activities. In another instance, a Licensed Vocational Nurse (LVN) improperly doffed personal protective equipment (PPE) after administering medication to Resident 53. The LVN removed her gown by grabbing the front with bare hands, contrary to proper PPE removal procedures. Resident 53, who had diagnoses including cerebral infarction, hypertension, and dementia, required moderate assistance for various activities. The LVN acknowledged the importance of proper PPE use to prevent infection spread but failed to adhere to the correct procedure. The facility's Infection Preventionist Nurse emphasized the importance of hand hygiene before and after entering a resident's room, regardless of the level of contact, to prevent cross-contamination. The facility's policies on hand hygiene and standard precautions were reviewed, highlighting the necessity of performing hand hygiene and proper PPE use to contain pathogens. These deficiencies in infection control practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 15 out of 35 resident rooms met the required space standards of 80 square feet per resident in multiple resident rooms. Specifically, Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34, which housed two residents each, and Rooms 18, 20, 21, 35, and 36, which housed four residents each, did not meet these requirements. The total square footage for the two-resident rooms was 153.33 square feet, and for the four-resident rooms, it ranged from 283.5 to 296.66 square feet, falling short of the mandated space per resident. Despite the deficiency in room size, observations and interviews conducted from December 9 to December 12, 2024, indicated that the residents' care needs and health were not adversely affected by the room size. Resident 15, when interviewed, expressed no issues with the room space and stated that there was adequate space for belongings. Additionally, neither the residents nor the facility staff providing care reported any complaints about insufficient space affecting the quality of care. The facility submitted a request to continue the room waivers on December 12, 2024.
Failure to Develop Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident who reported difficulty sleeping due to previous trauma. The resident, who was admitted with diagnoses of major depressive disorder and anxiety disorder, had a history of trauma including being raped at a young age, participating in a war, and experiencing the suicide of his wife. Despite these significant trauma indicators, the facility did not have a care plan addressing the resident's trauma, which was confirmed during interviews with the resident, a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON). The resident expressed that the medications provided by the facility only slightly helped with sleep issues and that he experienced unspecified triggers related to his trauma. The LVN and RN were unaware of the resident's trauma, and there were no specific trauma-related tasks assigned to the staff. The Social Service Director mentioned the resident's trauma assessment during interdisciplinary team meetings, but no individualized care plan was developed. The facility's policy required a comprehensive person-centered and trauma-informed care plan, which was not implemented for this resident.
Deficiency in Call Light Response and ADL Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement effective methods to measure the success of actions addressing ongoing concerns from the Resident Council. These concerns included delays in call light response during the 11 p.m. to 7 a.m. shift and inadequate delivery of Activities of Daily Living (ADLs) care. The deficiency was identified through interviews and record reviews, which revealed that the facility's QAPI project aimed to improve call light response times but lacked specific measures to assess the effectiveness of implemented actions. The Resident Council minutes from several meetings highlighted persistent issues with call light response times and ADL care, particularly during the night and evening shifts. Despite the facility's efforts to conduct daily spot checks and receive feedback from the Resident Council, the Administrator acknowledged that the Angel Rounds used for assessment did not directly address the residents' concerns or measure the success of interventions. This oversight potentially affected all 73 residents in the facility, as it risked them not receiving the necessary quality care to meet their highest potential well-being.
Failure to Conduct Timely IDT Meetings Causes Communication Breakdown
Penalty
Summary
The facility failed to conduct a timely Interdisciplinary Team (IDT) meeting for a resident, resulting in a delay in communication between the resident and the IDT. This deficiency caused frustration and anxiety for the resident and had the potential to delay the delivery of needed care and services. The resident, who was admitted with multiple medical conditions including a displaced fracture of the left femur and left hemiplegia following a stroke, had the capacity to understand and make decisions, as indicated in her medical records. The resident's care plan, initiated in May 2024, indicated impaired and fluctuating Activities of Daily Living (ADLs) skills related to her medical conditions. Despite this, the last documented IDT meeting was held in July 2024, and another meeting was overdue. The resident expressed frustration with the lack of communication regarding her plan of care, specifically concerning physician appointments and physical therapy goals. She had been coordinating her own physical therapy appointments outside the facility due to insurance coverage issues, and the facility was not fully aware of these appointments or their impact on her care. Interviews with facility staff, including the Director of Social Services, Director of Rehabilitation, and Director of Nursing, confirmed the lack of regular IDT meetings and communication regarding the resident's care. The facility's policy and procedure indicated the importance of regular IDT meetings to ensure quality care, but this was not adhered to, leading to the deficiency. The staff acknowledged the need for regular IDT meetings to update the resident's plan of care and ensure all parties were informed of her appointments and care needs.
Failure to Provide Commode for Resident's ADL Needs
Penalty
Summary
The facility failed to provide a resident with the appropriate care and services to maintain her Activities of Daily Living (ADLs), specifically by not providing a requested commode. The resident, who was admitted with a displaced fracture of the left femur, left hemiplegia, and hemiparesis following a stroke, was continent and had the capacity to understand and make decisions. Despite her ability to communicate her needs and the recommendation from the Director of Rehabilitation that she was appropriate for transfer with assistance, the resident was not provided with a commode, forcing her to use a bedpan. This situation caused the resident to feel embarrassed and degraded. The resident's care plan indicated she had an ADL self-performance deficit related to limited mobility and required assistance for transfers. The resident had requested a bedside commode during a care conference, but this request was not addressed by the Interdisciplinary Team (IDT). Interviews with the Director of Nursing and the Director of Rehabilitation confirmed that the resident should have been provided a commode to maintain her independence and dignity. The facility's policy on ADLs emphasized providing appropriate treatment and services to maintain or improve residents' abilities, which was not adhered to in this case.
Failure to Provide Psychiatric Services to Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care services as indicated by physician orders. The resident, who was admitted with multiple diagnoses including a displaced fracture, left hemiplegia, and hemiparesis following a stroke, had an order for psychiatric evaluation and treatment. Despite this, the resident was not seen by a psychiatrist or psychologist since admission, as confirmed by the Social Services Director and the Director of Nursing. This lack of psychiatric consultation was attributed to the resident's insurance not covering the facility's contracted psychiatric visits, and no alternative arrangements were made. The resident's care plan, initiated months after admission, documented behaviors such as fabricating stories, impulsivity, and attention-seeking actions, with goals and interventions outlined to address these issues. However, the resident expressed frustration with the communication regarding her care plan and appointments, leading to increased depression, anxiety, and a desire to see a mental health professional. The facility's failure to facilitate psychiatric services placed the resident at risk for mental health decline and decreased quality of life. The facility's assessment and policies indicated a commitment to providing behavioral health services and managing psychiatric conditions, yet these were not effectively implemented for the resident in question. The Director of Nursing acknowledged the oversight and the risk it posed to the resident's mental health and well-being, highlighting a gap between the facility's stated policies and the actual care provided.
Failure to Provide Shower and Personal Clothing
Penalty
Summary
The facility failed to ensure that a resident was offered and provided a shower and was dressed in her personal clothing, as per the family's preference. The resident, who had severe cognitive impairment and was dependent on staff for hygiene and dressing, had not received a shower for 28 days. The responsible party was not informed of any refusals by the resident to take a shower, and the staff was unable to provide information on the resident's shower schedule or the last time she received a shower. Observations revealed the resident in a hospital gown, contrary to the family's preference for her to be dressed in personal clothing. Interviews with staff indicated a lack of awareness regarding the resident's shower schedule and the last time she was offered or provided a shower. The Director of Nursing confirmed that the Bathing Point of Care Flow Sheet showed no documentation of showers or refusals for 28 days, highlighting a deficiency in maintaining the resident's dignity and personal preferences.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident with poor safety awareness and severe cognitive impairment had a call light button within reach, which is crucial for calling nursing staff for assistance. The resident, who was dependent on staff for hygiene, toileting, showering, and bathing, was observed lying in bed unable to reach the call light button, which was placed on the top left side of the bed, out of her reach. This oversight was confirmed during an observation and interview with a registered nurse, who acknowledged that the call light was not within the resident's reach and that staff should have ensured the resident could see and touch the call light button before leaving the room. The resident's care plan, which highlighted her risk for falls due to confusion, gait/balance problems, hypotension, and incontinence, specified that the call light should be within her reach and that she should be encouraged to use it to call for assistance. The Director of Nursing also stated that nursing staff must ensure residents' call lights are within reach before leaving the room, as per the facility's policy and procedure. The failure to adhere to these guidelines resulted in a delay in care and services for the resident, with the potential for her to act without assistance and sustain a fall or injury.
Failure to Reposition Resident Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for care, was repositioned every two hours as required. This deficiency was observed in the case of a resident with severe cognitive impairment, hemiplegia, hemiparesis, and generalized muscle weakness, who was at risk for developing pressure ulcers. The resident's care plan, which included interventions for turning and repositioning every two hours, was not followed, as evidenced by observations of the resident lying on her back for extended periods without being repositioned. Interviews with the resident's responsible party and facility staff confirmed the failure to adhere to the care plan. The responsible party expressed concerns about the resident not being turned regularly, and a CNA admitted to last repositioning the resident several hours before the observation. The Director of Nursing acknowledged the importance of repositioning dependent residents to prevent skin breakdown, aligning with the facility's policy on skin management, which mandates preventative measures to avoid pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure injury on the sacrum, leading to a deficiency in infection prevention and control. The resident, who was admitted with conditions including hemiplegia, hemiparesis, type 2 diabetes, and blindness, required substantial assistance for daily activities and had two stage 2 pressure injuries. The care plan for the resident indicated the need for personal protective equipment (PPE) during high-contact care activities to prevent infection. However, during an observation, a Certified Nursing Assistant (CNA) did not wear an isolation gown while repositioning the resident and removing an incontinent brief, despite the presence of an EBP sign on the resident's door. Interviews with staff revealed that the CNA acknowledged the oversight and the Licensed Vocational Nurse (LVN) confirmed the requirement for EBP, expressing uncertainty about why the gown was not worn. The Director of Nursing (DON) emphasized the importance of staff education on EBP and the necessity of wearing proper PPE to prevent the spread of infections. The facility's policy on EBP, dated March 2024, outlined the use of gowns and gloves during high-contact activities to prevent the transfer of multidrug-resistant organisms (MDROs), which was not adhered to in this instance.
Failure to Assist in Grievance Filing for Medication Concerns
Penalty
Summary
The facility failed to assist a resident's Responsible Party (RP) in filing a grievance regarding medication administration. The RP discovered three tablets of an HIV medication left in the resident's 30-day supply and reported this to the licensed nurses and the Director of Nursing (DON). However, the RP's concerns were not addressed, and he was not informed about the grievance filing process, leading to his frustration. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) were aware of the RP's concerns but did not take action to inform the DON or assist in filing a grievance. The Social Services Director (SSD) also confirmed that no grievance was filed, and the facility's policy required staff to inform and assist residents and their RPs in filing grievances. The Administrator acknowledged the importance of encouraging and assisting residents and their families in filing grievances to ensure concerns are resolved.
Unaccounted Morphine Tablets in Emergency Kit
Penalty
Summary
The facility failed to account for the disposition of eight Morphine Sulfate tablets from one of the two emergency medication kits. This issue was identified during a shift change when LVN 3 and LVN 6 reconciled the contents of the emergency medication kit and found the tablets missing. There was no receipt or signature to indicate which resident required the medication or which staff member removed the tablets. LVN 3 stated that controlled medications, including those in the emergency kit, need to be reconciled before and after each shift. The Director of Nursing Services (DON) confirmed that there were missing signatures in the Controlled Sign in Sheets Logbook for Incoming and Outgoing Nurses, indicating a lack of proper documentation and accountability. The facility's policies require that emergency medications be stored in sealed containers and that a physical inventory of all controlled substances be conducted by two licensed nurses at each shift change. However, the procedures were not followed, leading to the unaccounted-for morphine tablets.
Failure to Timely Document Pain Medication Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 2 failed to document the administration of pain medication for Resident 1 immediately after it was given, as required by professional standards of practice. Resident 1, who was admitted to the facility with diabetes mellitus and neuropathy, had an order for Norco to be administered 30 minutes prior to wound care. On June 12, 2024, the medication was administered at 9 a.m., but LVN 2 did not sign the narcotic count sheet until 2:31 p.m., several hours later. Interviews with LVN 3 and the Director of Nursing Services confirmed that the correct procedure is to document medication administration immediately to prevent errors. The facility's policies on medication administration and storage also require timely documentation to ensure accurate records and prevent discrepancies. This failure to document promptly could lead to risks of overmedication or undermedication for Resident 1.
Failure to Inform and Involve Responsible Party in Care Plan Changes
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) care conference involving a resident and the resident's Responsible Party (RP) prior to discontinuing the resident's speech therapy. The resident, who had severe cognitive impairment and other significant medical conditions, was receiving speech therapy services from mid-February to early March. However, the therapy was discontinued without informing the RP, who only discovered the discontinuation during daily visits. The RP expressed frustration and distrust towards the facility for not being notified and involved in the decision-making process regarding the resident's care plan. The Director of Rehabilitation (DOR) and the Director of Nursing (DON) both acknowledged that the facility failed to inform the RP and involve them in the care plan changes. The DOR explained that the therapy was discontinued due to the resident's frequent refusals and aggressive behavior during sessions. Despite this, the facility did not hold an IDT meeting to discuss the resident's condition and treatment changes with the RP, violating the resident's and RP's rights to be informed and participate in the care plan. The facility's policy on comprehensive resident-centered care planning also emphasized the importance of involving the resident and their family or RP in care plan development, which was not adhered to in this case.
Failure to Prevent G-Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) had measures in place to prevent the tube from being inadvertently dislodged. The resident, who had severe cognitive impairment and received nutrition through a feeding tube, experienced two incidents where the G-tube was unintentionally removed. The first incident occurred on 1/19/2024, when the resident pulled the G-tube out, and the second incident occurred on 3/31/2024, when the G-tube slid out of the abdominal binder during medication administration. Both incidents required the resident to be transferred to a general acute care hospital for surgical intervention to replace the G-tube. The facility did not revise the resident's care plans to include interventions to prevent future unintentional dislodgements of the G-tube. The care plans did not reflect the use of the abdominal binder, which was used to secure the G-tube. The MDS nurse confirmed that the care plans were not updated after the incidents, and specific care plan revisions were not discussed in the IDT meeting following the incidents. The Director of Nursing (DON) acknowledged that it was her responsibility to ensure that staff provided appropriate care and services as indicated in the resident's plan of care. The facility also failed to investigate the cause of the resident's multiple G-tube dislodgements. The DON stated that the facility had not investigated the reasons for the dislodgements and that failing to do so placed the resident at risk for future unintentional G-tube dislodgements. The facility's policy and procedure indicated that the IDT should develop and implement a comprehensive person-centered care plan to meet the resident's needs, but this was not done in this case.
Lack of Required Training for CNAs
Penalty
Summary
The facility failed to ensure required in-service training and skills checklists for abuse and dementia care were provided to two of four sampled Certified Nursing Assistants (CNAs). During a concurrent interview and record review, it was found that the employee files for two CNAs lacked the necessary skills checklists and training documentation. The Director of Nursing confirmed the absence of these records. The facility's policy, revised in December 2023, mandates training on abuse prevention and dementia care, but this was not adhered to for the two CNAs in question.
Failure to Prevent Fall and Injury in High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident assessed as high risk for falls and totally dependent on staff for activities of daily living (ADL). The resident fell out of bed and sustained injuries, including a non-displaced left intertrochanteric fracture, a bump on the forehead, and an abrasion on the left arm. The incident occurred when a Certified Nurse Assistant (CNA) left the resident unattended to get supplies for incontinence care, during which time the resident fell from a bed that was not in its lowest position and without floor mats in place as care planned. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for ADLs, with functional limitations in the lower extremities. The resident's Care Plan, which aimed to prevent falls, included interventions such as keeping the bed in the lowest position and placing floor mats beside the bed. However, these interventions were not followed on the night of the incident. The CNA who found the resident on the floor confirmed that the bed was at bedside table height and could not recall if floor mats were in place. Interviews with facility staff, including CNAs, a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), revealed that the resident's bed should have been in the lowest position and floor mats should have been in place. Additionally, two staff members should have been present while providing care to the resident. The facility's policy on Fall Management System emphasized the importance of maintaining an environment free of accident hazards and providing appropriate assessments and interventions to prevent falls and minimize complications.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident assessed as high risk for falls. The care plan required floor mats next to the resident's bed and the bed to be in the lowest position. However, these interventions were not in place, resulting in the resident falling from her bed, which was in a high position, and landing on the floor without floor mats. The resident was subsequently transferred to a General Acute Care Hospital (GACH) and diagnosed with a non-displaced left intertrochanteric fracture. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was admitted with a diagnosis of generalized muscle weakness. The resident's Minimum Data Set (MDS) and Fall Risk Evaluation indicated a high risk for falls. Despite this, the care plan's interventions to prevent falls were not followed. On the night of the incident, the resident was found on the floor by a Certified Nurse Assistant (CNA) after a loud thud was heard. The bed was noted to be at bedside table height, and no floor mat was in place. Interviews with staff confirmed that the care plan's interventions were not implemented. The Director of Nursing (DON) acknowledged that the bed should have been in the lowest position and floor mats should have been in place to minimize injury risk. The facility's policies on care planning and fall management were reviewed, indicating that the interdisciplinary team should develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents' needs. However, these policies were not adhered to in this case.
Failure to Document and Order Low Air Loss Mattress for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents by not documenting the presence of a low air loss mattress on the treatment administration record (TAR) and not ensuring an order for the mattress was in place. Resident 1, who was admitted with severe cognitive impairment and a stage 3 pressure sore, did not have an order for a low air loss mattress documented, and there was no monitoring of the mattress usage. The Licensed Treatment Nurse admitted to forgetting to write the order and was unaware of the need to document the mattress usage on the TAR. Similarly, Resident 2, who had a stage 4 pressure ulcer and was dependent on staff for various activities, had an order for a low air loss mattress, but there was no documented evidence of its usage on the TAR. The TX nurse also admitted to not knowing the requirement to document the mattress usage. The MDS Coordinator confirmed the lack of documentation and orders for the low air loss mattress for both residents. The facility's policy on Skin and Wound Monitoring and Management required licensed nurses to document the presence of pressure-reducing devices on the TAR and to monitor these devices daily. The failure to adhere to these policies had the potential to result in poor wound healing for the residents involved.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify the responsible party when a resident experienced a significant weight loss of 12 pounds within a month. The resident, who had a history of diabetes mellitus, hypertension, and acute respiratory failure with hypoxia, was dependent on assistance for daily activities. Despite the facility's policy requiring notification of the responsible party for any change in condition, there was no record of such notification or a change of condition form being initiated. This was confirmed through interviews with the Licensed Vocational Nurse, Minimum Data Set Coordinator, and the Director of Nursing, all of whom acknowledged the oversight and emphasized the importance of family notification and involvement in the resident's care plan. The deficiency was identified during a review of the resident's weight summary and admission records, which showed a weight drop from 116 pounds to 104 pounds over a span of three weeks. The facility's policy, dated May 2019, mandates that any change in a resident's condition must be documented and communicated to the responsible party. However, this protocol was not followed, resulting in a violation of the resident's right to be informed about their care and services. The failure to notify the family was verified by multiple staff members, including the Director of Nursing, who confirmed that no change of condition form was started and the family was not informed of the resident's weight loss.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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