French Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 600 E Washington Avenue, Santa Ana, California 92701
- CMS Provider Number
- 555103
- Inspections on file
- 57
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at French Park Care Center during CMS and state inspections, most recent first.
A resident who was determined to have decision-making capacity received a written notice of proposed transfer and discharge to a board and care facility, citing improved health status and nonpayment as reasons. However, record review showed there was no physician order for discharge, no physician documentation that the resident’s condition had improved or that discharge was safe, and the post-discharge plan of care and summary were incomplete from nursing and social services. An RN confirmed that facility policy requires a physician discharge order and a completed IDT post-discharge plan prior to discharge, and verified these elements were missing.
A resident with severe cognitive impairment and documented nonverbal status had multiple nursing progress notes and skilled nursing evaluations indicating they were alert and oriented x3, verbally communicative with clear speech, able to follow commands, and denying pain or neurological symptoms, which conflicted with the physician note and MDS. Nursing notes also documented GT feeding, wound vac care, and IV antibiotics after the resident had been discharged to the hospital. During interview and record review, the DON acknowledged significant confusion and inaccuracies in the nursing documentation and questioned whether nurses were actually assessing the resident or copying and pasting entries.
A resident was admitted with severe cognitive impairment and multiple documented pressure injuries and other wounds, but no baseline wound care plan was developed within 48 hours of admission despite facility policy and staff expectations that each wound have its own care plan and specific interventions. The same resident had physician orders for NPO status and enteral tube feeding, supported by a swallowing evaluation and physician progress note, yet the nutritional care plan instead focused on honoring food preferences, offering meal substitutes, and allowing time to eat and drink, implying oral intake. The DON, IP, and an LVN all confirmed that the wound care plan was missing and that the nutritional care plan did not reflect the resident’s NPO and enteral feeding orders, and the DON stated this incorrect plan could have led to oral intake and aspiration.
A cognitively intact resident with an order to go out on therapeutic pass had multiple departures documented on a Release for Temporary Absence form, but many return times were illegible or missing. A social services note stated the resident went out daily for more than six hours, which conflicted with the incomplete sign-out/sign-in documentation. The resident, receptionist, SSD, and ADON all confirmed that the resident routinely signed out at reception, that some return times were not recorded, and that there was no consistent process to sign the resident back in when reception staff were no longer present, resulting in an inaccurate medical record.
A resident with CHF and hypotension, who lacked decision-making capacity, had an order for Midodrine 10 mg via GT every eight hours with instructions to hold the dose if SBP was greater than 100 mmHg. Facility policy required medications to be given per MD orders and to hold medications when vital signs were outside ordered parameters. Review of the MAR showed that staff repeatedly administered Midodrine despite SBP readings above 100 mmHg, and an RN later confirmed that the medication should not have been given under those conditions and that this could affect the resident’s health.
Surveyors found that the facility did not employ a qualified full-time social worker as required for a facility with more than 120 beds. The job description for the Social Services Director (SSD) required at least a bachelor’s degree in social work or another human services field plus one year of supervised social work experience in a health care setting. Review of the SSD’s file showed only a high school diploma and prior SSD experience in another nursing facility, and in an interview the SSD confirmed this was the highest level of education despite serving in the full-time SSD role for over two years.
A resident reported two separate incidents of verbal threats and intimidation by another resident with a history of schizophrenia and verbal aggression. Despite informing both an LVN and the DON, the facility's Administrator was not made aware of the allegations and did not initiate the required abuse investigation or reporting to the state agency, as mandated by facility policy. Another resident corroborated the threatening behavior, but the incidents were not properly addressed or documented.
A resident's personal belongings were not properly inventoried or documented upon admission, and the required signature was not obtained, despite the resident's capacity to sign. Later, the resident reported missing money from a wallet that was sent to the laundry, and the missing items were not listed on the belongings form. Staff confirmed the documentation was incomplete and did not follow facility policy.
A resident was discharged without the required physician documentation indicating that their health had improved sufficiently and that they no longer needed facility services. The medical record did not show that the physician assessed the resident for a safe discharge prior to the planned discharge date, as required by facility policy.
Surveyors identified that three ice machines were not maintained in sanitary working condition, with visible residues and stains on internal components and storage bins. The facility also failed to follow manufacturer cleaning specifications, as a generic cleaner was used instead of the recommended product. These deficiencies had the potential to affect 145 residents receiving oral diets.
Surveyors found that the facility did not consistently complete or document required bed entrapment assessments for several residents using bed rails or grab bars. In multiple cases, the necessary measurement for Zone 7 was missing from maintenance records, and some worksheets lacked clear units of measurement. Facility staff, including the Maintenance Director, acknowledged these documentation gaps, which were observed during resident care and record reviews.
A resident with cognitive impairment and depression was prescribed mirtazapine for depressive symptoms, specifically crying spells. Despite experiencing numerous episodes of depression while on the medication, there was no documentation that non-pharmacological interventions were identified or implemented, as required by facility policy and federal regulations. Both an LVN and the DON confirmed the absence of such interventions in the resident's record.
A deficiency was identified when a resident was discharged home and the facility failed to provide documentation that the required notice of discharge was sent to the State LTC Ombudsman. Although discharge instructions were given to the resident's caregiver and the discharge was documented in the medical record, both the Medical Records Director and SSD confirmed that no evidence of Ombudsman notification could be found.
A resident with a history of lung damage from COVID-19 received continuous oxygen at a rate higher than the physician's order, without clear documentation or care plan parameters for titration. Nursing staff were uncertain about the maximum allowable rate, and the care plan did not specify oxygen administration guidelines, resulting in inconsistent and non-individualized care.
The facility failed to ensure timely communication and scheduling of an urgent MRI for a resident as recommended by an Infectious Disease physician, and did not document intake and output as ordered for another resident. Staff interviews and record reviews confirmed lapses in communication, scheduling, and required documentation, resulting in unmet care needs for two residents.
The facility did not ensure that LAL mattress pressure settings matched residents' weights, as required by policy and manufacturer guidelines. Several residents, including those with cognitive impairment and high risk for pressure ulcers, were observed on mattresses set at incorrect pressure levels. Staff and leadership confirmed the discrepancies and acknowledged that the settings did not align with residents' actual weights or established protocols.
A resident with contractures did not consistently receive physician-ordered application of a left AFO and bilateral elbow splints, and required skin assessments were not documented. Additionally, another resident did not have physician-ordered floor mats placed on both sides of the bed for fall prevention, increasing the risk of injury.
A resident with moderate cognitive impairment and a high risk for falls was found in bed without the required bilateral floor mats, despite a physician's order and care plan intervention for their use. Staff confirmed the absence of the mats and acknowledged awareness of the resident's needs and the standing order.
Surveyors found that three residents with indwelling urinary catheters did not receive proper care: two had catheter drainage bags touching the floor, and one did not receive catheter care as outlined in the care plan, with no physician's order or documentation of care. Staff and administration acknowledged these failures, which did not follow facility policy.
Surveyors found that several residents did not receive respiratory care in accordance with physician orders and facility policy, including improper oxygen administration, lack of documentation for PRN oxygen use, and inadequate maintenance and labeling of respiratory equipment. Staff interviews confirmed these lapses, and facility leadership acknowledged the findings.
A resident with a left upper arm AV shunt receiving hemodialysis three times weekly did not have their dialysis access site assessed for bruit and thrill every shift as required by facility policy. Instead, staff only performed and documented these assessments on dialysis days, and the DON confirmed the lack of documentation for the required assessments during the review period.
Surveyors found that a resident did not receive scheduled medications after returning from dialysis, and that required narcotic logbook signatures were missing on three medication carts. Additional issues included incorrect medication labeling, missing dosage information, improper separation of oral and external medications, expired insulin not removed from carts, and an unlabeled anti-fungal powder at a bedside without a physician's order.
Surveyors observed that a nurse administered a liquid iron supplement without being able to confirm the total dose in mg, and medications for different routes (oral, topical, rectal, ophthalmic) were stored together instead of separately. An opened insulin vial was kept past the facility's 28-day discard policy, and a resident received antifungal powder applied by staff without a physician's order. The DON confirmed these practices did not follow facility policy.
A resident who was prescribed a consistent carbohydrate diet with no added salt was served a blueberry streusel dessert instead of the required two pear halves. An LVN confirmed the resident's dietary order but did not verify the specific menu items, leading to the resident receiving an incorrect dessert. The DSS later confirmed the resident should have received the appropriate dessert for their prescribed diet.
Surveyors identified unsanitary conditions in the kitchen, including soiled ice scoop holders with standing water, a sticky plate cover rack, and over twenty worn and frayed plate covers lacking smooth, cleanable surfaces. These issues were confirmed by facility staff and affected food and ice service for a large number of residents.
Surveyors found that the facility failed to ensure safe food handling and storage for foods brought in by visitors. Food items in a shared refrigerator were labeled only with room numbers, not resident names, and a leaking ice cream container was present. A resident stored multiple food items in a shared restroom's bathtub without documented education on safe storage. The facility's policy did not address essential food safety practices such as time and temperature control or safe handling, as confirmed by staff interviews and document review.
The facility's assessment did not include active participation from direct care staff, residents, or their representatives, and failed to address required plans for recruitment, retention, and contingency staffing. The Administrator confirmed these omissions during document review and interview.
Surveyors identified deficiencies in infection control practices, including improper storage of soiled laundry in a clean area, failure by an LVN to perform hand hygiene between glove changes during wound care for a resident with a pressure injury, and incorrect transmission-based precaution signage for a resident on contact isolation for a multidrug-resistant infection. These lapses were confirmed through observation and staff interviews.
A resident was prescribed antibiotics despite not meeting McGeer's or Loeb minimum criteria for infection, as required by the facility's antibiotic stewardship program. Documentation and interviews confirmed that the resident was afebrile and lacked purulent sputum, but antibiotics were still administered without proper evaluation or physician notification based on established protocols.
A resident's call light was repeatedly found on the floor and out of reach, preventing the resident from summoning staff for assistance and leading the resident to call out verbally for help. Staff confirmed the call light should have been accessible and acknowledged the issue, noting that the call light often fell due to the resident's movement in bed and was not consistently secured as required by facility policy.
A resident who was cognitively intact and had executed an advance directive did not have a copy of that directive maintained in their medical record, despite facility policy requiring it. This was confirmed by both documentation review and staff interview, resulting in a deficiency for not ensuring the resident's wishes were properly documented.
A resident's care plan was not revised to reflect the discontinuation of a physician-ordered breathing treatment, despite facility policy requiring care plan updates after each assessment. The resident continued to have a nebulizer at bedside, and the care plan still referenced the treatment after the order had ended. The DON confirmed the care plan had not been updated.
The facility did not comply with state law requiring separation of organic waste from the general waste stream. During an observation and interview, facility leadership confirmed that there were no separate bins for organic waste and that the required separation was not being performed.
The facility failed to maintain accurate and complete records, including conflicting medication administration times for a resident, incomplete documentation of Resident Council meeting outcomes, and an inaccurately completed transfer/discharge form for another resident, with missing signatures and incorrect hospital information. Staff and leadership confirmed these documentation discrepancies.
Nursing staff did not administer medications within the required timeframes, as confirmed by direct observation and resident interviews. Several residents reported receiving their medications late, and staff attributed the delays to attending to other residents' changes in condition or medical appointments. The DON acknowledged the late administration and confirmed that all sampled residents were affected.
A facility failed to monitor and record a resident's fluid intake and output while on IV therapy, as required by policy. The resident, with a history of ovarian cancer and abdominal surgery, was receiving TPN and sodium chloride IV solution. Staff confirmed the lack of documentation, acknowledging the policy's requirement to prevent fluid overload or deficit.
A facility failed to timely notify a physician of a resident's change in condition, resulting in a delay in care. The resident, unable to make decisions, had a POLST for full treatment. Despite critical vital signs, the physician was not notified for two hours, leading to a hospital transfer. The DON confirmed the delay.
The facility failed to prevent pressure injuries for two residents. A nurse did not assess or manage pain for a resident during wound care, and the facility did not develop care plans for another resident's skin issues, leading to deterioration. The DON confirmed these lapses in care planning and pain management.
A LTC facility failed to maintain effective infection control practices, as evidenced by a lack of physician orders for contact precautions for a resident with Klebsiella pneumoniae ESBL and inadequate resources for Enhanced Barrier Precautions for a resident with a pressure ulcer. Staff were unaware of the necessary precautions, and the facility did not provide essential resources like trash cans for PPE disposal, indicating systemic issues in infection control adherence.
A facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe. The resident, who had fluctuating decision-making capacity, alleged rape by an unidentified male. The report was delayed by two days, potentially affecting the investigation. The Administrator and DON confirmed the delay, acknowledging the failure to adhere to the facility's policies.
A resident in a LTC facility was found using a portable heater in her room, posing a fire hazard. The resident, who was cognitively intact, had been using the heater for about a month without notifying staff. Facility staff, including an RN and the Administrator, were unaware of the heater's presence, which violated facility policies on safety and personal belongings.
The facility failed to provide accessible call lights for two residents, one of whom was at high risk for falls and the other who was repeatedly calling out for water. Staff confirmed that the call lights were not within reach, contrary to the facility's policy.
The facility failed to monitor and document the therapeutic leave of two residents, resulting in incomplete sign-in/sign-out sheets and lack of proper assessments upon leaving and returning. Staff interviews confirmed these deficiencies.
The facility failed to follow infection control practices for three residents with indwelling medical devices. Residents with gastrostomy tubes and a PICC line did not have the required Enhanced Standard Precautions (ESP) signs or personal protective equipment (PPE) availability outside their rooms. Staff were observed not following ESP guidelines, and the Infection Preventionist confirmed the deficiencies.
The facility failed to maintain proper infection control practices, including inadequate hand hygiene by staff during wound care, improper handling of soiled linen, and failure to follow Enhanced Barrier Precautions. Staff members acknowledged these lapses during interviews.
The facility failed to ensure the safe and sanitary handling of foods brought in by family and visitors. Two bottled drinks were found on the floor near the window and air conditioner, with one bottle labeled as needing refrigeration. Muffins were also found on top of the air conditioner. A CNA confirmed that these items should have been properly stored, labeled, and dated, as per the facility's policy and the 2017 USDA FDA Food Code requirements.
The facility failed to maintain a complete and accurate medical record for a resident with an ADL self-care performance deficit. The review revealed missing documentation for several night and morning shifts in February and March 2024. The Medical Records Director and the DSD acknowledged the missing documentation.
The facility failed to maintain accurate and complete medical records for a resident, including missing documentation of physician notification and medication administration, as well as discrepancies in medical diagnoses. These issues were confirmed by the LVN and DON during interviews and record reviews.
The facility failed to promptly notify a resident's family of the resident's transfer and admission to an acute care hospital, as required by the facility's policy. The family was only contacted one day after the transfer, which was confirmed by interviews with staff and a review of the resident's medical record.
Failure to Obtain Physician Discharge Order and Complete Post-Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident’s discharge was ordered and assessed by a physician in accordance with its transfer/discharge policy. The facility’s policy required the physician to document medical reasons for transfer or discharge in the medical record for any reason other than nonpayment or facility closure, and to attach a copy of the physician’s discharge order to the discharge notice. For community discharges, the policy also required preparation of a discharge summary and plan of care. The resident, who had been admitted on an earlier date and had a history and physical dated 6/8/25 indicating capacity to understand and make decisions, received a Notice of Proposed Transfer and Discharge dated 1/27/26. The notice cited that the resident’s health had improved sufficiently so that facility services were no longer required and that the resident had failed, after reasonable and appropriate notice, to pay, and it identified the name and address of the board and care facility to which the resident was to be discharged. Despite this, review of the resident’s Order Summary Report dated 2/27/26 showed no physician’s order for discharge. The Post Discharge Plan of Care and Summary report dated 1/7/26 contained incomplete documentation from nursing and social services. Further review of the last two physician progress notes dated 2/3/26 and 2/13/26 did not show documentation that the resident’s health status had improved or that the resident was deemed safe for discharge. During an interview and concurrent record review on 3/3/26, an RN confirmed that a physician’s order is required for discharge and that the Post Discharge Plan of Care and Summary must be completed by the IDT prior to discharge, and verified that the resident did not have a discharge order and that the post-discharge documentation was incomplete. The Administrator was informed of and acknowledged these findings.
Inaccurate and Conflicting Nursing Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that documentation in a resident's medical record was factual, accurate, and consistent with accepted professional standards, as required by its policy titled "Documentation in Medical Record" revised 12/19/22. For one resident, the physician progress note dated 1/31/26 documented that the resident was nonverbal, and the MDS assessment indicated severe cognitive impairment. However, multiple nursing progress notes and skilled nursing evaluations from 1/31/26 to 2/2/26 documented that the resident denied pain or discomfort, followed commands, denied weakness, tremors, numbness, or tingling, was alert and oriented x3, communicated verbally with clear speech, and had only mild cognitive impairment with some confusion. These entries conflicted with the physician documentation and MDS findings that the resident was nonverbal and severely cognitively impaired. Additionally, the nursing progress notes contained documentation of nursing care being provided to the resident after discharge. The record showed the resident was transferred to the hospital on 2/2/26 for a low hemoglobin level, yet a nursing progress note dated 2/4/26 documented that the resident was on GT feeding, had a wound vac in place and functioning as ordered, was receiving IV antibiotics, and had no signs of active infection. During an interview and concurrent record review on 2/12/26, the DON acknowledged confusion and inaccuracies in the nursing record, stating that the documentation made it appear the resident was nonverbal on one shift and then alert and talking on the next, and that the resident had left on 2/2/26 so the nurse could not have assessed the resident on 2/4/26. The DON stated it was unclear whether nurses were actually performing assessments or copying and pasting documentation and affirmed that she expected the documentation to be accurate.
Failure to Develop Accurate Baseline Wound and Nutritional Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that accurately reflected a resident’s identified conditions and physician orders. Policy and procedure required a baseline care plan within 48 hours that included minimum health care information and interventions for special needs such as wound care and dietary orders. The resident was admitted with severe cognitive impairment and an initial skin assessment documented 10 pressure injuries and wounds, including pressure injuries to the sacrococcygeal area, hips, gluteal fold, heel, side of the right foot, a surgical incision with separated wound edges, a skin tear on the right arm, and open wounds on the right knee and left ear. Despite these findings, review of the baseline care plan initiated shortly after admission showed no care plan addressing pressure injuries or wounds. During interviews, the IP, an LVN, and the DON each confirmed that no wound care plan had been developed for any of the resident’s wounds, and all stated that each wound should have its own care plan with specific interventions and goals, and that the absence of such a plan could compromise or jeopardize the resident’s plan of care. The facility also failed to create an accurate baseline nutritional care plan consistent with the resident’s NPO status and enteral feeding orders. Physician orders documented that the resident was NPO and receiving enteral tube feedings, and a swallowing evaluation noted loss of liquids/solids from the mouth, residual food after meals, and coughing or choking during meals or when swallowing medications. A physician progress note further documented that the resident was nonverbal, NPO, and fed via GT. However, the nutritional care plan developed for the resident included interventions such as honoring food preferences, offering substitutes if less than 50% of the meal was eaten, and allowing ample time to eat and drink, which implied oral intake. In an interview, the DON confirmed that the nutritional care plan did not reflect the physician’s NPO and enteral feeding orders and acknowledged that the care plan was incorrect and could have led staff to believe the resident was able to take food or water by mouth, with a stated risk of aspiration into the lungs if oral intake occurred.
Inaccurate Documentation of Resident Temporary Absences
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for one resident regarding temporary absences from the facility. The resident had a history and physical dated 12/12/25 indicating they could make their needs known and make medical decisions, and a physician’s order dated 7/5/25 allowing them to go out on pass for therapeutic purposes. An MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The resident’s Release for Temporary Absence form documented multiple days on which the resident left the facility, with specific departure times recorded. However, on numerous dates listed in November and December, the resident’s Release for Temporary Absence form either had illegible return times or no return times documented at all. For example, on several days the resident’s departure time was recorded, but the return time was missing or not legible. Despite this, a Social Services Progress Note dated 12/9/25 stated that the resident was able to go out on pass every day for more than six hours a day, which conflicted with the incomplete documentation on the temporary absence form. Interviews with staff and the resident confirmed the inconsistencies in the record. The resident stated they received a copy of their medical records and verified they were able to go out on pass every day for more than six hours. The receptionist confirmed that the resident signed out and back in at the reception desk, but acknowledged that some return times were not documented on the form. The Social Services Director stated the receptionist left at 1900 hours and verified that some dates lacked return times, explaining that when the resident returned after 1900 hours there was no staff at reception to sign them back in. The ADON also verified that some return times were missing, stated the resident usually returned around 1800 hours, and indicated the resident should have been signing back in at the nursing station when the receptionist was no longer present. These findings showed the medical record did not accurately reflect the resident’s temporary absences and returns.
Failure to Follow Midodrine Hold Parameters for Hypotensive Resident
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. Facility policy revised 12/19/22 required that medications be administered by licensed nurses or other legally authorized staff as ordered by the physician, including obtaining and recording vital signs when applicable and holding medications when vital signs were outside prescribed parameters. Resident 2, who had a history of congestive heart failure and hypotension and lacked capacity to make medical decisions, had a physician’s order dated 8/20/25 for Midodrine HCl 10 mg via GT every eight hours for hypotension, with instructions to hold the medication if systolic blood pressure (SBP) was greater than 100 mmHg. The resident’s care plan for hypotension dated 9/4/25 directed staff to administer Midodrine for hypotension, monitor vital signs, and notify the MD of significant abnormalities. Review of the January 2026 MAR showed that staff administered Midodrine multiple times when the resident’s SBP exceeded the ordered hold parameter of 100 mmHg. Specifically, the medication was given when SBP readings were 106/61, 156/78, 102/60, 112/71, 139/70, 139/68, 124/76, 136/70, 127/64, 116/68, 106/66, 138/68, 126/72, and 108/66 mmHg on various dates and times in January. During an interview and concurrent record review on 1/16/26, an RN confirmed the Midodrine order, verified that the medication had been administered despite SBP readings above 100 mmHg, and stated that the medication should not have been given on those occasions and that this could affect the resident’s health. The administrator and nursing consultant were informed of and acknowledged these findings.
Unqualified Social Services Director Employed in Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility with more than 120 beds, affecting the provision of medically related social services for 196 residents. The facility’s job description for the Social Services Director (SSD) specified that any facility with more than 120 beds must employ a qualified social worker on a full-time basis and that the social services department must be directed by a qualified professional social worker with at least a bachelor’s degree in social work or another human services field, such as sociology, gerontology, special education, rehabilitation counseling, or psychology, plus one year of supervised social work experience in a health care setting. Review of the SSD’s personnel file showed that the SSD’s highest level of education was a high school diploma, with no documentation of a bachelor’s degree in social work or a related human services field, although the SSD had prior SSD experience in another nursing facility. In an interview, the SSD confirmed she had been working full-time in the role for two and a half years and verified that her highest educational attainment was a high school diploma. The Administrator and Nursing Consultant were informed of and acknowledged these findings.
Failure to Identify, Report, and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify, report, and investigate two separate allegations of abuse made by a cognitively intact resident against another resident. On two occasions, the resident reported feeling threatened, scared, and unsafe after being verbally threatened and intimidated by another resident, who was known to have a diagnosis of schizophrenia and a history of verbal aggression. The first incident involved the alleged aggressor raising a clenched fist and threatening to kill the reporting resident over a dispute about a wheelchair. The second incident involved the alleged aggressor threatening to cut the reporting resident into pieces. Both incidents were reported by the resident to facility staff, including an LVN and the DON. Despite these reports, the facility's Administrator, who also served as the Abuse Coordinator, was unaware of the allegations and did not initiate the required reporting to the state agency or conduct an investigation as outlined in the facility's abuse policy. The policy required immediate investigation and reporting of all alleged violations to the Administrator and state agency, with thorough documentation and follow-up. Interviews confirmed that the LVN and DON were informed of the incidents, but the Administrator did not receive this information and therefore did not fulfill the mandated procedures for abuse allegations. Additionally, another resident corroborated the occurrence of verbal threats by the alleged aggressor, stating that such behavior was frequent. The medical records indicated that the alleged aggressor lacked capacity to understand and make decisions, while the reporting resident was cognitively intact and able to articulate her concerns. The failure to follow established protocols for abuse allegations resulted in the incidents not being properly addressed or investigated by facility leadership.
Failure to Safeguard Resident's Personal Property Due to Incomplete Documentation
Penalty
Summary
The facility failed to provide reasonable care for the protection of a resident's personal property from loss or theft. Upon admission, the resident's personal belongings form was not signed by the resident, despite the resident having the capacity to understand and make decisions. The form was also not accurately completed, as it did not include all of the resident's personal items, such as a wallet and an undisclosed amount of money. The facility's policy required that all personal items be inventoried at admission and documented in the medical record, but this was not done in this case. Interviews with facility staff confirmed that the resident's signature was missing from the belongings form and that the documentation was incomplete. The resident later reported that a jacket containing a wallet with money was sent to the laundry, and while the wallet was returned, the money was missing. The missing items were not listed on the resident's belongings form, and staff acknowledged the deficiencies in documentation and procedure.
Failure to Document Physician Assessment Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for one of three sampled residents. Specifically, the medical record for the resident did not contain documentation from the physician indicating that the resident's health had improved sufficiently to warrant discharge from the facility. There was also no evidence that the physician had assessed the resident for a safe discharge prior to the planned discharge date. The facility's policy and procedure on transfer or discharge requires that the physician document the medical reasons for transfer or discharge in the medical record, except in cases of nonpayment or facility closure. Additionally, a copy of the physician's order for discharge should be attached to the discharge notice. In this case, although there was a physician's order indicating a possible discharge to a program with home health for safety evaluation, the medical record lacked documentation that the resident was assessed and determined to be ready for discharge by the physician. The resident involved had the capacity to understand and make decisions, as indicated by a prior history and physical examination. However, the absence of physician documentation regarding the resident's readiness for discharge and the lack of an assessment for a safe discharge were confirmed during a telephone interview with the Administrator, who verified the findings. This failure had the potential to result in an unsafe discharge for the resident.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1 was affected by this deficient practice. Resident 1 is still residing in the facility. On 8/25/2025, IDT team notify primary care physician about discharge planning for resident 1. On 8/25/2025, Administrator in-serviced IDT team about facility policy and procedure for discharge planning and process. Administrator emphasize the need to involve primary care physician during discharge process to make sure PCP can assess and document resident's care needs and if safe for discharge. 2. 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 discharged residents were potentially affected by this deficient practice. On 8/25/2025, Medical records audited all residents discharged in the last 30 days for physician documentation and found no other issue. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee the discharge planning and process. IDT team will initiate discharge planning during initial care plan meeting and notify PCP of the initial plan. Any resident found by IDT that indicated their health significantly improved, PCP will be notified and assess if resident is safe for discharge and document in their progress notes and order for discharge. If PCP agreed and documented that resident is safe for discharge, IDT team will start discharge process and notify the resident or responsible party. Medical record will audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025 Audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025
Ice Machines Not Maintained in Sanitary Condition
Penalty
Summary
Surveyors found that the facility failed to maintain three ice machines in sanitary working condition, as required by federal regulations. During observations with the Maintenance Director, residues of various colors (brown, yellow, gray, black, and red) were found on critical internal components of the ice machines, including the evaporator, water curtain, ice chute, and ice storage bin deflector. Additionally, stained metal screws were observed in the ice storage bin. These findings were verified by the Maintenance Director during the inspection. Further review revealed that the facility did not follow manufacturer specifications for cleaning one of the ice machines. The manufacturer’s instructions required the use of a specific scale remover (Scotsman Clear 1), but the vendor responsible for cleaning the machines used a generic cleaner (Nucalgon nickel safe ice machine cleaner) instead, citing cost and practicality as reasons. The vendor admitted to not using the appropriate cleaner for each brand of ice machine. At the time of the survey, 145 residents were receiving oral diets and were potentially affected by the condition of the ice machines.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: 145 residents were affected by this deficient practice. On 7/15/25, all three ice machines were immediately taken out of service by the maintenance director and designee; certified vendor inspected, served, and thoroughly sanitized the ice machines following the manufacturer's specific cleaning and scale removal instructions. On 7/16/25, Dietary Supervisor and designee contacted certified vendor to initiate replacement of identified non-compliant ice machines, and vendor confirmed delivery and installation of new ice machines on 8/1/25. 2. 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 the potential to be affected by this deficient practice. On 8/1/2025, Administrator and Maintenance Director checked all ice-handling processes and related equipment. All ice machine equipment was cleaned and sanitized. The ice machine inside the kitchen was replaced on 8/1/2025. No other noncompliance was found. On 8/1/2025, Ice machine technician in-serviced maintenance department on how to clean and sanitize the ice machine, making sure deep cleaning was done including compartments not easily visible using approved chemical for cleaning ice machine. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee this process and compliance. Maintenance will do monthly deep cleaning and sanitation of ice machine. The dietary supervisor and designee will do daily ice machine cleaning and inspection, with records kept. Vendor will perform quarterly service and cleaning to ensure cleanliness and compliance with equipment and sanitation protocols. Administrator or designee will check the ice machine weekly and randomly for 3 months to make sure cleaning and sanitation compliance is being followed. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The Administrator or designee will be responsible for ensuring the monitoring process remains in place to confirm compliance. Any findings and noncompliance will be immediately corrected and presented to the monthly Safety Committee meetings and the Quality Assurance (QA&A) committee meetings. The Plan of Correction was presented at the QA&A meeting on 8/14/25. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for 3 months. 5. Corrective action completion date: 8/1/2025. --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Residents 35, 36, 49, 51, 85, 122, 146, and 153 were affected by this deficient practice. On 7/23/2025, Maintenance Director re-assessed all residents 35, 36, 49, 52, 85, 122, 146, and 153 for entrapment to make sure measurement of zone 7 reflected on the form being used. On 7/23/2025, Administrator provided 1:1 in-serviced to Maintenance Director for facility policy and procedure for measuring entrapment and using the form that reflects zone 7 to show if it passes or fails.
Incomplete Bed Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate and complete entrapment assessments for residents using bed rails and grab bars. Specifically, for several residents, the Bed System Measurement Device Test Results Worksheets did not document whether Zone 7—the space between the head or foot board and the mattress end—was measured or whether it passed or failed the entrapment assessment. This omission was observed across multiple sampled and nonsampled residents, despite the presence of physician orders for bed rails or grab bars for mobility, turning, or repositioning. The facility's policy required regular inspection and assessment of all bed frames, mattresses, and bed rails to identify possible entrapment areas, but the documentation was incomplete for the required zones. Observations included residents in bed with bilateral grab bars or side rails elevated, and in some cases, residents were not present but their beds were observed with the rails in use. Medical record reviews confirmed that these residents had orders for the use of bed rails or grab bars, and in some cases, care plans addressed the risk of entrapment. However, the maintenance records failed to show complete measurements for all required entrapment zones, particularly Zone 7. Interviews with the Maintenance Director confirmed discrepancies and acknowledged that Zone 7 was not consistently assessed or documented, and in some cases, units of measurement were missing for other zones as well. The deficiency was further substantiated by interviews with facility leadership, including the ADON and DON, who acknowledged the findings. The lack of complete and accurate entrapment assessments had the potential to negatively impact residents by increasing the risk of entrapment, serious injury, or death, as described in the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. The facility's failure to adhere to its own policies and federal requirements for bed safety assessments was evident in the incomplete documentation and inconsistent measurement practices.
Plan Of Correction
2. 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 were potentially affected by this deficient practice. On 7/23/2025, the Maintenance director audited all residents' beds for entrapment measurement of zone 7, and all 182 residents were found to have issues related to the form use not reflecting zone 7 if it fails or passes the entrapment measurement. The Maintenance team immediately re-measured all zone 7 in resident beds, and the entrapment measurement form was revised to reflect zone 7 measurement of fail or pass. All zone 7 entrapment measurements passed. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator or designee will oversee this process and compliance. Maintenance will measure zone 7 for entrapment and make sure it reflects on the measurement for the entrapment form. Any bed not in compliance with zone 7 entrapment will be removed. The Administrator will review entrapment records randomly for compliance for 4 weeks and monthly thereafter. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The Administrator will monitor the effectiveness of the process and report any findings, which will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Failure to Implement Non-Pharmacological Interventions for Depression
Penalty
Summary
A deficiency was identified when a facility failed to ensure that non-pharmacological interventions were implemented for a resident who was receiving psychotropic medication for depression. The facility's policy required that non-pharmacological interventions be attempted unless contraindicated, in order to minimize the need for psychotropic medication, use the lowest possible dose, or discontinue the medication. However, review of the medical record for a resident with a diagnosis of depression and cognitive impairment revealed that, despite ongoing episodes of depression manifested by crying spells, there was no documentation that non-pharmacological interventions were identified or implemented. The resident in question had a history of memory problems and severely impaired cognitive skills for daily decision making. The resident was prescribed mirtazapine, an antidepressant, to be taken at bedtime for depression as manifested by crying. Over a period of time, the resident experienced 56 episodes of depression, specifically crying spells, while on this medication. Despite these ongoing symptoms, the medical record did not show any evidence that alternative, non-drug interventions were considered or used to address the resident's depressive episodes. During interviews, both an LVN and the DON confirmed that the resident was receiving mirtazapine and had multiple episodes of depression, but they were unable to provide documentation of any non-pharmacological interventions being used. The lack of such interventions was contrary to the facility's own policy and federal requirements, resulting in the resident being at risk of receiving unnecessary psychotropic medication.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was identified as affected by this concern. Resident is currently receiving a routine antidepressant medication. It was noted during an interview on 7/22/2025 that LVN 2 was unable to readily identify where non-pharmacological interventions (NPI) were documented in the medical record. On 7/22/2025, the DON educated LVN on how to locate NPIs in the care plan and the importance of documenting NPIs when resident behaviors are observed. Resident 89's plan of care was updated to include NPI for depression and making sure licensed nurse is documenting Resident 89's behavior when it occurs and when NPI was provided. 2. Identify Other Residents Who May Have Been Affected by the Deficient Practice: Residents receiving psychotropic medications may have been impacted by this issue. On 8/4/2025, the DON and Unit Manager audited 10 random residents' medical records receiving psychotropic medication and found no other issues noted. From 8/5/2025-8/8/2025, the Director of Nursing (DON) or designee in-serviced all licensed nurses about residents receiving psychotropic medication, in particular routine psych medications, to include NPIs and recording behavior per facility policy and procedure. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee ongoing education and compliance monitoring. All residents on psychotropic medications will continue to have care plans that include individualized NPIs. From 8/5/2025, licensed staff received continued education on documenting behavioral observations and corresponding NPIs in the medical record. Medical records or designee will review all new psychotropic medication orders daily, including new admissions and re-admissions, and report findings to the DON. New orders will be reviewed in clinical meetings to ensure NPIs are considered and included in the resident's care plan by the interdisciplinary team (IDT), as appropriate. Resident's plan of care will be updated per facility policy and procedure. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The DON or designee will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 194 was affected by this deficient practice. Resident 194 was no longer in the facility. On 7/22/2025, the Medical Record Director sent a copy of the resident 194 Notification of discharge to the ombudsman. On 8/5/2025, the Administrator in-serviced Medical Records, Social Services, and the Case Manager on the process of notifying the ombudsman of any resident transfer or discharge per facility protocol. From 8/5/2025-8/8/2025, the DON in-serviced all licensed nurses about the facility policy and process for notifying the ombudsman about resident discharges and transfers. 2. 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 discharged were potentially affected by this deficient practice. On 8/5/2025, medical records were audited for transfers and discharges in the last 30 days to ensure notification of the ombudsman was done, and no other issues were noted. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The administrator or designee will oversee the process. Social Services and the Case Manager will notify the ombudsman for any resident discharge to the community, and Medical Records will notify the ombudsman for any resident transferred to an acute setting. Medical records will audit residents' medical records when discharged or transferred to ensure notification of the ombudsman was completed. The administrator or designee will review the notification of ombudsman log monthly for three months to ensure it's completed.
Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to send a copy of the notice of discharge to the representative of the Office of the State Long Term Care Ombudsman for one of three sampled residents reviewed for closed records. The facility's policy and procedure required that evidence be maintained showing the Ombudsman was notified for non-emergency transfers or discharges initiated by the facility. However, upon review of the closed medical record for the resident in question, there was no documentation indicating that the Ombudsman had been notified of the discharge. The resident was admitted to the facility and later discharged to home with medications, as indicated by a physician's order and progress notes. Discharge instructions were provided to the resident's caregiver, and the resident was discharged home. Despite these actions, the medical record did not contain any evidence that the required notification to the State LTC Ombudsman had been completed. Interviews with the Medical Records Director and the Social Services Director (SSD) confirmed that neither could provide documentation of the Ombudsman notification for the resident's discharge. The Medical Records Director also indicated that there was no documentation in the resident's medical record and was unsure if a separate log book existed for such notifications. The SSD similarly verified the absence of a copy of the Ombudsman notification. The findings were acknowledged by the facility's Administrator, Administrator Assistant, and DON.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process, and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025. 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 86 was affected by this deficient practice. Immediately, the Unit Manager updated Resident 86's care plan to reflect oxygen administration parameters. On 8/5/2025-8/8/2025, the DON provided 1:1 education to LVN 12 and in-serviced all Licensed Nurses about facility policy and procedure of developing comprehensive care plans for each resident, in particular care plans for oxygen administration. The DON also in-serviced staff about policy and procedure for assessing residents' medical needs to ensure the care plan was updated. 2. 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 receiving oxygen could potentially be affected by this deficient practice. The DON and Unit Managers audited all residents' care plans who were receiving oxygen and found no other issues. The DON will provide ongoing education and training to Licensed Nurses about developing comprehensive care plans for individual residents. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee this process. The DON or designee will review all new admissions and re-admissions for oxygen orders and will ensure comprehensive care plans are developed to include oxygen parameters, especially for residents receiving oxygen. Any findings will be reviewed and reported during clinical meetings. Medical record audits of oxygen orders will be conducted to ensure the care plan reflects the resident's oxygen administration parameters for three months, with reports to the DON for any non-compliance.
Failure to Include Oxygen Administration Parameters in Care Plan
Penalty
Summary
A deficiency was identified when a resident receiving continuous oxygen therapy did not have a comprehensive care plan that included specific oxygen administration parameters. The resident, who had a history of lung damage due to a past COVID-19 infection, was observed receiving oxygen via nasal cannula at a rate of six liters per minute, despite the physician's order specifying administration at two liters per minute with titration to maintain an oxygen saturation of 92% or greater. The resident was unaware of the oxygen rate being administered, as this was managed by the nursing staff. During interviews and medical record reviews, it was found that nursing staff, including an LVN and an RN, were uncertain about the maximum oxygen rate permissible via nasal cannula, with the LVN stating the order did not specify a maximum rate and the RN referencing facility policy that set a maximum of five liters per minute for nasal cannula use. Documentation in the resident's medical record did not specify the rate of oxygen being administered, and the care plan addressing oxygen therapy failed to include the necessary parameters for titration or maximum allowable rates. The ADON confirmed that the care plan should have included the oxygen administration parameters and that staff should have attempted to administer the lowest amount of oxygen required to maintain the resident's oxygen saturation at or above 92%, as per the physician's order. The lack of clear documentation and guidance in the care plan led to the resident receiving a higher rate of oxygen than specified, without appropriate titration or monitoring as required.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON or designee will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 The DON or designee will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 104 was affected by this deficient practice. Immediately, Unit manager removed resident 104's nebulizer machine at bedside and updated care plan. On 8/6/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for timing and revision of resident's plan of care, in particular updating plan of care when an order was discontinued and making sure any equipment related to the plan of care was removed from resident's bedside. 2. 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 were potentially affected by this deficient practice. DON and Unit managers audited 10 random residents to make sure the plan of care is up-to-date and found no other issue. DON or designee will provide ongoing in-services to all licensed nurses about timing and revision of care plan per facility policy and procedure. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON will oversee the process of revising and updating the plan of care. Unit Manager or designee will review 24-hours and 72-hours audits to make sure all discontinued treatment will reflect on the plan of care. Medical records will audit all new and discontinued orders to make sure the plan of care was updated and will report during clinical meetings for any non-compliance (M-F) x 3 months.
Failure to Provide Timely Physician-Ordered Services and Documentation
Penalty
Summary
The facility failed to provide necessary care and services to two residents as required by professional standards and facility policy. For one resident, an Infectious Disease physician recommended an urgent MRI of the right hip to assess an abscess. The recommendation was documented during a telemedicine appointment, but there was no evidence that licensed staff reviewed the physician's notes or communicated the recommendation to the ordering physician in a timely manner. Additionally, there was no documentation that arrangements for the urgent MRI were made or scheduled promptly. The MRI was eventually scheduled more than a month after the initial recommendation, and staff interviews confirmed that the process for communication and scheduling was not followed as required. For another resident, there was a physician's order to record intake and output (I&O) every shift for 30 days, with a reassessment after that period. However, a review of the medical record found no documented evidence that the I&O values were recorded as ordered. Multiple staff members, including an LVN, an RN, and the Medical Records Director, verified that the required documentation was missing from the resident's record. Both deficiencies were confirmed through interviews with facility staff, including the Administrator, DON, and other relevant personnel, who acknowledged the lack of documentation and communication. The failures had the potential to affect the well-being of the residents involved, as the necessary care and services were not provided in accordance with physician orders and facility policy.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 85 and 195 was affected by this deficient practice. Resident 195 was no longer in the facility. Resident 85 has scheduled MRI was completed on 7/28/2025 and no negative outcome was noted. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurse about facility policy and procedure when resident coming from an appointment and scheduling any follow-up order such as an MRI to prevent any delay of treatment. 2. 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 resident were potentially affected by this deficient practice. RN supervisor and Unit manger audited all residents that came back from an appointment in last 90 days and found no other issue noted with follow up order or plan of care. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all resident's medical record when coming back from an appointment and follow up at medical office to make sure all follow up order or procedure was notated in resident's medical record. DON or designee will review 24-hours and 72-hours summary report during clinical meeting (M-F) to make necessary care and services was being followed-up and plan of care was updated. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Failure to Set LAL Mattress Pressure According to Resident Weight
Penalty
Summary
The facility failed to ensure that residents received necessary care and services to prevent the development and worsening of pressure injuries and to promote the healing of existing pressure injuries. Specifically, the facility did not consistently set low air loss (LAL) mattress pressure levels according to residents' weights, as required by both manufacturer recommendations and facility policy. Observations revealed that several residents were lying on LAL mattresses with pressure settings that did not correspond to their current weights, which could impact the effectiveness of the mattresses in preventing and treating pressure ulcers. For example, one resident was observed on a LAL mattress set at a pressure level intended for a much higher weight than the resident's actual weight, and the resident reported discomfort. Another resident, who was nonverbal and unable to express comfort, was found on a mattress set at a level for a significantly higher weight than their own, with staff acknowledging the discrepancy. In some cases, the mattress settings were changed between observations, but still did not match the residents' actual weights. Additionally, there were instances where physician orders for the use of LAL mattresses were missing from the medical record, despite the mattresses being in use. Interviews with nursing staff and facility leadership confirmed that the LAL mattress settings should be based on resident weight and comfort, and that the observed discrepancies were not in line with facility policy or manufacturer guidelines. Staff acknowledged the importance of correct mattress settings for therapeutic benefit and comfort, and verified that the settings observed did not match the residents' documented weights. The failure to follow established protocols for LAL mattress use was observed in multiple residents, including those with cognitive impairment and those at high risk for pressure ulcers.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Residents 98, 122, 28, and 131 were identified as impacted by this concern. On 7/17/2025, the Director of Nursing (DON) and Unit Manager assessed and adjusted all low air loss (LAL) mattress settings to correspond with each resident's weight. For residents able to communicate, staff inquired about comfort level, and settings were adjusted based on resident preference as needed. For residents unable to clearly express comfort level, mattresses remained set according to weight-based recommendations. 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 using LAL mattresses were considered potentially affected. On 7/16/2025, the DON and designee compiled a list of all residents with LAL mattresses and ensured settings were reviewed and adjusted to align with each resident's current weight. For those who could communicate, adjustments were made based on individual feedback regarding comfort. Residents unable to verbalize preferences remained on weight-based settings. All mattress settings were reviewed and reflected in the residents' care plans. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for Low air loss mattress (LAL) setting and to update resident's plan of care if resident's has preferred setting based on their comfort level. On 7/21/2025-7/25/2025, DSD in-serviced all CNA about policy and procedure for low air loss mattress setting to consult licensed nurse if LAL needed to be adjusted during care. Measures Put Into Place to Provide Systemic Changes in the Facility: The DON or designee will oversee ongoing monitoring of LAL mattress settings. Treatment nurses or designee will ensure that mattress settings are initially established based on resident weight. Adjustments will be made if a resident communicates discomfort. For residents unable to communicate, settings will remain at weight-based recommendations unless otherwise directed. A current list of residents with LAL mattresses and corresponding settings will be maintained and reviewed weekly. Updates to orders and care plans will be made as necessary. How the Facility Plans to Continue Monitoring: The DON or designee will review mattress settings and related documentation on an ongoing basis. Any discrepancies or concerns will be addressed promptly. Findings and compliance status will be reported during the monthly Quality Assurance (QA) meetings on 8/14/2025 and for a minimum of three months. Corrective action completion date: 8/23/2025 The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 5 was affected by this deficient practice. Resident 5 is currently not in the facility.
Failure to Follow ROM and Fall Prevention Orders
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM. Specifically, the facility did not consistently follow physician's orders for the application of a left ankle-foot orthosis (AFO) and bilateral elbow splints for a resident with contractures in both upper and lower extremities. Documentation showed inconsistent entries regarding the application and removal of these devices, with several dates lacking clear records of whether the devices were applied or removed. Additionally, there was no documented evidence that skin assessments were performed when the devices were applied, despite this being an intervention listed in the care plan and required by facility policy. Interviews with restorative nursing assistants (RNAs) and registered nurses (RNs) confirmed that the required documentation was missing or inaccurate. The RNAs stated that skin checks were performed before and after device application, but acknowledged that these assessments were not documented in the resident's medical record. The RNs also verified the absence of documentation for both the timing of device application/removal and the required skin assessments. The director of nursing (DON) was informed of and verified these findings. Another deficiency was identified related to accident prevention. The facility failed to implement physician-ordered floor mats on both sides of a resident's bed, which was a safety intervention intended to reduce the risk of injury from falls. This omission was contrary to the facility's falls prevention policy, which requires individualized interventions based on assessed fall risk. The failure to provide the ordered safety equipment placed the resident at high risk for serious injury from a fall.
Plan Of Correction
2. 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 with splints were potentially affected by this deficient practice. DON, ADON, and Unit managers conducted an audit on all residents receiving splints, braces, and ROM devices and found no other issues noted. On 8/5/2025, DON in-serviced all licensed nurses about facility policy and procedure of splint, braces, and ROM devices assessment and to add monitoring for skin integrity at least every 2 hours and as needed. On 8/6/2025-8/8/2025, DSD in-serviced all CNA and RNA about facility policy and procedure of application of ROM devices, splint, and braces to report immediately to licensed nurses if skin breakdown was noted beneath the devices. Plan of care was updated for all residents with medical devices application for splinting, braces, and ROM devices to include monitoring of skin breakdown at least every 2 hours and as needed when devices were applied on the resident. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. All new medical devices orders will be reviewed during clinical meetings to make sure RNA is following the treatment plan and monitoring for skin integrity was included in the plan of care. IDT will review monthly and as needed all residents with medical devices application and update the plan of care. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F689 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 4 was identified as affected by this concern. On 7/21/25, the Director of Nursing (DON) or designee reviewed the use of floor mats for the resident with the interdisciplinary team (IDT). After evaluation, it was determined that floor mats were no longer indicated. The recommendation to discontinue use was communicated to the physician, and the order was discontinued. The resident's care plan was updated accordingly. 2. 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 fall risk residents using floor mats were considered potentially impacted. On 8/4/2025, DON and unit manager reviewed all residents with floor mat orders and found no other issues. On 8/4/2025, the DON and designee created a list of all residents using floor mats. The IDT reviewed each case to determine ongoing need. For residents where use was no longer clinically indicated, recommendations were made to discontinue use, and care plans were updated to reflect current interventions. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for placing floor mats for residents at risk for fall, in particular assessing residents who are no longer on fall risks and have orders for floor mats to discontinue the devices as they are potentially an accidental hazard. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee this process. Unit managers and designee will conduct routine audits to ensure appropriate placement and condition of mats, accurate documentation in the care plan, and use in accordance with current physician orders and clinical justification.
Failure to Provide Required Fall Prevention Equipment for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, who was assessed as being at risk for falls and had moderate cognitive impairment, was observed in bed without the required bilateral floor mats in place. The resident's medical record included a physician's order and a care plan intervention to have bilateral floor mats at the bedside for safety precautions, due to the resident's inability to understand and make decisions, as well as left-sided weakness and total dependence for all ADLs. Despite these documented interventions, staff confirmed during interviews and observations that no floor mats were present at the bedside. Further review and interviews revealed that the CNA and RN were aware of the resident's physical limitations and the order for floor mats, but the mats were not in place. The RN indicated that the physician should have been notified to discontinue the order if the intervention was no longer appropriate, but this had not occurred at the time of the observation. The DON was informed and verified the findings.
Plan Of Correction
IDT will review all residents with order for floor mats quarterly to ensure it is still appropriate for the resident and update plan of care accordingly. Department heads and designee will do room rounds daily to make sure floor mats were in place for residents with orders for 3 months. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 F0690 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 12, 63, and 89 were affected by this deficient practice. Immediately, licensed nurse put a basin underneath the indwelling catheter bag to prevent it from touching the floor. For resident 89, on 7/17/2025, RN updated the plan of care for the resident to include indwelling catheter care in the resident's order. 2. 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 with indwelling catheters were potentially affected by this deficient practice. On 7/17/2025, RN supervisor and unit manager audited all residents with indwelling catheters to ensure they have an order for indwelling catheter care and that no indwelling bag was touching the floor, with no other issues noted. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses and CNAs about facility policy and procedure for indwelling catheter care, in particular making sure residents with indwelling catheters have an order for indwelling catheter care to prevent residents from developing UTI and to update the plan of care. DON also emphasized ensuring all indwelling catheter bags and medical tubing were not touching the floor. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. Unit manager and designee will review all new admissions and re-admissions to make sure residents with indwelling catheters have an order for indwelling catheter care. IDT will review during clinical meetings to ensure the plan of care for residents with indwelling catheters is being followed. Medical Records will audit all new admissions and re-admissions to verify that residents with indwelling catheters have updated care plans. Any noncompliance will be reported to the DON for three months.
Failure to Provide Proper Catheter Care and Maintain Drainage Bag Position
Penalty
Summary
Surveyors identified deficiencies in the facility's management of indwelling urinary catheters for three residents. For two residents, the urinary catheter drainage bags were observed touching the floor during routine observations. In one instance, a resident's drainage bag was seen hanging on the side of the bed and making contact with the floor. In another case, the drainage bag was also found on the floor, and staff acknowledged that the bag should have been placed in a basin to prevent this. These observations were confirmed by nursing staff, who recognized that the drainage bags were not properly positioned as required by facility policy. For a third resident, the facility failed to provide indwelling urinary catheter care as outlined in the resident's care plan. The care plan specified that catheter care should be provided as ordered, but there was no physician's order for catheter care in the resident's medical record. Additionally, there was no documentation to show that catheter care had been performed. The resident had a history of urinary tract infections and severe cognitive impairment, and was admitted and readmitted to the facility with an indwelling urinary catheter. Nursing staff confirmed the absence of both the required physician's order and documentation of catheter care. The facility's policy required that catheter care be performed every shift and as needed, and that drainage bags not touch the floor. The failures to follow these protocols were acknowledged by nursing staff and administration during interviews. These lapses in care and documentation had the potential to contribute to the development of urinary tract infections among residents with indwelling catheters.
Plan Of Correction
Department heads and designee will do daily room rounds to make sure no indwelling catheter bag is touching the floor. Any non-compliance will be addressed immediately and reported to the morning meeting. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Deficiencies in Respiratory Care Administration and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the provision and documentation of respiratory care, including oxygen therapy, nebulizer treatments, and BIPAP equipment maintenance for several residents. In several cases, oxygen was not administered according to physician orders, and there was a lack of documentation regarding the administration and reasons for PRN oxygen use. For example, one resident received continuous oxygen therapy at varying rates without documentation of the reason for administration or the specific amount delivered, despite having a physician order specifying PRN use and titration parameters. Another resident received oxygen at a rate exceeding both the physician's order and the facility's policy for nasal cannula use, with no attempt to titrate the oxygen to the lowest effective rate as required. Additional deficiencies were observed in the handling and maintenance of respiratory equipment. One resident's oxygen tubing was found touching the floor, and another's oxygen tubing was not labeled or dated as required by facility policy. A resident's nebulizer machine, mask, and tubing remained at the bedside undated and not stored in a clear plastic bag after the physician's order for nebulizer treatments had been discontinued. For a resident using a BIPAP device, there was no documentation that the tubing assembly, water tub, and mask were regularly cleaned as recommended by the manufacturer's user guide and facility policy, and the available logs did not specify when cleaning occurred. Surveyors also found that physician orders for oxygen therapy were not consistently followed. In one case, a resident was observed receiving oxygen at a higher rate than ordered, and in another, a resident had an active order for oxygen therapy that was not being implemented or discontinued in a timely manner. Interviews with nursing and respiratory staff confirmed the lack of adherence to orders and documentation requirements, and facility leadership acknowledged these findings during the survey.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 36, 54, 69, 80, 86, 89, 104, 122 were affected by this deficient practice. Immediately, Licensed nurse updated the plan of care for residents 36, 86, 89, 104, 122. Licensed nurse immediately replaced oxygen tubing that was touching the floor for resident 69 and replaced tubing of 80 with no label. On 7/18/2025, Respiratory Therapist supervisor reviewed the BIPAP user guide manual and provided 1:1 education to RT 1 about BIPAP cleaning guidelines and documentation. On 7/16/2025, DON provided 1:1 education to LVN 2 and 12 regarding oxygen administration and making sure to document when providing PRN order. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility policy and procedure of developing a comprehensive care plan for each resident, in particular the care plan for oxygen administration. DON in-serviced also about policy and procedure for assessing residents' medical needs to make sure the plan of care was updated and documenting when providing oxygen as needed. DON also in-serviced about oxygen setting monitoring and following physician orders. On 8/5/2025-8/8/2025, RT supervisor in-serviced all Licensed Nurses about facility policy and procedure for managing and maintaining BIPAP machine which included cleaning schedule and making sure it was documented when cleaning and replacing parts of the BIPAP, such as tubings and mask. 2. 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 receiving oxygen could potentially be affected by this deficient practice. DON and Unit managers audited all residents' care plans who were receiving oxygen and found no other issues. DON will provide ongoing education and training to Licensed nurses about developing comprehensive care plans for individual residents. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. DON or designee will review all new admissions and re-admissions for oxygen orders and will make sure comprehensive care plans are developed to include oxygen parameters, especially for residents receiving oxygen. Any findings will be reviewed and reported during clinical meetings. Department Heads and designee will do daily room rounds to ensure all oxygen tubings are labeled and not touching the floor. Any issues will be addressed immediately and reported to the morning meeting for three months. Medical record audits will be conducted to ensure oxygen orders reflect residents' oxygen administration parameters every three months, with reports to the DON for any non-compliance. The Respiratory Therapist will review BIPAP cleaning and maintenance logs monthly to ensure RTs are following the user guide manual for cleaning and maintenance of BIPAP. Any non-compliance will be reported to the DON for three months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented at the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F0698 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 9 was affected by this deficient practice. Immediately on 7/23/2025, RN Supervisor assessed Resident 9's dialysis access site and found it to be in working order with no issues noted—bruit and thrill were present on assessment. Resident 9's plan of care was updated by RN supervisor to ensure dialysis access site was being assessed every shift. On 7/23/2025, DON provided 1:1 education to LVN 8 about facility policy and procedure for assessing dialysis access site and to ensure it was being documented in the resident's medical record. 2. 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 dialysis residents were potentially affected by this deficient practice. RN supervisor and Unit managers reviewed all dialysis residents and found no other issues. From 8/5/2025-8/8/2025, DON in-serviced all Licensed nurses about facility policy and procedure for assessing dialysis access sites, ensuring they are assessed every shift and as needed for functionality, and reporting any issues to the primary physician. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new dialysis residents to ensure dialysis access sites are assessed every shift. The IDT team will review during clinical meetings to ensure the plan of care is being followed. Medical record audits will be conducted to review care plans and MAR for assessing dialysis access sites, with any non-compliance reported to the DON for three months.
Failure to Assess Dialysis Access Site Every Shift
Penalty
Summary
The facility failed to ensure that dialysis care was provided in accordance with its own policies and procedures for a resident requiring hemodialysis. Specifically, the facility's policy required that the dialysis access site (AV shunt or graft) be assessed for patency by auscultating for a bruit and palpating for a thrill every shift, not just on dialysis days. However, medical record review revealed that there was no documentation of these assessments being performed every shift for the resident during the month of June and from July 1 through July 17. Interviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the assessments were only being performed and documented on dialysis days, rather than every shift as required by policy. The resident in question had a left upper arm AV shunt and was receiving hemodialysis three times a week per physician's orders. Despite this, the facility staff did not consistently assess the dialysis access site every shift, as evidenced by the lack of documentation in the medical record. The DON acknowledged that the facility's policy was not followed and verified the absence of required documentation for the specified periods.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DO will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Deficiencies in Medication Administration, Controlled Substance Accountability, and Drug Storage/Labeling
Penalty
Summary
Surveyors identified multiple deficiencies related to pharmacy services and medication management. For one resident receiving hemodialysis, scheduled morning medications were not administered after the resident returned from a dialysis appointment, despite physician orders and facility policy requiring administration within a specific time window. Medical record review confirmed that several prescribed medications, including anticoagulants, antidepressants, and diabetes medication, were not given as ordered, and this was verified by nursing staff during interviews. Additionally, the facility failed to maintain proper controlled substance accountability on three medication carts. Narcotic logbooks for these carts showed multiple instances where required signatures from outgoing and incoming licensed nurses were missing during shift changes. Facility policy mandates that two licensed nurses account for all controlled substances and sign the logbooks at each shift change, but this was not consistently followed, as confirmed by staff and the Director of Nursing during interviews and document reviews. Further deficiencies were observed in the labeling and storage of drugs and biologicals. One resident's medication bottle was labeled with an incorrect administration time, and another medication bottle and its corresponding physician order did not specify the prescribed dose. Orally administered medications were not kept separate from externally used medications on medication carts, and opened insulin pens or vials that had exceeded the recommended use period were not promptly removed. Additionally, an opened bottle of anti-fungal powder was found at a resident's bedside without a physician's order. These findings were confirmed through observation, record review, and staff interviews.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 9 was affected by this deficient practice. Immediately on 7/23/2025, RN supervisor clarified resident's 9 medication administration order with primary physician to administer daily medication, scheduled in morning, after resident returned from dialysis. All residents receiving narcotic medication in cart A, B, and C were affected by this deficient practice. Immediately on 7/17/2025, Unit manager and Licensed nurse in charge of the Cart A, B, and C reviewed narcotic logs to make sure all narcotics were accounted for and narcotic log sheet was being signed by incoming and outgoing nurses. 2. 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 were potentially affected by this deficient practice. RN supervisor and Unit manager reviewed all dialysis residents and found no other issue with medication administration during dialysis days. Unit manager reviewed all narcotic logs and found no other issue on other carts. On 8/6/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for administration of medication to residents during their dialysis treatment days. DON emphasized clarifying with resident's primary physician any medication administration order that will be conflicted with resident's dialysis treatment time and to make sure to update the plan of care. DON also in-serviced all licensed nurses about policy and procedure of narcotic reconciliation, including making sure signing the narcotic log sheet for incoming and outgoing nurses, and its importance to prevent narcotic diversion. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new dialysis residents to make sure all their medication administration times do not conflict with their dialysis treatment schedule, and if it does, it will be clarified with primary physician immediately and update the plan of care. IDT will review during clinical meetings (M-F) to make sure the plan of care was being followed. Medical records will be audited for orders and MAR for non-compliance and will be reported to the DON every 3 months. Unit manager or designee will review narcotic log sheets daily for 4 weeks, then weekly thereafter. Any non-compliance with narcotic log sheets will be reported to the DON. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1 and resident 171 were affected by this deficient practice. Resident 1 is currently not in the facility. On 7/21/2025 and 7/24/2025, Unit manager clarified medication order for resident 171 of Olanzapine and Ferrous sulfate with primary physician and notified pharmacy for correct medication label. All residents were affected by facility failure to separate oral medication vs external use medication in the medication room and medication cart. Immediately on 7/16/2025, RN supervisor and Charge nurse organized the storage to make sure there is a separation between oral medication and external use medication. On 7/17/2025, RN 4 removed the insulin that was opened for more than 28 days per facility P&P, and re-ordered the medication. 2. 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 were potentially affected by this deficient practice. On 8/4/2025, DON and Unit managers reviewed all 10 random residents to ensure all medication labels and orders were correct and found no other issues. On 7/24/2025, Unit manager and RN supervisor checked all medication carts and medication storage to ensure there is a separation between oral medication and external use medications such as suppositories, eye drops, etc., and found no other issues. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility P&P for medication label management and storage, in particular ensuring physician order and medication label matching. DON also emphasized storage and separation of oral medication and externally used medications to prevent cross-contamination. DON also in-serviced licensed nurses about facility P&P for medication at bedside and verifying medications for new admissions and readmissions from acute care, emphasizing the importance of reconciling all medications with the resident or responsible party. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new admissions and readmissions to verify orders with physicians, and charge nurses will ensure all medication labels from pharmacy match current physician orders, notifying pharmacy of discrepancies. IDT will review all admissions during clinical meetings (M-F) to ensure all plans of care are in place and all orders verified. Unit managers or designee will conduct daily medication storage checks for 4 weeks and weekly thereafter to ensure oral and external use medications are stored separately. Any non-compliance will be reported to the DON. Department heads and designee will conduct daily room rounds to check for any medication at bedside and address issues immediately, reporting to morning meetings for 3 months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the process's effectiveness and report to the Administrator. Findings will be presented at the Monthly QA&A meeting. The Plan of Correction was presented at the QA&A committee meeting on 08/14/2025. Ongoing audit findings will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Medication Administration, Storage, and Labeling Deficiencies
Penalty
Summary
A nurse administered a prescribed dose of ferrous sulfate liquid solution to a resident via gastrostomy tube but was unable to state the total dose in milligrams, and the medication bottle label did not display the prescribed total dose. Additionally, medications intended for different routes of administration, including oral medications, enemas, suppositories, and eye ointment, were observed stored together on the same shelf in the medication room, contrary to facility policy requiring separation by route. The Director of Nursing confirmed that medications of different routes were not separated as required. An opened vial of insulin was found in a medication cart with an open date exceeding the facility's 28-day discard policy, and the nurse confirmed it should have been discarded and replaced. Furthermore, a resident was found to have an opened bottle of antifungal powder at bedside, and both the resident and a nurse confirmed that nursing staff had applied the powder without a physician's order. The Director of Nursing later confirmed that the antifungal powder is considered a medication and should not have been administered without a physician's order.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident who was prescribed a consistent carbohydrate diet with no added salt by their physician was served an incorrect dessert during lunch. The resident's meal ticket indicated the need for a consistent carbohydrate diet, and the facility's menu spreadsheet specified that the appropriate dessert for this diet was two pear halves. However, the resident was observed eating a blueberry streusel dessert instead. During the observation, an LVN confirmed that the resident was supposed to receive a consistent carbohydrate diet but did not have access to the menu spreadsheet to verify the specific food items. The LVN relied solely on the meal tray ticket and diet list, which did not specify the correct dessert. The Director of Staff Services (DSS) later verified that the resident should have received two pear halves, confirming the discrepancy between the physician's order and the food served.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 93 was affected by this deficient practice. Immediately on 7/15/2025, RN supervisor assessed and observed resident for any adverse reaction and no issue was noted. On 7/15/2025, Registered Dietitian in-serviced all dietary staff about P&P for therapeutic diet and making sure all residents diet slip was being followed. 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 receiving consistent carbohydrate diet were potentially affected by this deficient practice. On 7/15/2025, RD and Dietary supervisor audited all resident receiving Consistent carbohydrate diet and found no other issue noted. On 7/25/2025, RD and Dietary supervisor implemented new process of putting label for all dessert appropriate for resident with consistent carbohydrate diet order to make it easier for floor staff to recognize and address the issue if resident received inappropriate meal. On 7/25/2025, 7/28/025-7/31/2025, RD and Dietary supervisor in-serviced all Dietary staff, and Nursing department regarding P&P for therapeutic diet and the implementation of new process for recognizing dessert for resident with consistent carbohydrate diet order. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and Registered Dietitian or designee will oversee this process. RN supervisor or designee will review all new admission and readmission diet order and RD will follow up for therapeutic diet. IDT team will discuss all new resident with therapeutic diet during clinical meeting (M-F) making sure plan of care was in placed. Dietary supervisor will make sure diet order and diet slip is accurate during meal tray line daily and Licensed nurse on the floor will double check every meal to make sure resident is receiving correct meal based on their physician therapeutic diet order. Any non-compliance will be reported to DON daily x 3 months. Facility plans to monitor effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Sanitation Failures in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation failures in the facility's kitchen and food service areas. Specifically, two out of three ice scoop holders were found to be visibly soiled, with one containing standing water, and the third also showing signs of contamination. The Maintenance Director confirmed these findings and stated that housekeeping staff were responsible for cleaning the ice scoop holders. Further review with the Housekeeping Director revealed that, despite claims of daily cleaning with soap and water, the ice scoop holders were not clean and contained standing water, which was acknowledged as unacceptable. Additionally, more than twenty plate covers were observed to be visibly worn and frayed, lacking a smooth and cleanable surface as required by professional standards. The plate cover rack itself was also found to be soiled with a sticky residue. These deficiencies were confirmed by the Assistant Dietary Services Supervisor (DSS), who acknowledged that both the plate covers and the rack did not meet cleanliness and sanitation standards. These failures were identified in a facility where 145 residents consumed food prepared in the kitchen and used ice from the affected machines.
Plan Of Correction
F0812 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: 145 of 180 residents were affected by this deficient practice. On 7/17/25, immediately the maintenance director and designee removed identified soiled ice machine scoop holders and replaced soiled with brand new clean and sanitized ice scoop holders. On 7/18/25, the Dietary Service Supervisor (DSS) and designee removed and discarded all identified worn and frayed meal plate covers, and replaced with smooth, cleanable, and brand new plate covers. On 7/18/25, the Dietary Supervisor and designee removed soiled plate cover rack and replaced with properly cleaned and sanitized plate cover rack. 2. 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 the potential to be affected by this deficient practice. On 7/18/25, the Registered Dietitian, Dietary Service Supervisor (DSS), and designee conducted a facility-wide audit for kitchen equipment, including plate cover, plate cover rack, and ice machine scoop holders, and found no other noncompliance. On 8/5/25 - 8/7/25, the Administrator in-serviced Dietary staff about the facility P&P for food procurement and maintaining all equipment used in the kitchen, emphasizing that all equipment should be cleaned and sanitized, and uncleanable equipment such as worn or frayed plate cover racks should be discarded and replaced. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator and Dietary Service Supervisor (DSS) or designee will oversee the process. The dietary supervisor or designee will check all kitchen equipment daily for cleanliness and sanitation. The Administrator or designee will check kitchen equipment randomly and weekly to ensure all equipment is clean and not worn or frayed, and dietary staff are following sanitation processes. Any noncompliance will be reported during morning meetings. The dietary supervisor or designee will be responsible for ordering and replacing any kitchen equipment that is not up to standard per facility P&P. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator or designee will be responsible for ensuring the monitoring process remains in place. Any findings and noncompliance will be immediately corrected and presented to the monthly Safety Committee meetings and the Quality Assurance (QA&A) committee meetings. The Plan of Correction was presented at the QA&A meeting on 8/14/25. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for 3 months. 5. Corrective action completion date: 8/23/2025
Deficient Food Handling and Storage Practices for Outside Food
Penalty
Summary
The facility failed to implement and enforce a safe food handling policy for foods brought in by visitors, resulting in several deficiencies. During an observation of a residents' refrigerator, multiple food items, including shrimp fried rice and chocolate chip ice cream, were found labeled only with room numbers and not with residents' names. The ice cream container was leaking inside a plastic bag, and the Infection Preventionist (IP) confirmed that labeling with only room numbers was insufficient, as residents may change rooms, and that the leaking ice cream should be discarded for infection control reasons. Additionally, food items belonging to a resident were found stored in a shared restroom's bathtub, including boxes of cookies and chicken noodles. Medical record reviews showed that the resident had intact cognition, but there was no documentation that the resident had been educated about the risks of storing food in a restroom. Staff interviews confirmed that the resident had hoarding tendencies and had declined to remove the food, and that there was no documentation of education provided regarding safe food storage. The facility's policy and procedure (P&P) for the use and storage of foods brought in by family or visitors did not address key food safety concerns such as time and temperature control, safe food handling, and preparation. Staff interviews and document reviews confirmed that the policy lacked these critical elements, and that nursing was only required to check for diet compatibility, not for food safety or proper storage.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 49 was affected by this deficient practice. On 7/21/2025, the Unit Manager and Social Services met with the resident regarding his food storage and explained to the resident the risks of storing food items in a resident-shared bathtub. Resident 49 understood the risks, and the Interdisciplinary Team (IDT) updated the plan of care. All residents receiving outside food from family or visitors were affected by this deficient practice. On 8/5/2025, the Registered Dietitian (RD) and Dietary Supervisor provided the facility’s Policies and Procedures (P&P) to all residents receiving food from outside, and an educational flyer for food handling was given to families and visitors bringing food from outside. On 7/15/2025, food found unlabeled in Refrigerator A was discarded by the Infection Prevention (IP) nurse. 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 were potentially affected by this deficient practice. The IP nurse checked all refrigerators for residents and found no other issues noted. From 8/5/2025 to 8/8/2025, the Registered Dietitian in-serviced all staff regarding the facility P&P for personal food policy, in particular ensuring any food from outside is labeled and stored appropriately. Education about food handling and the risks of bringing food from outside was provided to residents, family members, and visitors. The plan of care will be updated accordingly. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: The Administrator and RD or designee will oversee this process. The RD and Dietary Supervisor will discuss with all new admissions and their responsible parties during the initial care plan meeting about the personal food policy and will provide education about food handling if family or visitors plan to bring food from outside. Department heads and designees will conduct daily room rounds to check for any food stored in areas that are not appropriate for food storage and will educate residents about the facility P&P for storing food. Any non-compliant resident will be reported during the morning meeting, and the IDT will meet with the resident to develop a plan of care. The Dietary Supervisor or designee will check resident refrigerators daily to ensure food is properly labeled per facility P&P. Any non-compliant food labels will be discarded. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: The Administrator will monitor the effectiveness of the process, and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Facility Assessment Lacked Required Stakeholder Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure that its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, residents, residents' representatives, and family members. The assessment dated 5/14/25 did not show evidence that these groups were actively involved in its development, as required by federal regulations and recent CMS guidance. This omission was confirmed during an interview and document review with the Administrator, who acknowledged the lack of participation from these key stakeholders. Additionally, the Facility Assessment did not include a plan to maximize recruitment and retention of direct care staff. The assessment also failed to address contingency planning for staffing needs in situations that do not require activation of the facility's emergency plan. These elements are specifically required by CMS regulations to ensure that the facility is prepared to meet resident care needs under various circumstances, including weekends and non-emergency events. The deficiency was identified through a review of the facility's documentation and interviews with facility leadership. The Administrator verified that the Facility Assessment had not been updated to reflect the latest CMS guidance and did not contain the required components related to staffing plans and stakeholder involvement. All residents were considered to be affected by this deficient practice, as the assessment is intended to address the needs of the entire resident population.
Plan Of Correction
5. Corrective action completion date: 8/23/2025 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee this process. Administrator will make sure any changes to facility assessment regulation, facility assessment will be updated. Annually, IDT team will update facility assessment with inputs from required representative. Administrator will present facility assessment for approval annually and when changes were made during monthly QA meeting. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025 for approval. Corrective action completion date: 8/23/2025
Infection Control Deficiencies: Soiled Linen Storage, Hand Hygiene, and Isolation Signage
Penalty
Summary
The facility failed to implement infection control practices as required by federal regulations, resulting in multiple deficiencies. During an observation of the laundry area, two uncovered bins containing soiled mops and towels were found stored in the clean laundry area. The facility's policy requires that soiled linen be collected at the point of use, placed in a designated receptacle, and kept separate from clean linen. The Housekeeping Supervisor confirmed that the soiled laundry bins should not have been in the clean area. In another instance, a wound care observation for a resident with a coccyx pressure injury revealed that the LVN performing the procedure did not follow proper hand hygiene protocols. The LVN changed gloves multiple times during the wound care process without performing hand hygiene between glove changes, contrary to the facility's policy, which mandates hand hygiene before donning and after removing gloves. The LVN acknowledged the lapse in hand hygiene during an interview. Additionally, the facility failed to ensure appropriate transmission-based precaution signage was posted for a resident with a physician's order for contact isolation due to a multidrug-resistant organism (MDRO) in the urine. Instead of the required contact isolation signage, an EBP (Enhanced Barrier Precautions) sign was posted on the resident's door. The error was confirmed by the LVN and the DON during the survey. These failures were identified through observation, interview, and review of facility policies and had the potential for cross-contamination and spread of infectious organisms.
Plan Of Correction
2. 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 were potentially affected by this deficient practice. On 7/18/2025, IP nurse checked the laundry area to make sure soiled and clean areas were separated and no soiled laundry was crossing the clean laundry area. On 7/25/2025, 8/4/2025-8/8/2025, DON, DSD, and IP nurse in-serviced all staff regarding facility P&P for infection control and prevention. The in-service focused on hand hygiene, cross contamination, making sure clean and soiled laundry were separated, and isolation precautions. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility P&P for residents with new orders of isolation and to put appropriate isolation signs immediately. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and IP Nurse or designee will oversee this process. IP nurse will do random checks of the laundry area to make sure soiled laundry is not stored in the clean area. Any non-compliance will be addressed by training staff and reported to DON. IP will provide ongoing training and education to all staff about hand hygiene monthly for 3 months, and random hand hygiene compliance will be completed. Results will be reported monthly during infection control committee meetings. IP nurse will review all isolation signage to ensure residents in isolation have proper signage. Any new isolation order received by the Charge nurse will be reported to the IP nurse and discussed during the clinical meeting to ensure the plan of care was updated. Any non-compliance will be reported to DON for 3 months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: DON and IP nurse will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A and infection control meetings. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Failure to Follow Antibiotic Stewardship Protocols for Infection Criteria
Penalty
Summary
The facility failed to accurately monitor and address the use of antibiotics for a resident when the resident's symptoms did not meet the McGeer's criteria or Loeb minimum criteria for a true infection. According to the facility's policy, the Antibiotic Stewardship Program is intended to optimize infection treatment and reduce adverse events by using established criteria to define infections and guide antibiotic use. However, documentation for one resident showed that antibiotics were prescribed despite the resident being afebrile and lacking purulent sputum, which did not meet the required criteria for initiating antibiotic therapy. The Infection Surveillance Monthly Report and Infection Screening Evaluation did not clearly indicate whether the resident's symptoms met the McGeer's or Loeb criteria, and the medical record lacked evidence of fever or increased sputum at the time antibiotics were ordered. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the resident's symptoms did not meet the criteria for a true infection and that the physician should have been accurately notified of this when the antibiotic was ordered. The IP acknowledged that the facility's process was not followed, as the resident's symptoms were not properly evaluated against the McGeer's criteria before antibiotics were administered. This failure to adhere to the facility's antibiotic stewardship protocols resulted in the use of antibiotics without sufficient clinical justification as outlined in the facility's own policies.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was affected by this deficient practice. On 7/18/2025, DON provided 1:1 education to IP nurses about facility P&P for antibiotic stewardship program, in particular following the McGeer's criteria and Loeb minimum criteria and notifying primary physician of resident's signs and symptoms for appropriate use of antibiotic medication. 2. 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 were potentially affected by this deficient practice. On 8/4/2025, DON and IP nurse reviewed residents in the last 30 days who received antibiotic and making sure McGeer's and Loeb criteria was followed and verified with primary physician and no other issue was noted. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility P&P for Antibiotic Stewardship program and identifying signs and symptoms in line with McGeer's Criteria and Loeb minimum criteria and verifying with primary physician for appropriate usage of antibiotic medication, especially if resident does not meet McGeer's or Loeb criteria. DON emphasize on documenting in resident's medical record if primary physician insisted on continuing the Antibiotic even if resident infection does not meet McGeer's or Loeb Criteria for unnecessary use of Antibiotic. Resident plan of care will also be updated. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and IP nurse or designee will oversee this process. If a resident developed signs and symptoms of possible infection, RN supervisor or charge nurse will notify primary care physician (PCP) for the COC. If PCP ordered antibiotic, RN supervisor or charge nurse will initiate appropriate use of antibiotic and might suggest to PCP for additional testing, such as labs before initiating antibiotic use. If PCP insisted to start antibiotic, RN supervisor or charge nurse will document in resident medical records and initiate McGeer's criteria or Loeb minimum criteria and reported to IP nurse. IP nurse will re-evaluate Antibiotic use and if McGeer's Criteria or Loeb criteria was not met, IP nurse would verify with primary physician for antibiotic use and suggest antibiotic timeout. IP nurse would update plan of care based on PCP order. IP Nurse will report antibiotic use monthly to infection control committee and any PCP not complaint with McGeer's and Loeb Criteria will be discuss with Medical Director. Medical record will audit all new antibiotic order for compliance to antibiotic stewardship program and report to DON x 3 months. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident's call light was repeatedly found out of reach, specifically on the floor, during multiple observations. The resident, who was in bed and awake during these times, expressed a need for assistance but was unable to locate the call light button. Instead, the resident resorted to calling out for staff verbally. Staff members, including a registered nurse and a certified nursing assistant, confirmed that the call light should have been within the resident's reach and acknowledged that it was found on the floor during their checks. The facility's policy and procedure on call light accessibility and timely response required that call lights be within reach of residents and secured as needed. Despite this policy, staff interviews revealed that the call light for this resident often fell to the floor, particularly because the resident moved frequently in bed. The call light was equipped with a clip intended to secure it to the bedsheet, but this was not consistently utilized, resulting in the call light being inaccessible to the resident on more than one occasion. Medical record review indicated that the resident had been admitted to the facility several weeks prior to the observations. During the deficiency events, the resident was in need of assistance, including pain management, but was unable to summon help using the call light due to its inaccessibility. Staff acknowledged the issue and confirmed that the call light should always be within the resident's reach, as per facility policy.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 63 was affected by this deficient practice. Immediately, both RNA 1 and CNA 1 put the call light next to resident. DSD provided 1:1 education to RNA 1 and CNA 1 about call light placement and making sure call lights are within reach. On 7/25/2025 and 8/4/2025-8/8/2025, DON and DSD in-serviced all staff regarding call light placement and making sure they are within resident reach. In-serviced included frequent monitoring of call lights within resident reach for residents who have a tendency to push the call light away and making sure the nursing supervisor is made aware and the plan of care is updated. 2. 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 were potentially affected by this deficient practice. On 7/24/2025, all department heads did a room rounds to check if any other resident was affected and found no other resident with issues. On 8/4/2025, the Administrator and Maintenance Director checked all call lights to make sure they have clips to keep call lights next to residents’ reach and no other issues were noted. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator and designee will oversee this process. Department heads and designee will do daily room rounds to check for call light placement and report to daily morning meetings for any non-compliance for 4 weeks. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator will monitor the effectiveness of the process and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction will be presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator will monitor the effectiveness of the process and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction will be presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Failure to Maintain Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of an executed advance directive in the medical record for one resident. According to the facility's policy, upon admission, if a resident has an advance directive, copies are to be made and placed in the resident's chart and communicated to staff. In this case, the resident was admitted and readmitted to the facility, and documentation showed the resident had the capacity to make decisions and had executed an advance directive, as indicated by both the Physician Orders for Life Sustaining Treatment (POLST) and an Advance Directive Acknowledgment form. Despite this documentation, there was no copy of the actual advance directive in the resident's medical record. This was confirmed during a medical record review and interview with the Assistant Director of Nursing (ADON), who verified that the advance directive should have been present in the chart to confirm the resident's wishes. The absence of the advance directive in the medical record constituted noncompliance with facility policy and federal requirements.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 51 was affected by this deficient practice. Immediately, the Social Services Director updated resident 51's advance directive record to reflect the current wishes of the resident. On 8/5/2025-8/8/2025, the Administrator in-serviced all Social Services and Licensed Nurses regarding advance directives, ensuring a copy of the resident's advance directive was placed in the resident's medical records and that it reflects the current wishes of the resident. 2. 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 the potential to be affected by this deficient practice. On 8/5/2025, medical records and social services audited all residents' advance directives to ensure they reflect current treatment plans and the wishes of the residents. If an advance directive is applicable, a copy was placed in the residents' medical records, and no other issues were noted. Social Services will review advance directives with residents during quarterly care plan meetings and as needed for any significant changes or if the responsible party or resident wishes to make changes to their advance directive. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: DON and Social Services Director or designee will oversee this process. Social Services will review and discuss advance directives with all new admissions and re-admissions, and if a copy of the advance directive is available, it will be placed in the resident's medical records. Social Services will conduct quarterly audits of residents' advance directives and update the plan of care. Medical record audits will be performed on all new admissions and re-admissions to ensure a copy of the advance directive is in the medical record, if available. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON and Social Services will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Care Plan Not Updated After Discontinuation of Breathing Treatment
Penalty
Summary
A deficiency was identified when the facility failed to update a resident's comprehensive care plan to reflect current care needs and interventions. Specifically, the care plan was not revised after the discontinuation of a physician's order for a breathing treatment (ipratropium-Albuterol solution via nebulizer) that had been prescribed for shortness of breath. The care plan continued to reference the breathing treatment even after the order had ended, contrary to the facility's policy requiring care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. The issue was discovered during an observation and interview with the resident, who reported using a nebulizer at bedside for breathing problems. The nebulizer and mask were observed in the resident's room, and a review of the medical record confirmed the breathing treatment order had been discontinued. The Director of Nursing was informed and verified these findings, confirming that the care plan had not been updated to reflect the change in the resident's treatment regimen.
Plan Of Correction
4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance. Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025
Failure to Separate Organic Waste per State Law
Penalty
Summary
The facility failed to comply with California State law SB 1383, which requires the separation of organic waste from the general waste stream. During an observation and interview with the Director of Social Services (DSS) and the Maintenance Director in the facility's trash area, it was found that the facility did not have separate bins for organic waste as mandated by the law. Both the DSS and Maintenance Director confirmed that the facility was not separating organic waste from other waste and did not possess the required organic waste bins. This deficiency was identified through direct observation and staff interviews, confirming that the facility was not adhering to state regulations regarding waste management. There were no specific residents or patient medical histories mentioned in relation to this deficiency. The failure to separate organic waste was verified by facility leadership during the survey process.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: All residents were affected by this deficient practice. On 7/18/25, immediately, the maintenance director contacted the waste management provider to initiate and coordinate organic waste bin service and delivery. On 7/23/25, appropriate organic waste bins were placed in the designated waste disposal area. The Maintenance Director in-serviced all dietary staff about the facility P&P for organic waste disposal per regulatory requirements. 2. 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 the potential to be affected by this deficient practice. On 7/23/25, the Maintenance Director and designee verified with the contracted waste management provider of compliance and conducted a facility-wide waste audit to ensure waste disposal practices are met per SB 1383; no other deficiencies were identified. On 7/25/2025, 8/4/2025-8/8/2025, the Administrator in-serviced all staff regarding organic waste regulation under SB 1383. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator and Dietary Supervisor or designee will oversee the process. The dietary supervisor or designee will monitor compliance, making sure dietary staff are following the regulation under SB 1383 for separation of organic waste from the waste stream. The Administrator will check randomly to make sure staff are compliant with SB 1383 regulation three months.
Incomplete and Inaccurate Medical and Facility Recordkeeping
Penalty
Summary
The facility failed to maintain complete and accurate medical and facility records for multiple residents and the Resident Council, as required by federal regulations. For one resident, there was conflicting documentation regarding the administration time of olanzapine zydis 5 mg, an antipsychotic medication. The physician's order specified administration at noon, but the scheduling details listed both 0900 and 1200 hours. This discrepancy was confirmed by a licensed vocational nurse, who acknowledged that the 0900 time was inaccurate and not in accordance with the physician's order. Additionally, the facility did not ensure complete documentation of the Resident Council Agenda/Minutes for several months. While issues raised by the Resident Council and departmental responses were recorded, the sections indicating whether the issues had been resolved to the residents' or families' satisfaction were left unchecked for multiple months. Interviews with residents confirmed that their concerns had been resolved, but the documentation did not reflect this follow-up, and the Activities Director acknowledged responsibility for this incomplete recordkeeping. For another resident who was discharged, the Notice Proposed Transfer/Discharge form was not accurately completed. The form lacked the required signature of the resident or their representative and listed a different hospital destination than the one specified in the physician's transfer order. Both a licensed vocational nurse and a registered nurse verified these discrepancies, and facility leadership acknowledged the findings. These documentation failures resulted in inaccurate records regarding resident care and facility operations.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 171 and 195 were affected by this deficient practice. On 07/21/2025, the Unit Manager clarified the medication scheduling record and notified the pharmacy to send medication with the correct label. Resident 195 is no longer residing in the facility. On 7/16/2025, the Administrator provided 1:1 education to the Activity Director about facility policies and procedures for ensuring accurate documentation on the resident council agenda/minutes record, particularly reviewing and following up on resident council grievances. 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 were potentially affected by this deficient practice. On 8/4/2025, the DON and Unit Manager audited 10 random residents' Medication Administration Records and found no other issues noted. On 8/4/2025, medical records were audited for the last 30 days of transfer and discharge records, and no other issues with the completion of notification of transfer/discharge records were found. On 7/16/2025, the Activity Director reviewed all resident council meeting minutes from the last 4 months and followed up on any grievances, all of which were addressed. From 8/5/2025 to 8/8/2025, the Director of Nursing (DON) or designee in-serviced all Licensed Nurses about the facility policies and procedures for documentation accuracy and ensuring medication labels were correct based on physician orders. On 8/5/2025, the Administrator in-serviced Social Services and the Case Manager about the facility policies and procedures for completing and signing proposed notification of discharge/transfer forms. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON and Administrator or designee will oversee this process. The RN supervisor or designee will review all new admissions and re-admissions to verify that all orders, particularly medication administration times, are confirmed with the primary physician and that the pharmacy is notified of any label discrepancies. The Unit Manager or designee will review 24-hour and 72-hour summary reports and report during clinical meetings for any non-compliance. The Administrator or designee will review all resident council agenda minutes to ensure they are completed accurately, and all grievances are addressed and followed up before signing. Medical records will be audited daily after resident discharge or transfer to ensure all necessary information is completed and signed. Any non-compliance will be reported to the Administrator and DON during the morning meetings (Monday through Friday) for three months. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: The DON and Administrator will monitor the effectiveness of the process and report any findings at the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 120 was affected by staff not performing hand hygiene between glove changes during treatment. On 7/18/2025, the DON provided 1:1 education to LVN 11 about facility policy and procedures for infection control and prevention, especially emphasizing hand hygiene between glove changes during wound treatment to prevent cross-contamination. Resident 162 was affected by this deficient practice. Immediately on 7/15/2025, LVN 9 changed the isolation sign from EBP to contact isolation. All residents were affected by soiled laundry stored in the clean laundry area. On 7/18/2025, the Infection Prevention (IP) nurse in-serviced all laundry staff about facility policies and procedures for cross-contamination prevention and proper separation and storage of clean and soiled laundry.
Failure to Administer Medications Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications were administered to residents within the prescribed timeframes, as required by their own policies and federal regulations. Facility policy stated that medications should be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician. Observations and interviews revealed that medications scheduled for 0900 hours were not administered on time to multiple residents. Nursing staff confirmed that they were late in administering medications due to being occupied with other residents experiencing changes in condition or needing assistance with medical appointments. Multiple residents reported that they sometimes received their medications late, and this was corroborated by direct observation of nursing staff administering medications past the scheduled times. For example, one nurse began medication administration at 0830 hours but was still administering 0900 medications to several residents after 1000 hours. Another nurse also confirmed being late with 0900 medications for several residents. Residents interviewed during the survey confirmed that they had not yet received their scheduled medications or that late administration was a recurring issue. The facility's documentation and interviews with staff indicated that the delays in medication administration were not isolated incidents but affected all 16 sampled residents. The Director of Nursing acknowledged the late administration and stated that the expectation was for medications to be given on time. The facility's failure to provide timely medication administration did not align with their established procedures and had the potential to negatively impact resident care.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 was affected by this deficient practice. Immediately, Residents' primary care provider was notified by Licensed Nurse and DON about late medication administration. All affected residents were monitored for any adverse reaction. On 6/13/2025, DON provided 1:1 education to LVN 6 about medication administration policy and procedure. 2. 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 were potentially affected by this deficient practice. On 6/24/2025, DON and Medical records audited medication administration x 1 month and found no other concern. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee the process and monitor medication administration through observation of medication administration daily for 4 weeks. From 6/24/2025, DON and ADON in-service all licensed nurses about medication administration policy and procedure and their responsibilities when they are aware that they might not meet the medication administration time-frame, including asking for help from RN supervisor or Unit Managers to make sure all residents received their medications on time. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and designee will monitor daily medication administration x 4 weeks. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 07/9/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for three months. Corrective action completion date: 7/04/2025
Failure to Monitor and Record Fluid Intake and Output for Resident on IV Therapy
Penalty
Summary
The facility failed to ensure the necessary care and services were provided for a resident who required intravenous (IV) therapy. Specifically, the facility did not monitor and record the resident's IV and oral fluid intakes, as required by their policy. This oversight was identified during a review of the resident's medical records, which showed no documentation of daily fluid intake and output, despite the resident being on IV therapy. The facility's policy mandates that all residents receiving IV therapy should have their intake and output recorded to prevent potential fluid overload. The resident in question had a history of ovarian cancer and had undergone extensive abdominal surgery, resulting in an abdominal fistula and ileostomy. The resident was receiving cyclic total parenteral nutrition (TPN) and sodium chloride intravenous solution as part of their treatment. Interviews with facility staff, including a registered nurse and the administrator, confirmed the lack of documentation for the resident's fluid intake and output. Both staff members acknowledged that the facility's policy requires such documentation to mitigate the risks associated with fluid overload or deficit.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. The deficiency involved a failure to timely notify the physician of a change in the resident's condition. The resident, who had no capacity to understand and make decisions, was admitted with a POLST indicating full treatment and a physician's order for full code. On a specific date, the resident's pantoprazole sodium was not administered due to desaturation, and vital signs showed significantly low blood pressure and oxygen saturation levels. Despite the resident's critical condition, there was no documented evidence that the physician was notified of the desaturation episode until approximately two hours later. The resident's condition continued to deteriorate, with oxygen saturation levels dropping further, leading to a transfer to an acute care hospital by paramedics. The Director of Nursing confirmed the lack of timely physician notification and acknowledged the findings during an interview and medical record review.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure injuries for two residents. For Resident 4, the licensed nurse did not assess and manage the resident's pain during wound care treatment. Despite the resident moaning in discomfort while the wound on the sacrococcyx was being cleaned, the nurse continued with the treatment without checking the resident's pain level or administering pain medication as ordered. The Director of Nursing (DON) confirmed that the nurse should have assessed for pain and administered medication if necessary. For Resident 6, the facility did not develop a care plan to address the resident's Moisture-Associated Skin Damage (MASD) to the bilateral buttocks extending to the sacrococcyx, which deteriorated into an unstageable pressure injury. Additionally, there was no care plan for a purplish nonblanchable area on the resident's right heel. The resident was at high risk for pressure ulcers, as indicated by the Braden Scale, and required extensive assistance with bed mobility and toileting. The DON acknowledged that a comprehensive care plan should have been developed within seven days after the comprehensive assessment. These deficiencies indicate a failure to follow the facility's policy and procedures for pressure injury prevention and management. The facility's policy requires a systematic approach, including prompt assessment, treatment, and development of a relevant care plan with measurable goals and appropriate interventions. The lack of proper assessment and care planning for these residents had the potential to compromise their care and management needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, the facility did not ensure that a resident with Klebsiella pneumoniae ESBL had a physician's order for contact precautions. This resident, who had the capacity to understand and make decisions, was receiving treatment for the infection but lacked the necessary documentation and signage to inform staff of the required precautions. Interviews with various staff members, including a CNA, LVN, and RN, revealed a lack of awareness regarding the resident's contact isolation status, indicating a communication breakdown in the facility's infection control procedures. Secondly, the facility did not adhere to its policy regarding Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. The resident's room lacked a trash can for discarding PPE, which is a critical component of the facility's EBP policy. During a wound care treatment observation, it was noted that staff had to search for a trash can from another room, highlighting a failure to provide the necessary resources for infection control. The Infection Preventionist and the Director of Nursing acknowledged these findings, confirming the absence of proper isolation setup in the resident's room. These deficiencies demonstrate a failure in the facility's infection control practices, potentially increasing the risk of infection transmission. The lack of physician orders and proper signage for contact precautions, along with inadequate resources for EBP, indicate systemic issues in the facility's adherence to its own policies and procedures.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, specifically an allegation of sexual abuse, in accordance with section 1150B of the Act. The facility did not report the allegation of sexual abuse involving a resident to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program, Long Term Care (LTC) Ombudsman office, and local law enforcement agency within the required two-hour timeframe. The incident involved a resident who alleged she was raped by an unidentified male wearing blue nursing clothes. The report was delayed by two days, which could have potentially delayed the investigation and necessary corrective actions. The resident involved in the incident was admitted to the facility with a history of fluctuating capacity to understand and make decisions, as noted in her health and physical examination. On the day of the alleged incident, the resident exhibited increased confusion and made false accusations of rape, as documented in the eINTERACT Change in Condition Evaluation. Despite the resident's condition, the facility's Administrator and Director of Nursing (DON) acknowledged that the report of the alleged sexual abuse was not made immediately as required by the facility's policies and procedures. The failure to report promptly was confirmed during interviews with the Administrator and the DON.
Portable Heater Hazard in Resident's Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by allowing a portable space heater in a resident's room. Resident 4, who was cognitively intact with a BIMS score of 14, had been using a portable heater in her room for about a month without informing the staff. The heater was observed in use during an interview with the resident, who stated she used it when the room temperature dropped to 62 degrees. The resident was unaware that having a portable heater was against facility policy. Interviews with facility staff, including an RN, the Administrator, and the Maintenance Director, revealed that the staff was unaware of the heater's presence in the resident's room. The RN stated that the heater was a hazard and not allowed, while the Administrator confirmed that portable heaters were prohibited due to safety concerns. The Maintenance Director acknowledged seeing the heater earlier and confirmed its removal from the resident's room. The facility's policies on resident personal belongings and maintaining a safe environment were not adhered to, leading to this deficiency.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs of two residents, Resident 9 and Resident 12. Resident 12 was observed lying in bed without his call light within reach, which was found underneath his pillow. Despite being at high risk for falls, as indicated by a star on his name label and his care plan, the call light was not accessible. LVN 3 confirmed that the call light was not within Resident 12's reach, which is against the facility's policy that requires call lights to be accessible to residents at all times. Similarly, Resident 9 was observed multiple times calling out for water without his call light within reach. The call light was found hooked to the top of the bed and hanging off to the side, making it inaccessible. CNA 6 verified that the call light was not within Resident 9's reach. The Director of Nursing (DON) confirmed that call lights should always be within reach for resident safety. These observations indicate a failure to adhere to the facility's policy on call light accessibility, potentially leaving residents' care needs unmet.
Failure to Monitor and Document Therapeutic Leave
Penalty
Summary
The facility failed to ensure that Resident 1 did not exceed the maximum hours for her therapeutic leave as ordered by the physician and did not notify the physician when Resident 1 stayed out longer than ordered. Additionally, the facility did not assess Resident 1 upon leaving and returning to the facility, and the Release for Temporary Absence sign-in and sign-out sheets were not completed each time Resident 1 left and returned from her therapeutic leave. Resident 1, who had bipolar disorder and anxiety disorder, was observed to be out of the facility beyond the four-hour limit on multiple occasions without proper documentation or notification to the physician. Similarly, the facility failed to ensure that Resident 10 was assessed upon leaving and returning to the facility from his therapeutic leave. The Release for Temporary Absence sign-in and sign-out sheet for Resident 10 was also incomplete, with missing departure times and no nursing progress notes documenting his condition upon leaving and returning. Resident 10 had the capacity to understand and make medical decisions and had a physician's order allowing him to go out on pass with a family member for therapeutic purposes. Interviews with staff, including LVNs, Unit Managers, and the DON, confirmed these findings. The staff acknowledged that residents were supposed to sign in and out in the Out on Pass binder and that nurses were expected to document brief assessments in the progress notes when residents left and returned. However, these procedures were not consistently followed, leading to incomplete documentation and lack of proper communication with the physician regarding the residents' therapeutic leave activities.
Failure to Implement Enhanced Standard Precautions
Penalty
Summary
The facility failed to ensure infection control practices were followed for three residents with indwelling medical devices. Resident 5, who had dysphagia and was on gastrostomy tube (GT) feeding, did not have an Enhanced Standard Precautions (ESP) sign or personal protective equipment (PPE) availability outside the room. Staff were unsure of the meaning of the red dot beside Resident 5's name, which was supposed to indicate the need for ESP. The Unit Manager confirmed that any resident with an indwelling medical device should be on ESP and that appropriate signage and PPE should be available outside the room, which was not the case for Resident 5. Resident 6, who had a spinal cord abscess and a peripherally inserted central catheter (PICC) line, also did not have an ESP sign or PPE availability outside the room. The Infection Preventionist (IP) confirmed that ESP became mandatory for residents with indwelling medical devices and chronic wounds as of April 1, 2024. The IP verified that Resident 6 should have had an ESP sign and a PPE cart outside the room to minimize the risk of infection. Resident 7, who had dysphagia and was on GT feeding, similarly lacked an ESP sign and a red dot by the name outside the room. During an observation, staff entered Resident 7's room without donning a gown, which was required under ESP guidelines. The IP confirmed that there should have been an ESP sign and PPE supplies outside the room and that staff should have worn gowns when providing high-contact care. The IP also noted that a red dot should have been placed by Resident 7's name to indicate the need for ESP.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations and staff interviews. Treatment Nurse 1 did not perform hand hygiene after removing a dirty dressing and before cleaning a wound, and also wore double gloves, which is against the facility's policy. Similarly, CNA 3 did not perform hand hygiene between glove changes while providing wound care to a resident, and also wore double gloves. Both staff members acknowledged their failure to follow proper hand hygiene protocols during interviews. Additionally, an unattended and overflowing soiled linen bin was found in the hallway, which should have been attended to and closed to prevent infection spread. LVN 4 and CNA 4 confirmed that the bin should not have been left unattended and overflowing. Furthermore, CNA 5 was observed leaving an Enhanced Precaution room without removing gloves and gown or performing hand hygiene, and then touched clean linen with soiled gloves. This action was against the facility's Enhanced Barrier Precautions policy, which requires staff to discard PPE and perform hand hygiene before exiting the room or providing care to another resident. The RN Supervisor acknowledged these findings during an interview.
Improper Storage of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to ensure the safe and sanitary handling of foods brought in by family and visitors, as per their policy and standards of practice. During an observation in Room A, two bottled drinks were found on the floor near the window and air conditioner, with one bottle labeled as needing refrigeration. Additionally, muffins were found placed on top of the air conditioner. An interview with a CNA confirmed that these items should not have been stored in such a manner and should have been properly labeled and dated. This failure had the potential to expose residents to food contamination, as it did not comply with the facility's policy and the 2017 USDA FDA Food Code requirements for food storage and labeling.
Incomplete ADL Documentation for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of eight sampled residents. Specifically, the facility did not ensure the completion of the ADL- Bed Mobility Intervention/Task documentation for Resident 1. This resident had an ADL self-care performance deficit related to impaired function and limited mobility. The medical record review revealed missing documentation for several night and morning shifts in February and March 2024. The Medical Records Director and the DSD both acknowledged the missing documentation, confirming that the CNAs assigned should have completed it.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of seven sampled residents. Specifically, the medical record for Resident 1 did not document the date or time when the physician was notified of the resident's transfer to the acute care hospital for abnormal vital signs. Additionally, there was no evidence that essential medications were administered on the morning of the transfer, nor was there documentation explaining the missed doses or notifying the physician about them. This lack of documentation was confirmed by both the LVN and the DON during interviews and concurrent medical record reviews. Furthermore, the medical diagnoses listed in Resident 1's records were found to be inaccurate and did not match the diagnoses provided by the acute care hospital. The discrepancies included significant medical conditions such as community-acquired pneumonia and severe protein-calorie malnutrition, which were not reflected in the facility's records. The DON acknowledged that the medical diagnoses should have been reviewed for accuracy by the MDS and Medical Records departments. These deficiencies in documentation and record accuracy posed a risk for delays in necessary care and treatment for Resident 1.
Failure to Promptly Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that the family of a resident was promptly informed of the resident's transfer and admission to an acute care hospital. According to the facility's policy and procedure (P&P) titled 'Notification of Changes,' the facility must promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification, including a transfer or discharge. However, in the case of Resident 1, who was transferred to the acute care hospital for abnormal vital signs, there was no documented evidence that the resident's family was promptly informed of the transfer. The family was only contacted and left a phone message one day after the transfer occurred. Interviews with facility staff, including an LVN and the Director of Nursing (DON), confirmed that the family should have been notified as soon as possible. The DON verified that the staff did not promptly communicate with Resident 1's family representative as per the facility's P&P. The closed medical record review also failed to show documented evidence that the resident's family member was notified promptly of the admission to the acute care hospital. This failure had the potential for the resident's family to be unaware of the resident's changes in condition.
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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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