Eureka Rehabilitation & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, California.
- Location
- 2353 Twenty Third St, Eureka, California 95501
- CMS Provider Number
- 055003
- Inspections on file
- 30
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Eureka Rehabilitation & Wellness Center, Lp during CMS and state inspections, most recent first.
Surveyors found that one of two licensed nurses did not have CPR certification that included required hands-on skills training. The nurse, employed through an agency, obtained CPR certification from an online provider that offered only written testing without in-person or virtual instructor-led skills validation. The Administrator reported that all licensed nurses, including agency staff, were expected to maintain CPR for Healthcare Providers with hands-on practice on a mannequin. Facility policy required CPR training with a hands-on component in line with AHA guidelines, but this was not met for the nurse, decreasing the facility’s potential to provide effective basic life support and CPR for all residents during respiratory or cardiac emergencies.
A resident with COPD and asthma experienced progressive respiratory distress that was repeatedly reported by CNAs to an LPN, who did not promptly assess the resident, did not document a timely change-of-condition assessment, and did not notify the physician as required by facility policy and the resident’s care plan. The LPN later documented administering a nebulized breathing treatment without an active physician order and without clear documentation of the medication or date of administration, while the MAR showed no albuterol doses given that month. When the resident became unresponsive with severely low O2 saturation and labored breathing, the LPN called a non-emergent ambulance despite being instructed by another LPN to call 911, and the physician reported she was only notified after the resident had already coded and been transferred.
A resident with COPD and asthma experienced progressive respiratory distress during a shift, with CNAs repeatedly reporting abnormal, gurgling respirations and declining O2 saturations to an LPN who, according to CNA interviews and record review, did not promptly assess the resident or document a change in condition. The medical record contained no assessment, COC entry, or physician notification between mid-afternoon and early evening, despite facility policies and care plan directives requiring such documentation and action. Later notes by two LNs described rapid breathing, severely low O2 saturations, and subsequent unresponsiveness requiring CPR and EMS intervention, but a late-entry note by one LPN referenced a breathing treatment without specifying the medication or correct date, and the MAR showed no administration of the ordered albuterol nebulizer. The attending MD confirmed no prior notification of the resident’s shortness of breath or request for a respiratory treatment order that day, and the facility’s DON and policies indicated that nurses were expected to assess, obtain appropriate orders, and document all COCs and interventions.
The facility failed to employ a dedicated onsite RD and relied instead on a remote RD who only participated in virtual meetings to review resident weights and diets, without conducting in-person assessments or kitchen consultations. Surveyors found multiple dietary and kitchen issues, including failure to follow recipes, improper dumpster closure, and problems with sanitation, cleanliness, maintenance, equipment, and food storage. Interviews with the Dietary Supervisor, Regional Consultant, and Regional RD confirmed that the last full-time onsite RD had left months earlier, the Regional RD managed about 30 facilities with infrequent, unscheduled visits, and that an RD was expected to be physically present weekly but was not. Review of RD and Regional RD job descriptions and training records showed that required duties such as regular facility visits, inspection of food service areas, and ensuring regulatory compliance were not being carried out onsite.
Surveyors identified that kitchen staff failed to follow standardized recipes and use measuring tools during meal preparation. A cook prepared garlic bread, pureed bread, and a zesty spinach side dish without recipes at the workstation, adding unmeasured amounts of butter, garlic powder, and milk, and omitting required ingredients such as salt and red pepper flakes. Spinach was also spilled into a sink during draining, with only the remaining portion used. The dietary supervisor and regional RD later confirmed that recipes were required to be visible and followed, and that ingredients, including salt when listed, should be measured to maintain the planned nutrient content.
Surveyors found multiple failures in dietary sanitation and food service operations affecting a large number of residents. Kitchen staff were observed preparing food without required hair or beard nets and while wearing prohibited jewelry, contrary to facility policy and infection control expectations. The kitchen environment included a wall near cooking equipment with chipped and scratched paint and paint chips on the floor, as well as a dirty three-drawer utensil bin with sticky handles and food crumbs inside. Floors under and around handwashing and prep areas were soiled with grime, debris, and dried spills, and a utility cart used for food and beverage service was visibly dirty yet remained in use during meal service, with no cleaning log available despite policy requirements. Food-contact items, including scoops, were stored wet, a can opener had peeling metal and label remnants on the blade, and several discolored cutting boards had deep grooves, all of which were acknowledged by dietary leadership as unclean or unfit for use. Additionally, the facility’s emergency water supply was found to be expired, despite policies requiring regular rotation of disaster food and water stocks.
Surveyors found that staff failed to follow professional standards and facility policies in several areas. A resident with hypothyroidism received levothyroxine and famotidine together despite a pharmacist’s recommendation and documentation that levothyroxine should not be given with other medications. Two residents who experienced changes of condition, including diarrhea and unwitnessed falls, were not monitored every shift for 72 hours as required by the facility’s COC policy, and one of these residents did not have a care plan initiated or updated to address the new condition. For a resident with multiple fractures who sustained an unwitnessed fall and was transferred to the hospital, post-fall neurological checks were not completed at the required frequencies outlined in the facility’s neuro check and fall management protocols.
Surveyors found that the facility did not complete required annual competency/skills assessments for two CNAs and lacked documented abuse and dementia training for two other CNAs. One CNA’s last competency review was several months overdue, and another had an unsigned, undated skills checklist with no confirmation of completion. Training files for two additional CNAs lacked evidence of abuse prevention and dementia management education, despite facility policy and the facility assessment requiring annual competency validation and inclusion of dementia and abuse training. The DSD acknowledged these training gaps and that they could affect staff ability to respond to abuse situations and care for residents with dementia.
The facility failed to implement consultant pharmacist (CP) medication regimen review (MRR) recommendations for multiple residents receiving medications for BPH, constipation, hypothyroidism, HTN, gout, GERD, type 2 diabetes, and other conditions. The CP had recommended adding specific administration instructions (such as timing with meals, not crushing hazardous drugs, and separating famotidine from levothyroxine), adding hold parameters for laxatives, clarifying maximum daily acetaminophen dosing, specifying monitoring parameters for antihypertensives, and updating indications for melatonin. On review, these recommendations were not reflected in the residents’ active orders, and the DON confirmed that the December MRR recommendations had not been implemented or forwarded to the prescriber. The CP and Administrator both stated expectations that such recommendations be reviewed and acted upon in a timely manner, and facility policies required timely communication and documentation of CP recommendations, which did not occur.
Surveyors found that medications were not stored and labeled according to professional standards and facility policy during an inspection of a medication cart with the DON. Ten loose pills were discovered in the cart, six medications lacked required open dates after the manufacturer’s seal was broken, and six used insulin pens for different residents were comingled in the same drawer, allowing the pens to touch. The DON acknowledged that loose pills could be mistakenly given or taken, that open dates were needed to ensure medications were not outdated, and that insulin pens should not touch to prevent cross contamination.
Surveyors found that one of the facility’s dumpsters was overflowing with trash, left open without lids, and surrounded by garbage on the ground. A Dietary Supervisor confirmed the dumpster was too full to close and acknowledged that lids were supposed to be closed to keep pests and critters out, while the Maintenance Director stated that lids were to remain closed at all times for infection control and to prevent birds from accessing the waste. Facility policy required medical waste containers to be covered, closable, and stored so they are protected from animals and do not provide a breeding place or food source for insects and rodents.
A resident with spinal stenosis, strabismus, vascular dementia, and moderate cognitive impairment, who required partial to moderate assistance with mobility and ambulation, did not have a functional or accessible bed light. The pull cord behind the bed was only about three inches long and could not be reached, and the light did not work even when the wall switch was turned on, leaving the resident unable to control the room lighting and dependent on others. A CNA confirmed the cord length and nonfunctioning light. While the Maintenance Director initially claimed the issue had not been reported, the Business Office Manager and a regional consultant stated that the problem had been raised repeatedly over several months and that the Maintenance Director was aware the light needed repair, contrary to facility policies requiring a safe, hazard-free, and home-like environment.
Licensed nurses did not update care plans after an incident of resident-to-resident abuse involving two residents with severe cognitive impairment and behavioral issues, nor did they complete the required 72-hour monitoring after a resident with metabolic encephalopathy experienced a fall and returned from the emergency department. These actions did not meet professional standards or facility policy.
A resident with a recent history of falls and orthopedic injuries was incorrectly assessed as moderate fall risk upon admission, leading to a care plan that did not reflect their actual needs. The resident, who had moderate cognitive impairment and required moderate assistance for transfers, later fell and sustained a distal radial fracture. Facility staff and documentation confirmed that the fall prevention protocol was not properly followed.
The facility failed to label and date food items in the kitchen, as observed during tours with the Dietary Manager. Items such as sliced carrots, vegetable patties, and Salisbury steaks were found without labels or open/use-by dates. Staff interviews confirmed the expectation for all opened food items to be labeled, aligning with the facility's policy.
A facility failed to accurately complete a Level I PASRR for a resident with depression and PTSD, omitting these diagnoses and resulting in a missed Level II Evaluation. Staff interviews revealed that the MDS nurse was responsible for PASRR accuracy, and both the DON and Administrator expected accurate PASRR reviews.
A resident in an LTC facility developed severe pressure injuries due to inadequate care. The resident did not receive scheduled showers, and treatment plans for skin conditions were not consistently followed. The facility failed to turn and reposition the resident every two hours, and documentation of the resident's skin condition was inaccurate. These deficiencies led to the resident developing a Stage 4 pressure injury with infection.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and resident concerns about safety. Four residents, with conditions such as muscle weakness and chronic pain, reported waiting up to an hour for assistance. Staff confirmed the shortage, noting increased risks of falls and injuries. The facility did not meet the required Direct Care Service Hours Per Patient Day for 8 out of 10 days, falling short of the 3.5 nursing hours per patient day policy.
A facility failed to ensure licensed nurses had the necessary competencies, resulting in inaccurate documentation of a resident's skin impairment and failure to recognize UTI and sepsis. This led to a fall causing a severe hip fracture. The facility lacked specific policies for managing UTIs, sepsis, and accurate documentation.
A resident with severe cognitive impairment did not receive scheduled showers, receiving only one shower and one bed bath in April, and no showers with three bed baths in May. This failure, confirmed by staff, led to the resident's transfer to the emergency department for treatment of a sacral wound infected with MRSA. The facility lacked a specific policy for shower and ADL care.
A resident with a history of muscle weakness and severe cognitive impairment fell and sustained serious injuries due to the facility's failure to monitor and recognize signs of UTI and Sepsis. Despite being identified as a fall risk, the resident was not adequately supervised or assessed for infection, leading to a fall that resulted in a skin tear and a femoral fracture requiring surgery. The facility lacked specific policies for managing UTIs and Sepsis, contributing to the oversight.
Failure to Ensure Hands-On CPR Certification for Licensed Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained appropriate Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and American Heart Association (AHA) guidelines. One licensed nurse, hired as a registry nurse, obtained CPR certification through an online provider that offered training based solely on written exams without any hands-on skills validation. Review of the online provider’s website showed that while the course followed AHA 2020 cognitive guidelines and allowed unlimited test attempts at any time, it did not include any in-person or virtual instructor-led skills assessment, nor did it require demonstration of CPR techniques on a mannequin. During an interview, the Administrator stated that all licensed nurses, including registry nurses, were required to maintain CPR certification with hands-on training, specifically involving performance of skills on a mannequin, to validate proper technique. The facility’s written policy on Cardiopulmonary Resuscitation, dated 2022, required that licensed nursing staff maintain current CPR for Healthcare Providers through a provider whose training includes a hands-on session, either in a physical or virtual instructor-led setting, in accordance with accepted national standards. The surveyor concluded that the facility failed to ensure this requirement was met for one of two licensed nurses, which decreased the facility’s potential to implement life-saving measures and effective clinical interventions for all residents in the event of a respiratory or cardiac emergency.
Failure to Assess, Obtain Orders, and Appropriately Respond to Resident Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to provide nursing care that met professional standards for a resident with COPD and asthma who experienced a significant change in respiratory status. The resident’s care plan directed licensed nurses to administer ordered aerosol or bronchodilators, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. The facility’s orientation materials and Change in Condition policy required licensed nurses to promptly assess changes in condition, complete an S-BAR, notify the practitioner immediately, and document the assessment, interventions, and physician notification. The resident also had orders for CPR in the event of cardiac or respiratory arrest and for shift-by-shift lung sound documentation, which were later discontinued after the resident’s death. On the day of the incident, CNA 1 reported that at the start of her shift the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 measured the resident’s O2 saturation, which fluctuated between 85–95% on room air, and repeatedly notified LN 1, who responded that the resident was fine and did not initially assess him. CNA 1 stated she reported the resident’s worsening condition three or four more times as his breathing sounds deteriorated, but LN 1 continued to say he was fine. When the resident’s O2 saturation later dropped to 35%, CNA 1 asked CNA 2 to help get LN 1 to assess the resident because LN 1 had not been listening to her concerns. CNA 2 corroborated that CNA 1 had been worried from the beginning of the shift, that the resident was gurgling with very low O2 saturation, and that she notified LN 1 of these concerns. There was no documented assessment or change-of-condition note in the medical record for the period between approximately 3 p.m. and 6:30 p.m., and no documentation of physician notification, treatment provided, or monitoring of treatment effectiveness during that time. LN 1 later documented in a progress note that around 6:40 p.m. she was notified by CNA 1 that the resident was breathing rapidly, that his O2 saturation was 93%, and that she asked if he wanted to go to the hospital and he said no; CNA 1 later stated she did not hear LN 1 ask the resident about going to the hospital. LN 1 also documented, in a late entry, that she administered a breathing treatment at approximately 6:45 p.m. while on the phone, and that the resident started to code while she was on the call. However, there was no documentation of what medication was given, and the Medication Administration Record showed no albuterol nebulizer doses given that month. The DON confirmed the resident had medicated breathing treatments in the cart but no active order, as the prior order had expired. Around 7 p.m., CNA 1 reported to LN 2 that the resident had shortness of breath and an O2 saturation of 63% on room air; LN 2 recorded an O2 saturation of 72% on the monitor, found the resident unresponsive with labored, rapid breathing and a very faint pulse, and instructed LN 1 to call 911. LN 2 stated she specifically told LN 1 to call 911, but LN 1 instead called a non-emergent ambulance, and when questioned why she did so in an emergency, LN 1 did not respond. LN 2 documented that chest compressions were initiated, oxygen was applied via mask, and EMS arrived and took over CPR. The ER provider note indicated EMS reported the resident was found down and apneic by facility staff about 30 minutes before arrival, with last known normal at 6:30 p.m. The resident’s physician stated she had not been notified by LN 1 earlier in the day about the resident’s shortness of breath, had not been asked for a respiratory treatment order, and only received a call after the resident had coded and been sent to the hospital. The facility’s policies required assessment, timely physician notification, documentation of change in condition, and calling 911 in a cardiopulmonary emergency, all of which were not followed by LN 1 in this case.
Failure to Assess, Obtain Orders, and Accurately Document Resident Respiratory Change in Condition
Penalty
Summary
The deficiency involves a licensed nurse’s failure to complete and maintain an accurate medical record and to document a change in condition (COC) and related assessments and treatments for a resident with chronic respiratory disease. The resident had COPD and asthma and a care plan that directed licensed nurses to administer aerosol or bronchodilators as ordered, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. Facility policy and contract orientation information for the nurse required that when a change in condition was identified, the assigned licensed nurse complete an SBAR, notify the licensed independent practitioner immediately, and document the date, time, details of the event, assessment, physician notification, and any orders received. On the day in question, CNA 1 reported that at the start of her shift at 3 p.m. the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 stated the resident’s O2 saturation fluctuated between 85–95% on room air and that she escalated these concerns to LN 1, who responded that the resident was fine. CNA 1 reported that as time passed, the resident’s breathing sounds worsened and that she notified LN 1 three or four more times that the resident was getting worse, but LN 1 continued to say the resident was fine. CNA 2 corroborated that CNA 1 was worried about the resident early in the shift, that the resident was acting differently and gurgling, and that the O2 saturation was very low, the lowest CNA 2 had ever seen. CNA 1 stated that when the O2 saturation read 35%, she asked CNA 2 to help get LN 1 to physically assess the resident, and that LN 1 did not assess the resident until nearly four hours after the initial notification. The medical record review showed no documented assessment, COC entry, physician notification, treatment, or monitoring of treatment effectiveness related to the resident’s respiratory status between 3 p.m. and 6:30 p.m., despite an active order requiring staff to add a progress note each shift regarding lung sounds. The only documented COC by LN 1 was a progress note time-stamped 7:43 p.m., which stated that around 6:40 p.m. CNA 1 notified LN 1 that the resident was breathing rapidly, that the resident’s O2 saturation was 93%, and that LN 1 asked if the resident wanted to go to the hospital and the resident declined. LN 2’s note documented that upon arriving on shift at 6:53 p.m., CNA 1 reported the resident had shortness of breath and an O2 saturation of 63% on room air, that the monitor showed 72% on room air, that LN 2 instructed LN 1 to call 911, and that the resident was unresponsive with labored, rapid breathing and a very faint pulse, with CPR initiated by staff and then taken over by EMS. Further record review and interviews revealed discrepancies and omissions in documentation of a breathing treatment. The ER provider note indicated the resident’s last known normal was 6:30 p.m. and listed an albuterol nebulizer order as a PRN medication the resident was not taking. A late-entry progress note by LN 1, dated two days later at 3:34 p.m., stated that at approximately 6:45 p.m. on the day of the event, LN 1 administered a breathing treatment and that while LN 1 was on the phone, the resident started to code and the non-emergent transfer call was switched to 911. There was no documentation in that note of what specific medication was given or that it was administered on the correct date. The MAR showed no evidence that albuterol nebulization solution was administered on any day that month, and the physician confirmed she had not been notified of the resident’s shortness of breath that day and had not been called for a respiratory treatment order prior to the code. A physician’s order for a one-time albuterol nebulizer dose was created later that evening and then discontinued with the reason that the resident expired in the emergency department. The facility’s medical records department confirmed there were no other notes by LN 1 that day beyond the 7:43 p.m. entry, and the DON stated nurses were expected to document COCs, assessments, interventions, physician notifications, and resident responses, and to obtain and document orders for oxygen and breathing treatments when O2 saturation was critically low.
Lack of Onsite Registered Dietitian and Inadequate Oversight of Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff with appropriate competencies, specifically the lack of a dedicated onsite Registered Dietitian (RD) for a census of 87 residents. Surveyors identified multiple dietary and kitchen-related issues during the recertification survey, including recipes not being followed, a dumpster lid not being closed, and problems with kitchen sanitation, cleanliness, maintenance, equipment, and food storage. The Dietary Supervisor (DS) reported that one RD worked remotely, participating in weekly virtual meetings or email exchanges to discuss resident weight changes and diets, but did not physically come to the facility to assess residents’ nutritional status or consult on kitchen operations. Interviews with the DS, Regional Consultant (RC), and Regional Registered Dietitian (RRD) confirmed that the last full-time onsite RD worked from March to June of the previous year and that the RRD’s visits were infrequent, with the last visit occurring earlier in the prior year and no set visitation schedule in place. The RC stated that an RD was required to be physically present at the facility once a week, but this did not occur. A review of training documentation showed that a kitchen training on IDDSI requirements was attended only by the DS and one cook, and job descriptions for both the facility RD and the Regional Dietitian outlined responsibilities such as overseeing clinical nutrition operations, inspecting food service areas, ensuring regulatory compliance, and conducting regular facility visits—duties that were not being fulfilled onsite as required. This lack of consistent onsite RD presence and oversight contributed to the identified deficiencies in dietary services and kitchen operations.
Failure to Follow Standardized Recipes and Measure Ingredients During Meal Preparation
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus and standardized recipes were followed and that meals were prepared using methods that conserved nutritive value, flavor, and appearance for a census of 87 residents. During a kitchen observation, a cook was preparing lunch items, including herb crusted beef roast, mashed potatoes with gravy, zesty spinach, and garlic bread, without any recipes present at the cook’s station. The cook was seen adding an unmeasured amount of butter to a butter, garlic, and parsley mixture for garlic toast and later combining four tablespoons of garlic powder with one pound of melted butter to be used for zesty spinach intended to serve 72 residents, omitting red pepper flakes and salt that were included in the written recipe. The cook also poured unmeasured amounts of milk into dry breadcrumbs to prepare pureed garlic bread, despite the dietary supervisor confirming that a specific recipe existed for pureed bread products and that it should have been used. Further observation showed the cook spilling boiled spinach into the sink while attempting to drain it, leaving portions in the pot, strainer, and sink, after which the dietary supervisor intervened to strain the remaining spinach. The cook then added an unmeasured amount of the garlic and butter mixture to the spinach and stated she did not know how much was added. Both the cook and the dietary supervisor stated they did not add salt to anything, and the dietary supervisor said, "Yeah, we don't use salt," despite the zesty spinach recipe specifying salt and red pepper flakes. In interviews, the dietary supervisor and the regional registered dietitian both stated that recipes must be visible, used, and followed, and that measuring tools should be used to ensure correct ingredient amounts and nutrient content. The cook admitted she did not always follow recipes, did not like the recipe book on the table, and acknowledged that measurements were supposed to be precise. Review of facility recipes and the standardized recipes policy confirmed that standardized recipes, including specific ingredient amounts for zesty spinach and pureed bread products, were required to be used, but were not followed during the observed meal preparation.
Widespread Dietary Sanitation and Equipment Failures in Food Service Operations
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, prepare, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 87 residents. Surveyors observed multiple dietary staff in the kitchen without required hair restraints and with prohibited jewelry while handling and preparing food. Several dietary aides and cooks were seen without hair nets, and one cook with facial hair longer than one inch was not wearing a beard net. Another cook was observed wearing hoop earrings and a watch while preparing meals. The Dietary Supervisor and Infection Preventionist both confirmed that hair nets and beard nets were required in the kitchen and that watches and dangling earrings should not be worn due to contamination concerns. Facility policies and job descriptions reviewed by surveyors required staff to maintain a safe and sanitary work environment, cover hair and facial hair with effective restraints, and prohibit watches in food service areas. The physical condition and cleanliness of the kitchen and related equipment were also found to be deficient. Surveyors observed a wall near the stovetop and oven with multiple areas of scratched and chipped paint in different colors, with paint chips present on the floor beneath these areas. The Dietary Supervisor acknowledged the chipped and scratched paint and stated the wall should be repainted because paint chips could fall and possibly get into food. In addition, a three-drawer storage bin used to store cooking utensils such as measuring cups, spoodles, spatulas, and scoops was found with gray to dark brown and black smears and scuffs on the exterior, sticky drawer handles, and crumb-like particles inside one of the drawers. The Dietary Supervisor confirmed the bin was dirty inside and out and appeared to contain food crumbs. Further observations showed that the kitchen floor and dining room utility equipment were not maintained in a sanitary condition. The floor under and around a handwashing sink and adjacent food preparation tables contained black residue and grime, dark-colored particles of unknown substances, small objects such as a paper clip, dime, rubber band, and bread closure tab, and dried brown fluid on the wall behind one table. Paint chips were also seen on the floor near the stovetop and oven. The Dietary Supervisor confirmed these areas were dirty, described the floor as hard to clean, and stated the floors needed deep cleaning. A three-tiered utility cart in the dining room, used for beverage and food service, was observed with crumbs, dried orange-colored crusted particles, and large dust particles on all shelves while holding beverage pitchers. The cart remained uncleaned during meal service. The Dietary Supervisor and Director of Staff Development confirmed the carts were used for food and beverage service and should be cleaned after each use, but the Dietary Supervisor could not produce the cleaning log that was supposed to document daily cleaning tasks. Surveyors also identified improper handling and condition of food-contact utensils and equipment. Approximately four scoops used for food preparation and tray line were found stored wet in the same three-drawer storage bin, and the Dietary Supervisor confirmed they should not have been stored wet because a wet environment could increase bacterial growth. A can opener stationed on a food preparation table had label remnants on the pointed blade tip and visible peeling metal, and the Dietary Supervisor stated it was dirty, needed cleaning, and that the blade needed to be changed because metal could come off into food. Multiple cutting boards of different colors were observed with black discoloration and deep blade grooves that could be felt by touch; the Dietary Supervisor confirmed these boards were hard to clean, could harbor bacteria, and should not be used. FDA Food Code sections reviewed by surveyors indicated that can openers that become uncleanable must be replaced, cutting surfaces that are scratched and scored may harbor pathogenic microorganisms, and equipment and utensils must be air-dried before storage to prevent microbial growth. In addition, the facility failed to maintain its emergency dietary supplies in accordance with its own policies. During an observation with the Maintenance Director and Dietary Supervisor, the facility’s emergency water supply was found to be expired, with an expiration date that had already passed. Both the Maintenance Director and Dietary Supervisor confirmed the emergency water was expired and needed replacement. Review of the facility’s disaster planning and food storage policies showed that disaster food supplies were to be rotated at least every six months and that dry storage stock was to be rotated, but this had not been done for the emergency water. These combined observations and confirmations by facility staff demonstrated that the facility did not maintain food storage, preparation, equipment, and the kitchen environment in a sanitary and professionally compliant manner.
Failure to Follow Medication Guidelines, Change-of-Condition Monitoring, Care Planning, and Neuro Check Protocols
Penalty
Summary
The deficiency involves failure to administer medications according to professional standards and facility policy for one resident with hypothyroidism. The resident had physician orders for levothyroxine 88 mcg by mouth in the morning for hormone regulation and famotidine 20 mg by mouth in the morning for GERD. A medication regimen review dated 12/26/25 documented a pharmacist recommendation that famotidine could be given without regard to meals but should not be given at the same time as levothyroxine, and suggested changing famotidine administration time to 9 a.m. Review of the medication administration records from 12/21/25 to 1/29/26 showed both medications were administered together at 6 a.m. throughout this period. The consultant pharmacist confirmed that levothyroxine should not be given with other medications because it could bind with them and decrease effectiveness, and a licensed nurse also acknowledged that levothyroxine should not be given with other medications and that such an order should be clarified with the physician or pharmacist. The deficiency also includes failure to complete required 72‑hour monitoring after a change of condition (COC) for two residents. One resident with hemiplegia, hemiparesis following cerebral infarction, diabetes mellitus, and intact cognition reported multiple episodes of diarrhea over several days, including at least three brief changes in one day and decreased oral intake due to diarrhea and upset stomach. An SBAR communication form documented that this resident reported five episodes of green, mucus-like diarrhea without foul odor, constituting a COC. Review of progress notes from the time of the COC through several days later showed that the resident was only monitored on two occasions, rather than every shift for 72 hours as required by the facility’s Change in Condition policy. The DON confirmed that no 72‑hour monitoring was completed on multiple shifts following this COC. Another resident, admitted with fractures of the first cervical vertebra, left pubis, and multiple ribs and with moderately impaired cognition, experienced unwitnessed falls on two separate dates. Progress notes showed that following these COCs related to falls, the resident was monitored only on a limited number of dates and times, rather than each shift for at least 72 hours as required by policy. The DON confirmed that 72‑hour monitoring was not completed on specified shifts after the first fall and that the resident fell again several days later, after which 72‑hour monitoring was again not completed on certain shifts. The facility’s Change in Condition policy required the licensed nurse to update the care plan to reflect the resident’s current status and to document each shift for at least 72 hours when there is a change in the resident’s condition, and the LVN job description required completion of all required documentation and assistance in developing and updating plans of care. The deficiency further includes failure to initiate or revise a care plan following a COC for the resident with diarrhea. Review of the resident’s undated care plan report showed no evidence that a care plan was initiated or updated to address the diarrhea COC documented on the SBAR form. In interviews, the treatment nurse stated that every COC required a care plan to be initiated and/or updated and that care plans guided staff on how to care for residents, what to expect, and what to monitor. The DON also stated that a COC was required to be care planned so there would be a plan of care in place to know how to treat the COC, and confirmed that the resident’s care plan was not initiated or revised following the documented COC. Additionally, the deficiency includes failure to complete neurological checks according to facility policy following an unwitnessed fall for the resident with multiple fractures. The facility’s Neurological Flow Sheet and Fall Management Program policy required vital signs and neuro checks every 15 minutes for one hour, every 30 minutes for one hour (or two hours per the fall policy), every one hour for four hours, and then every four hours for the remainder of a 72‑hour period after an unwitnessed fall, unless discontinued by a physician. Review of the resident’s neurological checklists showed that post‑fall neuro checks were documented only at four time points over approximately 18 hours following the fall and hospital transfer/return, rather than at the frequencies specified in the neurological flow sheet and fall management policy. The DON stated that for an unwitnessed fall, neuro checks were expected to be ongoing for 72 hours after the fall, to begin immediately post‑fall and continue when the resident returned from the hospital, and confirmed that the assessments were not completed to her expectations and not in accordance with the timing flow chart.
Failure to Complete CNA Competency Reviews and Required Abuse/Dementia Training
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and competency/skills checks for two of five sampled CNAs. Review of CNA 4’s employee training file with the Director of Staff Development (DSD) showed that the last annual skill/competency assessment was completed on 9/16/24, making it four months overdue at the time of review. For CNA 6, the training file contained a skills/competency checklist with no employee signatures or dates, and the DSD could not confirm that CNA 6 had completed this or any other annual skills/competency assessment. The facility’s policy titled “Staff Competency Evaluation,” effective 6/04/24, required staff to have competency validation based on job description or assigned duties, with re-education and re-evaluation for staff unable to satisfactorily perform skills. The facility assessment, reviewed on 1/26/26, also specified yearly review of select clinical competencies. Surveyors also found that the facility did not ensure required abuse and dementia training for two additional CNAs in the sample. During review of CNA 3’s and CNA 7’s training files with the DSD, there was missing evidence of abuse and/or dementia training for each of these CNAs. The DSD acknowledged that these omissions meant the employees might not be able to respond properly to abuse situations or have the knowledge to effectively communicate with and care for certain residents. The facility assessment indicated that training requirements included dementia management training and abuse prevention training, and the DSD stated there were known training issues that needed to be addressed.
Failure to Implement Consultant Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to act upon and implement consultant pharmacist (CP) medication regimen review (MRR) recommendations in a timely manner for multiple residents. The CP completed an MRR covering 12/01/25 to 12/31/25 and documented specific recommendations for Residents 1, 3, 6, 14, 16, 17, 18, 19, 24, 57, 76, 83, and 85. These recommendations included clarifying administration times, adding hold parameters, specifying monitoring instructions, and documenting hazardous drug precautions. On review of the residents’ order summaries dated 1/29/26, the surveyors found that none of these recommendations had been implemented or communicated to the prescriber as required by facility policy. For Resident 1, admitted with BPH, the CP recommended specifying that tamsulosin 0.4 mg be given 30 minutes after the same mealtime each day and that capsules be swallowed whole without crushing, chewing, or opening. Resident 3, admitted with hereditary spastic paraplegia and receiving docusate sodium 100 mg two capsules twice daily, had an MRR recommendation to update the order to include “hold for loose stool.” Resident 6 and Resident 24, both receiving finasteride 5 mg daily for BPH, had MRR recommendations noting that finasteride is a hazardous medication that cannot be crushed or opened without appropriate PPE, and that the orders should be updated to state “Hazardous Drug – Please use appropriate PPE.” These changes were not reflected in the active orders at the time of review. Resident 14, with hypothyroidism and GERD, had orders for famotidine 20 mg and levothyroxine 88 mcg both given in the morning; the CP recommended changing the famotidine administration time to 9 a.m. so it would not be given at the same time as levothyroxine. Resident 16, with HTN and on lisinopril 20 mg at bedtime, had an MRR recommendation to add monitoring parameters to the order: “Hold if HR < 60 bpm or SBP < 100 mmHg.” Resident 17, admitted with constipation and receiving senna and PRN acetaminophen, had recommendations to add “hold for loose stool” to the senna order and “do not exceed 3 grams of acetaminophen in 24 hours from all sources” to the acetaminophen order. None of these recommended order clarifications or monitoring parameters had been added. Resident 18, admitted with gout and receiving allopurinol 300 mg daily, had an MRR recommendation to change the order to include “give with food/meals” and to add this to the directions to ensure compliance. Resident 19, with metabolic encephalopathy and multiple constipation medications (docusate sodium, polyethylene glycol, and senna), had recommendations to add “hold for loose stool” to the laxative orders and to specify for polyethylene glycol “stir in four to eight ounces juice or other liquids.” Resident 57, with type 2 diabetes and on melatonin 3 mg at bedtime, had a recommendation to change the indication to “for Circadian Rhythm Regulation.” Residents 76, 83, and 85, all receiving docusate and/or senna for constipation, had MRR recommendations to add “hold for loose stool” to their laxative orders. These changes were not present in the residents’ active orders on 1/29/26. During interviews, the DON confirmed that none of the CP’s recommendations from the 12/26/25 MRR had been implemented or provided to the physician, and acknowledged that the CP recommendations should be followed because they prevented potential medication errors from happening. The CP stated that he performed the MRR on 12/26/25 and that his expectation was that recommendations would be reviewed within two weeks and, if not addressed, escalated by the DON. The Administrator stated that the last MRR review signed by the physician was dated 11/21/25 and that her expectation was that the 12/26/25 CP recommendations should have been followed and implemented in a timely manner. Review of facility policies showed that findings and recommendations from the CP are to be reported to the DON, attending physician, medical director, and Administrator, and that recommendations are to be communicated and acted upon in a timely fashion, with responses expected prior to the next MRR. These policy requirements were not met in relation to the December MRR recommendations for the identified residents. The facility’s written policies titled “Medication Regimen Review” and “Documentation and communication of consultant pharmacist recommendations” specified that resident-specific irregularities and clinically significant risks associated with medications must be documented in the active record and reported to the DON, medical director, and prescriber as appropriate. The policies further required that the facility establish a system to ensure CP observations and recommendations are communicated to those with authority to implement them and that recommendations are acted upon and documented in an appropriate and timely fashion, enabling a response before the next MRR. Despite these policies, the survey findings showed that the December CP recommendations for the 13 residents were neither implemented nor documented as acted upon by facility staff or prescribers by the time of the survey on 1/29/26.
Improper Medication Storage and Labeling in Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices for a census of 87 residents when medications were not stored and labeled according to accepted professional standards and the facility’s own policy. During an inspection of the C wing medication cart with the DON, surveyors found 10 loose pills inside the cart, which the DON acknowledged could potentially be mistakenly administered to residents or taken by staff. Six medications were found without open dates, despite the facility’s policy requiring nurses to place a date opened sticker on medications when the manufacturer’s seal is broken, and the DON stated that open dates were necessary to ensure medications were not outdated and that administering such medications could potentially cause adverse effects or be less therapeutic. Additionally, six used insulin pens belonging to different residents were found comingled in the same drawer, and the DON confirmed that the pens should be prevented from touching each other because that could cause cross contamination. These observations, interviews, and record review demonstrated that the facility failed to follow its policy titled “Storage of Medications,” which required medications to be stored safely and properly, medication storage areas to be kept clean and free of clutter, and opened medications to be dated when first used.
Improper Garbage Containment and Open, Overflowing Dumpster
Penalty
Summary
The facility failed to properly contain garbage and refuse for a census of 87 residents when one of two dumpsters was observed overflowing with trash, left open without lids, and surrounded by litter. During an observation with the Dietary Supervisor, plastic bags filled with garbage were piled above the top of the dumpster, the lids were not in place to close the dumpster, and a bag of garbage and a box were on the ground next to it; the Dietary Supervisor confirmed the dumpster was too full to close and acknowledged that lids were supposed to be closed to keep pests and critters out. In a separate interview, the Maintenance Director stated that the dumpster lids were supposed to be able to close to prevent birds from getting into the dumpster and for infection control reasons, and further stated that the lids were to remain closed at all times. Review of the facility’s “Medical Waste-Containers & Storage- Infection Control Manual” policy, revised 1/1/12, indicated that medical waste containers are to be kept covered at all times, must be closable, and that medical waste is to be stored so it is protected from animals and does not provide a breeding place or food source for insects and rodents. This failure had the potential to expose the facility environment to odors, insects, pests, and disease, which could have caused harm to residents. No specific residents, medical histories, or individual conditions were described in the report; the deficiency pertained to environmental sanitation and infection control practices related to waste storage and disposal.
Failure to Maintain Accessible and Functional Room Lighting for a Resident
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident when the resident’s bed light was not in working condition and was not accessible. The resident had spinal stenosis, strabismus, and vascular dementia, with a Minimum Data Set showing moderate cognitive impairment and a need for partial to moderate assistance with bed mobility, transfers, and ambulation. During observation and interview, the resident reported that there was no usable pull cord on the light behind the head of the bed; the cord was observed to be approximately three inches long, and the resident stated she could not reach it. She further explained that even if she could reach the cord, the wall switch by the door had to be turned on first, and that when the switch was turned on, the light still did not function. The resident stated she had no control over turning her light on or off, consistently had to ask others to operate the light, and found this frustrating, especially when the sun set. A CNA confirmed that the resident could not reach the light switch, verified the pull cord length of about three inches, and confirmed that pulling the cord did not turn the light on. The Maintenance Director initially stated the issue had never been brought to his attention, but upon observing the light, confirmed it was only partially working and that the resident could not reach the pull cord. In contrast, the Business Office Manager stated that the Maintenance Director was aware the light required repair, that the issue had been mentioned multiple times in staff morning and stand-down meetings, and that it had been discussed for approximately four months without being fixed. The Regional Consultant also confirmed the Maintenance Director was aware the light required repair and stated that it was important for the resident to have access to her light to promote quality of life, that the issue affected the resident’s independence, and that it was a hazard for her not to be able to see. Facility policies and the Director of Environmental Services job description required providing a safe, hazard-free, home-like, and comfortable environment, which was not met in this situation.
Failure to Update Care Plans and Complete Post-Fall Monitoring
Penalty
Summary
Licensed nurses failed to initiate or update care plans following a resident-to-resident abuse incident involving two residents, both of whom had severe cognitive impairment and behavioral issues. One resident, diagnosed with Alzheimer's disease and known for physical aggression, grabbed another resident with hemiplegia and severe cognitive impairment, causing distress. Despite staff witnessing the event and facility leadership acknowledging that care plans should have been created or updated, no such documentation or guidance was provided to staff regarding appropriate interventions after the incident. Additionally, after a resident with metabolic encephalopathy and severe cognitive impairment experienced a fall and was sent to the emergency department, licensed staff did not complete the required 72-hour monitoring upon the resident's return. Facility policy required documentation of the resident's status each shift for at least 72 hours following a change in condition, but 48 hours of monitoring were missing. These lapses in nursing services and documentation did not meet professional standards of quality as required by facility policy.
Failure to Accurately Assess Fall Risk and Develop Person-Centered Care Plan
Penalty
Summary
The facility failed to accurately assess a resident's fall risk status and develop a person-centered care plan upon admission, despite the resident's recent history of falls and significant orthopedic injuries. The resident was admitted following a fall at home that resulted in a right distal femur fracture and a fracture around an internal prosthetic knee joint. Upon admission, the fall risk evaluation incorrectly assessed the resident as moderate risk, omitting the recent fall history that led to hospitalization. The care plan interventions were based on this inaccurate assessment and did not reflect the resident's actual high risk for falls. Subsequent documentation and interviews revealed that the resident had moderate cognitive impairment, limited mobility, and required moderate assistance for transfers, as confirmed by physical therapy records. Despite these needs, the care plan only indicated general fall prevention measures and did not specify the level of assistance required. The resident later experienced a fall while attempting to transfer from the commode, resulting in a nondisplaced distal radial fracture. Staff interviews and record reviews confirmed that the facility's fall prevention protocol, which requires individualized assessment and care planning, was not properly followed for this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, as observed during a kitchen tour with the Dietary Manager (DM). During the initial tour, several items in the reach-in refrigerator, including a quart-sized bag of sliced carrots, a quart-sized bag of vegetable patties, and a covered bowl of fruit, were found without labels indicating their contents or open/use-by dates. The DM confirmed that these items should have been labeled and dated according to the facility's policy on food storage and handling. A follow-up tour revealed a gallon-sized bag of Salisbury steaks in the reach-in freezer, also lacking a label or open/use-by date. Interviews with the DM and other staff members confirmed that all opened food items were expected to be labeled with the product name, open date, and use-by date. The Director of Nursing and the Administrator both stated their expectations that all food items be properly labeled and stored, highlighting a consistent understanding of the policy across the facility's leadership.
Inaccurate PASRR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for a resident. The resident was admitted to the facility with diagnoses of depression and post-traumatic stress disorder (PTSD), which were not accurately documented in the PASRR Level I Screening completed by the Medical Records Director. The screening incorrectly indicated that the resident did not have a diagnosed mental disorder, resulting in a negative Level I Screening and the absence of a required Level II Evaluation. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was primarily responsible for the accuracy of PASRRs. The MDS nurse confirmed that the resident had a diagnosis of PTSD upon admission, and if the Level I Screening had accurately reflected this, a Level II Evaluation would have been necessary. The Director of Nursing and the Administrator both expressed expectations for staff to ensure the accuracy of PASRRs, highlighting a lapse in the facility's processes for reviewing and completing these screenings.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident, leading to the development and worsening of pressure injuries. The resident, who was admitted with moisture-associated skin damage (MASD), did not receive showers as scheduled, which could have contributed to missed skin impairments. The facility's records showed that the resident received only one shower out of eight scheduled in April and none in May, with only a few bed baths provided. This lack of regular hygiene care may have contributed to the resident's skin condition deteriorating. The facility also failed to initiate and consistently follow treatment plans for the resident's skin conditions. Upon admission, there was no treatment order for the resident's MASD, and subsequent treatment orders for pressure injuries were not consistently signed off by nursing staff, indicating that treatments may not have been administered as ordered. The resident's care plan for skin breakdown was not developed until over a month after admission, despite the resident being at risk for skin impairment as indicated by the Braden Scale scores. This delay in care planning and treatment likely contributed to the resident developing a Stage 3 pressure injury, which later worsened to a Stage 4 injury with infection. Additionally, the facility did not ensure that the resident was turned and repositioned every two hours as required to prevent pressure injuries. Observations showed the resident lying on their back for extended periods, and there were missing signatures on the electronic treatment administration record for turning and repositioning orders. The facility's documentation of the resident's skin condition was also inaccurate and inconsistent, with conflicting reports on the presence and location of pressure injuries. These failures in care and documentation contributed to the resident's pressure injuries worsening and developing an infection that required hospitalization.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by complaints from residents and staff, as well as a review of staffing records. Four residents expressed concerns about the lack of staff, which resulted in delayed responses to call lights and feelings of insecurity during potential medical emergencies. The residents, who required assistance with personal care, reported waiting up to an hour for help, which they attributed to the facility being short-staffed. The residents' medical conditions included muscle weakness, chronic pain syndrome, general anxiety disorder, muscular dystrophy, multiple sclerosis, hyperlipidemia, and hypertension. Interviews with six staff members, including CNAs and licensed nurses, confirmed the facility's staffing issues. Staff reported that the shortage of personnel made it difficult to complete tasks and provide safe care, increasing the risk of falls, injuries, and elopements. The staffing coordinator admitted to not using any formal guidelines for staffing decisions and acknowledged that the facility was not meeting its target of 3.5 nursing hours per patient day. The Director of Nursing was aware of the staffing deficiencies and expressed concern about the impact on resident care. A review of the facility's records showed that the Direct Care Service Hours Per Patient Day (DHPPD) were below the required levels for 8 out of 10 days in the specified period. The facility's policy required a minimum daily average of 3.5 nursing hours per patient day, but the actual DHPPD ranged from 2.63 to 3.43 during the reviewed period. This failure to meet staffing requirements contributed to the residents' dissatisfaction and concerns about their safety and well-being.
Inadequate Nursing Competencies and Documentation
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies to provide adequate care for residents, as evidenced by inaccurate documentation and failure to recognize critical health conditions. Specifically, the licensed nurses did not accurately document the skin impairment and its location for a resident, leading to discrepancies in the treatment records. The Director of Nursing (DON) confirmed that the documentation was inconsistent and inaccurate, which raised concerns about whether the nurses were properly assessing the resident's wounds. The inaccurate documentation included several instances where the resident's skin was reported as intact despite having a pressure injury. Additionally, the licensed nurses failed to monitor and recognize signs and symptoms of a urinary tract infection (UTI) and sepsis in the same resident. The DON verified that there was no laboratory test requested to check for a UTI, and there were no nursing progress notes indicating that the resident was being monitored for these conditions. This oversight resulted in the resident experiencing a fall, which led to a severe hip fracture requiring surgical intervention. The DON confirmed that the fall was caused by sepsis secondary to an untreated UTI. The facility did not provide specific policies for resident care concerning UTIs and sepsis, nor did they have a policy on assessment and accurate documentation. The lack of these policies contributed to the deficiencies observed, as the nurses were not adequately guided in monitoring and documenting the resident's condition. The American Nurses Association emphasizes the importance of clear, accurate, and accessible documentation as a critical component of safe and quality nursing practice.
Failure to Provide Scheduled Showers Leads to Resident's Skin Infection
Penalty
Summary
The facility failed to ensure that a resident received showers twice a week as scheduled, which was necessary for maintaining skin integrity and preventing infections. The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, only received one shower and one bed bath in April, and no showers with only three bed baths in May, out of the scheduled showers. This lack of regular bathing was contrary to the facility's policy and was confirmed by multiple staff members, including the Infection Preventionist, Certified Nursing Assistant, and Licensed Nurses, who acknowledged the importance of regular showers to prevent skin breakdown and infections. The deficiency was further highlighted when the resident was transferred to the emergency department for wound evaluation and treatment, including debridement and IV antibiotics for a sacral wound infected with Methicillin-resistant Staphylococcus aureus (MRSA). The Director of Nursing confirmed the transfer and the resident's condition, emphasizing the critical need for regular showers to prevent such severe outcomes. The facility lacked a specific policy and procedure for shower and ADL care, contributing to the oversight in the resident's care.
Failure to Monitor UTI and Sepsis Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to recognize and monitor signs and symptoms of a Urinary Tract Infection (UTI) and Sepsis in one of the residents, leading to a fall and subsequent injuries. The resident, who had a history of muscle weakness, hyperlipidemia, and bipolar disorder, was admitted with severely impaired cognition and required substantial assistance with daily activities. Despite being identified as a fall risk due to intermittent confusion, poor vision, and balance problems, the facility did not implement specific interventions to prevent falls. On the day of the incident, the resident fell from the bed, resulting in a skin tear and an acute comminuted right femoral intertrochanteric fracture, which required surgical intervention. The hospital discharge summary confirmed that the fall was caused by sepsis secondary to a UTI, which had not been diagnosed or treated by the facility. The Director of Nursing verified that there were no laboratory tests conducted to check for a UTI, and the nursing staff did not monitor the resident for signs of infection prior to the fall. The facility's policy on fall management required a new fall risk assessment upon a significant change in condition, but this was not conducted. Additionally, there was no specific policy for managing UTIs and Sepsis, which contributed to the oversight. Interviews with licensed nurses revealed an awareness of the increased fall risk associated with confusion from infections, yet the necessary precautions and monitoring were not in place.
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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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