Glendora Canyon Transitional Care Unit
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 401 W. Ada Ave., Glendora, California 91741
- CMS Provider Number
- 555416
- Inspections on file
- 66
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Glendora Canyon Transitional Care Unit during CMS and state inspections, most recent first.
A resident with sepsis and DM, intact cognition, and functional limitations requiring assistance with ADLs did not have all meal intakes documented by CNAs as required. Review of documentation showed that while most meals had recorded intake amounts, several meals over two months lacked any meal intake entries. A CNA and the DON confirmed that CNAs were expected to chart meal intake, including refusals, after each meal and before the end of the shift, and that this was required by the CNA job description and the facility’s charting and documentation policy.
A resident with a lower leg fracture, hypertension, and dependence on staff for most ADLs lost health insurance coverage for skilled services after Medicare ended because the SSD did not follow through on assisting with a Medi-Cal application. During an IDT meeting, a family member requested help with Medi-Cal, and the SSD said the Business Office Manager would assist, but no effective follow-up occurred. This failure did not comply with the SSD job description and facility policy requiring social services staff to inform and educate about Medicare/Medi-Cal and financial assistance programs and to assist with related financial matters, resulting in the resident personally paying for skilled nursing services after Medicare coverage stopped.
A resident with severe cognitive impairment and legal blindness was physically pushed to the floor by another resident following a verbal altercation, resulting in a comminuted fracture of the hand. Staff and documentation confirmed the incident, and the facility's abuse prevention policy was not effectively implemented to prevent this event.
A resident with severe cognitive impairment and legal blindness alleged being pushed to the floor by another resident, an event witnessed and reported by an LVN. Despite facility policy and mandated reporting requirements, the incident was not reported to the state agency within the required timeframe, as the DON confirmed the delay in notification.
Surveyors observed that two resident shower rooms had temperatures above the facility's policy range, with one room at 82°F and another at 85°F. Both a CNA and an LVN reported the rooms felt hot and stuffy, and the Maintenance Supervisor confirmed ongoing AC issues affecting these areas.
A resident with diabetes and severe cognitive impairment experienced a critically high blood sugar level and required an additional dose of insulin. Facility staff failed to notify the resident's responsible party, did not document the event in the medical record, and did not complete the required SBAR Communication Form, contrary to facility policy.
During an outbreak of COVID-19 and influenza, multiple staff members, a medical provider, and a visitor failed to wear masks properly or at all, and a staff member did not perform hand hygiene before entering a room under enhanced barrier precautions. Despite clear facility policies and public health recommendations requiring mask use and hand hygiene, these protocols were not consistently followed or enforced, even in areas with residents who had active infections.
A resident with Parkinson's disease requested their medication, Pramipexole Dihydrochloride, be administered at 7:30 a.m. to manage tremors. Despite the request being acknowledged by the ADON during an IDT meeting, the facility continued to administer the medication at 9 a.m. until the time was changed days later. This failure to adhere to the resident's care plan potentially increased the resident's tremors.
A resident's medications were found unattended at their bedside, posing a risk due to the resident's severe cognitive impairment. An LVN confirmed the oversight, and the DON noted a similar past incident, highlighting a lapse in medication administration procedures.
Three residents in the facility were found with call lights that were not within reach, contrary to the facility's policy. One resident with hemiplegia had a call light stuck behind bed rails, another with a recent femur fracture could not find their call light, and a third with Alzheimer's had to go around the bed to access it. Staff interviews confirmed that call lights should be easily reachable to ensure timely assistance.
The facility failed to implement its Advance Directives Policy for four residents, resulting in missing or incomplete documentation in their medical records. This included missing Advance Directives and Acknowledgement Forms, which are crucial for ensuring residents' treatment preferences are respected. Interviews with staff confirmed these deficiencies and highlighted the importance of having these documents readily available.
Two residents in an LTC facility faced communication barriers due to ineffective implementation of the facility's language assistance policy. One resident, with heart failure and hypotension, preferred Turkish but was documented as preferring English, leading to communication issues with staff. Another resident, with dementia and hypertension, faced similar issues as the assigned CNA only spoke Spanish and relied on Google Translate without a communication board, contrary to policy.
The facility failed to implement a care plan for a resident with arterial ulcers by not offloading their heels, risking delayed wound healing. Additionally, the facility did not arrange transportation for another resident's medical appointment, resulting in a missed fistulagram. Both deficiencies were due to non-compliance with facility policies on repositioning and transportation.
A resident with Parkinson's disease and multiple pressure ulcers did not receive prescribed wound care for an unstageable pressure ulcer on the right midback for eight days. The treatment, which included cleansing with Normal Saline and applying a hydrocolloid dressing, was not administered due to a registry RN mistakenly discontinuing the order. The DON was unaware of the ulcer until it was inspected, revealing eschar and slough. The facility's policy required MD-ordered treatments, which were not followed, potentially delaying healing.
The facility failed to follow its Policy and Procedure for siderail use for two residents, leading to a deficiency. One resident had siderails installed without a doctor's order or consent, and no alternative interventions were attempted. Another resident had siderails as a mobility aid without a proper assessment or consideration of alternatives. Both residents were at risk for entrapment and injury due to these oversights.
The facility failed to follow its policies on psychotropic medication use for two residents. A resident received Lorazepam without a 14-day stop date, risking unnecessary use. Another resident was given Haloperidol without monitoring for target behavior or side effects, and the medication lacked a specific diagnosis. These actions did not comply with the facility's P&P, which requires stop dates and monitoring for psychotropic medications.
The facility failed to follow proper sanitation practices by allowing a staff member's personal lunch bag in the residents' refrigerator, risking cross-contamination. Additionally, a dome drying rack was found rusty and dirty, with no cleaning schedule in place, violating the facility's policies on equipment maintenance.
A resident's MDS was inaccurately coded, listing English as their preferred language instead of Turkish. This error was discovered when the resident, who has heart failure and hypotension, was observed speaking Turkish and unable to communicate in English. A CNA also struggled to communicate with the resident due to this language barrier. The MDS Coordinator admitted the mistake, acknowledging the need for accurate coding to ensure quality care.
A facility failed to create a baseline care plan for a resident with Parkinson's disease and other medical conditions within 48 hours of admission, as required by policy. The resident had severely impaired cognitive abilities and was dependent on staff for care. The Director of Nursing confirmed the oversight, acknowledging the risk of interrupted care due to the absence of a guiding care plan.
A facility failed to create an individualized care plan for a resident on Haloperidol, despite the resident's severe cognitive impairment and need for assistance with daily activities. Interviews with the IPN and DON confirmed the lack of a comprehensive care plan, contrary to the facility's policy requiring such plans within seven days of assessment.
A facility failed to monitor a resident's indwelling catheter for white sediments, a potential sign of UTI, as required by their care plan and facility policy. The resident, with spinal stenosis and hypertension, had a catheter with visible sediments, which were not reported or documented. The Infection Prevention Nurse and DON acknowledged the oversight, highlighting a lapse in monitoring and documentation.
The facility did not follow its policy to update the Daily Nursing Staff Posting (DNSP) within two hours of each shift's start. During a tour, it was found that the DNSP displayed was for the previous day. The Director of Staff Development acknowledged the oversight, stating that the night shift staff should have updated the DNSP. The facility's policy requires the DNSP to be updated and posted in a prominent location accessible to residents and visitors.
A resident with severe cognitive impairment and End Stage Renal Disease was allowed to sign a binding arbitration agreement without verifying their capacity to understand and make decisions. The Admission Coordinator did not check the resident's assessments, leading to a potential denial of the resident's rights.
A resident with MRSA was placed on Contact and Droplet Precautions, but an LVN failed to wear the required PPE while administering medication. The facility's policy required staff to wear a disposable gown and gloves to prevent infection spread, but this protocol was not followed, risking transmission of infectious microorganisms.
A resident's call light system was found to be non-functional, potentially delaying needed care. Despite the resident's capacity to understand and make decisions, and requiring assistance for personal hygiene and transfers, the call light had been non-functional for months. Staff confirmed the issue, and the Maintenance Supervisor acknowledged a communication failure and lack of documentation regarding the problem.
A facility's lack of specific guidelines in its Abuse Prevention Policy led to staff receiving and cashing checks from a resident, resulting in potential financial abuse. The resident, who was cognitively intact and had chronic health issues, signed checks to a CNA and an Activity Aide. Interviews confirmed that accepting money from residents was against policy, but the facility's policy lacked specific instructions on handling residents' money.
A facility failed to follow its policy for nail care by not ensuring a resident was referred to a podiatrist for toenail trimming. The resident, with conditions including gout and peripheral vascular disease, had long, overgrown toenails, raising concerns about infection risk. Despite the care plan's directive for daily foot inspections and podiatrist referrals, the necessary actions were not taken, as confirmed by staff observations and interviews.
A resident at high risk for falls, with conditions like muscle weakness and cognitive impairment, experienced an unwitnessed fall. Despite being confused and needing a sitter, the necessary supervision was not arranged by the LVNs. The MD was informed of the fall but not the resident's confusion, leading to inadequate supervision. The facility's policy on safety and supervision was not followed.
A resident with a history of gout and amputation-related pain was not reassessed for pain relief after receiving acetaminophen, contrary to facility policy. The resident later reported severe pain, and the LVN admitted to not following the protocol for reassessment. The DON confirmed the requirement for reassessment within one hour, highlighting a lapse in pain management procedures.
A CNA worked with an expired certification at a facility, as the DON failed to verify the certification status before scheduling. The facility's policy requires verification of licenses or certifications prior to employment and annually, which was not followed, potentially leading to inadequate resident care.
A resident with end-stage renal disease was transferred multiple times between rooms without documented notification to the resident or responsible party, as required by the facility's policy. Interviews with staff confirmed the lack of documentation and notification.
The facility failed to provide appropriate pressure ulcer care for a resident by not setting the LAL mattress correctly, not turning and repositioning the resident every two hours, and not providing timely incontinent care. These deficiencies were confirmed through observations, interviews, and record reviews.
Failure to Consistently Document Resident Meal Intake in Medical Record
Penalty
Summary
Facility staff failed to consistently document a resident’s meal intake in the medical record as required by facility policy and CNA job expectations. The resident was admitted with sepsis and diabetes mellitus and had intact cognition and decision-making capacity. According to the MDS, the resident required setup assistance with eating, supervision with oral hygiene, moderate assistance with toileting hygiene, showering/bathing, and personal hygiene, and maximal assistance with bed-to-chair transfers. Review of the Documentation Survey Report (DSR) for January 2025 showed CNAs documented the resident’s meal intake for 90 of 93 meals, and for February 1–15, 2025, CNAs documented meal intake for 40 of 45 meals, leaving multiple meals without recorded intake amounts. During interview, a CNA stated that CNAs were expected to document after each meal, including when a resident refused to eat, and that documentation should be completed before the end of the shift as a standard of practice. The CNA further stated that if there was no documentation on the DSR, staff would not know how much residents ate and that incomplete documentation would affect continuity of care. The DON similarly stated that without documentation, nursing staff would not know if the resident ate or refused the meal. The CNA job description required recording residents’ food and fluid intake, and the facility’s Charting and Documentation policy required that all services provided to residents be documented completely in the medical record, including date, time, and the signature and title of the person documenting. Despite these requirements, staff did not document the amount of meal intake for all meals during the review period for this resident.
Failure to Provide Social Services Assistance for Continuity of Health Insurance Coverage
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to assist a resident in maintaining mental and psychosocial well-being by ensuring continuity of health insurance coverage. The resident was admitted with a displaced bimalleolar fracture of the left lower leg and hypertension, and was dependent on staff for most ADLs. The resident had decision-making capacity. During an IDT meeting, the resident’s family member expressed interest in applying for Medi-Cal once Medicare coverage for skilled nursing services was ending, and the Social Services Director (SSD) stated they would refer the family member to the Business Office Manager (BOM) for assistance with the Medi-Cal application. The facility issued a Notice of Medicare Non-Coverage indicating the last day of Medicare coverage for skilled services. The SSD reported that they referred the family member to the BOM but did not follow up on the Medi-Cal application or otherwise assist the resident in applying for health insurance. The Assistant DON/Case Manager confirmed that the SSD told the family member during the IDT meeting that the BOM would assist with the Medi-Cal application. The DON reviewed the SSD’s job description, which required the SSD to provide information to residents and families about Medicare/Medi-Cal and other financial assistance programs and to refer them to appropriate social service agencies when needed, and stated the SSD did not follow this job description. The facility’s social services policy required provision of medically related social services, including informing and educating residents and families about health care options and assisting with financial matters. As a result of these failures, the resident had no health insurance after Medicare coverage ended and personally bore the cost of skilled nursing services received thereafter.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its abuse prevention policy. One resident, who had a history of schizoaffective disorder, legal blindness, and severely impaired cognition, was involved in a verbal exchange with another resident. During this interaction, the second resident pushed the first, causing the resident to fall to the floor. The incident was unwitnessed, but the injured resident reported being pushed, and this was corroborated by the other resident's admission and staff observations immediately following the event. Following the fall, the injured resident complained of pain and was assessed by staff, who noted significant discomfort and inability to get up. The resident was transferred to a general acute care hospital for evaluation, where imaging confirmed an acute comminuted fracture of the right 5th metacarpal. Staff interviews and documentation indicated that the resident who pushed the other had a disagreement and admitted to the physical act, with staff witnessing the aftermath and hearing the resident verbally acknowledge the push. The facility's policy and procedure on abuse prevention explicitly states that residents must be protected from abuse, including by other residents. Despite this, the incident occurred, resulting in physical harm to a resident with significant cognitive and physical vulnerabilities. The documentation and interviews confirm that the facility did not prevent the abusive act, leading to the resident's injury.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident with schizoaffective disorder and legal blindness. The resident, who had severely impaired cognition and required assistance with activities of daily living, reported being pushed to the floor by another resident. This allegation was corroborated by a Licensed Vocational Nurse (LVN), who witnessed the accused resident admitting to the act and observed the victim on the floor requesting help. The LVN notified the Administrator and Director of Nursing (DON) of the incident, and was instructed not to complete the abuse reporting form, as the Administrator and DON would handle the reporting. Despite facility policy requiring the reporting of abuse allegations within specified time frames, the incident was not reported to the California Department of Public Health (CDPH) within the required two-hour window. The DON confirmed that the facility failed to meet the mandated reporting timeline for this incident, as outlined in their Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy.
Failure to Maintain Safe and Comfortable Temperatures in Shower Rooms
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures in two resident shower rooms, as observed during a survey. On the third floor, the shower room thermostat read 82°F, and a CNA described the room as hot and stuffy. Similarly, the second-floor shower room was observed at 85°F, with an LVN also noting the room felt hot and stuffy. The Maintenance Supervisor confirmed that the air conditioning was malfunctioning and that high temperatures in the shower rooms had been noted, with repairs scheduled. Facility policy requires that resident areas, including bathing and shower rooms, maintain temperatures between 71°F and 81°F to ensure a safe, clean, and comfortable environment.
Failure to Notify Responsible Party and Document Change in Condition for Resident with Critically High Blood Sugar
Penalty
Summary
The facility failed to follow its policy and procedure regarding changes in a resident's condition or status by not informing a resident's responsible party when the resident experienced a critically high blood sugar level of 480 and required an additional dose of insulin. The responsible party was not notified of this significant change, despite the resident lacking the mental capacity to make medical decisions and being dependent on staff for most activities of daily living. The facility's policy required notification of the resident's representative in such circumstances. Additionally, the facility did not document the resident's blood sugar level of 480 in the medical record, nor did staff complete an SBAR Communication Form or a Change of Condition note as required by facility policy. The Director of Nursing confirmed that there was no documentation of the event, no SBAR form, and no notification to the responsible party in the resident's record. These omissions were identified during a review of the resident's records and interviews with facility staff.
Failure to Enforce Mask Use and Hand Hygiene During Infectious Disease Outbreak
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies and procedures, specifically regarding hand hygiene, standard precautions, enhanced barrier precautions, and transmission-based precautions. Multiple staff members, including the receptionist, certified nurse assistants, social services director, maintenance assistant, and a medical doctor, were observed not wearing masks properly, with masks pulled down below the nose and mouth while inside the facility. Additionally, a family member visiting a resident was not wearing a mask, and staff failed to educate or enforce mask-wearing for visitors, despite clear signage and policy requirements during an outbreak of COVID-19 and influenza. Direct observations revealed that staff and visitors were not consistently following mask protocols, even in areas housing residents with active COVID-19 and flu infections. For example, a family member was seen assisting a resident with severe cognitive impairment and multiple comorbidities without a mask, after being told by staff that mask-wearing was optional. Several staff members, including those with direct resident contact and those in administrative or support roles, admitted awareness of the outbreak and the need for proper mask use but did not comply. In one instance, a certified nurse assistant entered an enhanced barrier precautions room without performing hand hygiene, despite posted instructions and facility policy. The facility's own infection control policies, as well as recommendations from the Department of Public Health, required all staff and visitors to wear appropriate masks and perform hand hygiene, especially during an outbreak. Interviews with staff, including the infection prevention nurse and director of nursing, confirmed knowledge of these requirements and the importance of compliance. However, repeated failures to follow these protocols were observed and acknowledged by staff, contributing to the potential for transmission of infectious diseases within the facility.
Failure to Administer Medication at Resident's Requested Time
Penalty
Summary
The facility failed to protect the right of a resident to participate in their treatment plan by not administering Pramipexole Dihydrochloride at the resident's requested time. The resident, who was admitted with diagnoses including Parkinson's disease, had the capacity to understand and make decisions. Despite the resident's request to have the medication administered at 7:30 a.m. to help manage tremors associated with Parkinson's disease, the facility continued to administer the medication at 9 a.m. until the time was finally changed on January 27, 2025. The Assistant Director of Nursing (ADON) confirmed awareness of the resident's request during an interdisciplinary team meeting on January 21, 2025, but the change was not implemented until January 24, 2025. The facility's policy on resident rights, which includes the right to participate in care planning and treatment, was not adhered to in this instance. This oversight had the potential to increase the resident's tremors due to the delayed administration of the medication.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications for one of the sampled residents were kept locked in secure storage. During an observation, a medication cup containing three unidentified pills was found unattended at the bedside of a resident who was severely impaired in cognitive skills and required assistance for daily activities. The resident was unable to recall how long the medication had been there, indicating a lapse in proper medication administration and storage procedures. Licensed Vocational Nurse (LVN) 1 confirmed the unattended medications and identified LVN 2 as the responsible nurse, who was on a lunch break at the time. LVN 2 later acknowledged the oversight, admitting that they should have stayed with the resident to ensure the medications were taken. The Director of Nursing (DON) noted that this was not the first instance of such an oversight by LVN 2, emphasizing that staff are required to remain with residents during medication administration to ensure medications are swallowed and not left unattended.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, which is a violation of the facility's policy and procedure regarding the resident call system. Resident 14, who was admitted with hemiplegia and hemiparesis affecting the left side, was observed with a call light that was not accessible, as it was stuck at the back of the padded bed side rails. This resident was assessed as high risk for falls due to intermittent confusion and being chair-bound, and the care plan required the call light to be within reach to prevent falls and injuries. Resident 251, who had a recent fall resulting in a femur fracture and was at risk for falls, was also found with an inaccessible call light. The call light was placed at the upper right side of the bed, making it difficult for the resident to find and use it. The care plan for this resident specified that the call light should be within easy reach to ensure timely assistance from staff. Similarly, Resident 211, diagnosed with Alzheimer's disease and dementia, had a call light that was not within reach. The call light was rolled on the wall on the opposite side of the bed, requiring the resident to go around the bed to access it. The care plan for this resident indicated that the call light should be attached within reach to assist with activities of daily living and prevent falls. Interviews with staff confirmed the expectation that call lights should be placed within reach and on the strong side of the resident.
Failure to Implement Advance Directives Policy
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for four residents, leading to deficiencies in maintaining and documenting these critical legal documents. For Resident 47, the facility did not ensure that a copy of the Advance Directive was included in the resident's medical record or uploaded into the PointClickCare system. This oversight was confirmed during interviews with the Medical Records staff, the Social Services Director, and the Assistant Director of Nursing, all of whom acknowledged the necessity of having the Advance Directive readily available to guide care, especially in emergencies. Similarly, Resident 89's Advance Directive Acknowledgement Form was missing from the medical record. Interviews with the Infection Prevention Nurse, the Social Services Director, and the Director of Nursing revealed that the form was not initiated or included in the resident's chart, which is essential for understanding and respecting the resident's treatment preferences. The absence of this documentation could lead to care that does not align with the resident's wishes. For Resident 82, the facility did not complete the Advance Directive Acknowledgement Form upon admission, and the resident's family member reported that the purpose of an Advance Directive was not discussed. The Social Services Director confirmed that the form was blank, indicating a lack of education provided to the resident or responsible party. Additionally, Resident 92's Advance Directive was not found in the medical or electronic chart, despite the form indicating its existence. The Social Services Director and Director of Nursing both emphasized the importance of having this documentation to ensure the resident's wishes are known and respected.
Communication Barriers for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide an effective communication method for two non-English speaking residents, which had the potential to affect their quality of life and care. Resident 17, who was readmitted with heart failure and hypotension, was documented as having English as their preferred language in the Minimum Data Set (MDS), despite actually preferring Turkish. This discrepancy led to communication issues, as observed when a Certified Nursing Assistant (CNA) was unable to effectively communicate with Resident 17, relying solely on a communication board. The facility's policy indicated the use of bilingual staff, interpreters, and translation apps, but these were not effectively utilized in Resident 17's case. Similarly, Resident 92, who was admitted with dementia and hypertension, was also affected by communication barriers. Although Resident 92's MDS indicated English as the preferred language, a CNA assigned to provide one-on-one monitoring only spoke Spanish and used Google Translate to communicate. There was no communication board available at Resident 92's bedside, contrary to the facility's policy. This lack of effective communication tools posed a risk of unmet needs and potential emergencies, as noted by the Director of Nursing.
Failure to Implement Care Plans and Arrange Transportation
Penalty
Summary
The facility failed to implement the care plan for a resident with arterial ulcers on both feet. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with their heels lying directly on the mattress, contrary to the care plan's directive to offload the heels to prevent worsening of the wounds. Certified Nursing Assistant 2 acknowledged the need for offloading to prevent further complications, and the Director of Nursing confirmed that not following the care plan could delay wound healing. Another deficiency involved the facility's failure to provide transportation for a resident to a scheduled medical appointment. The resident, who had severe cognitive impairments and was dependent on staff, missed a fistulagram appointment due to the facility's oversight in arranging transportation. The resident's family member reported swelling around the fistula site, which was the reason for the appointment. The Director of Nursing and Licensed Vocational Nurse 2 confirmed that the transportation was not arranged, and there was no documentation of the appointment in the facility's records. The facility's policies and procedures for repositioning and transportation were not followed, contributing to these deficiencies. The repositioning policy required staff to adhere to the care plan for specific positioning needs, while the transportation policy mandated assistance in arranging transportation for appointments. Both policies were not implemented, leading to potential risks for the residents involved.
Failure to Provide Ordered Wound Care for Unstageable Pressure Ulcer
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the Medical Doctor for an unstageable pressure ulcer on the right midback of a resident, identified as Resident 82. This resident was readmitted to the facility with multiple diagnoses, including Parkinson's disease and various pressure ulcers. The care plan for potential skin breakdown required treatment initiation as ordered by the MD. However, from 10/30/2024 to 11/7/2024, the resident did not receive the prescribed treatment for the unstageable pressure ulcer, which involved cleansing with Normal Saline and applying a hydrocolloid dressing every three days. Treatment Nurse 1 confirmed the absence of treatment during this period and noted that the wound could worsen without proper care. The Director of Nursing (DON) revealed that the treatment order was mistakenly discontinued by a registry RN on 10/31/2024, and all admission orders were reentered, leading to the oversight. The DON was unaware of the unstageable pressure ulcer until the issue was raised. Upon inspection, the ulcer was found to have eschar and slough, with measurements indicating a lack of depth. The facility's policy required MD-ordered wound treatments, which were not followed, potentially delaying wound healing. The DON acknowledged that missing treatments could worsen the wound.
Failure to Follow Siderail Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of siderails for two residents, leading to a deficiency. For Resident 26, the facility did not obtain a doctor's order or consent for the use of siderails, nor did it attempt appropriate alternative interventions before installing the siderails. Resident 26, who had diagnoses including osteomyelitis, peripheral vascular disease, and dementia, was observed with 1/4 siderails up on both sides of the bed without documented evidence of necessary assessments or consent. The Assistant Director of Nursing confirmed the lack of documentation and stated that siderails should not have been used without a physician's order and consent. Similarly, for Resident 28, the facility did not conduct a siderail use assessment or attempt alternative interventions before installing siderails. Resident 28, who had multiple rib fractures, hemiplegia, and hemiparesis, was also observed with 1/4 siderails up on both sides of the bed. Despite having an order for siderails as a mobility aid, there was no documented evidence of an assessment or consideration of less restrictive alternatives. The Assistant Director of Nursing acknowledged the absence of documentation for the necessary assessments and interventions, which placed both residents at risk for entrapment and injury.
Failure to Implement Psychotropic Medication Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the use of psychotropic and antipsychotic medications for two residents. For Resident 82, the facility did not ensure that the PRN order for Lorazepam, prescribed for restlessness and agitation, included a stop date of 14 days. This oversight was acknowledged by both a Registered Nurse and the Director of Nursing, who confirmed that the absence of a stop date could lead to unnecessary medication use. For Resident 96, the facility did not monitor the target behavior and adverse side effects associated with the use of Haloperidol, an antipsychotic medication. The medication order lacked a specific diagnosis, and there was no documentation of monitoring for agitation or side effects since the resident's admission. Both the Infection Prevention Nurse and the Director of Nursing confirmed the lack of monitoring and documentation, emphasizing the need for specific diagnoses and regular monitoring to assess the medication's effectiveness. The facility's P&P requires that PRN psychotropic medications have a stop date and that any continuation beyond 14 days must be justified by the practitioner. Additionally, the P&P mandates that staff observe, document, and report the effectiveness and side effects of antipsychotic medications to the attending physician. These requirements were not met for Residents 82 and 96, leading to the potential for unnecessary medication use and adverse consequences.
Improper Food Handling and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a survey. A staff member's personal lunch bag was found inside the walk-in refrigerator designated for storing residents' food. This action was acknowledged by the Dietary Aide (DA 3) who admitted that personal belongings should not be placed in the residents' refrigerator due to the risk of cross-contamination, which could lead to food-borne illnesses among residents. Additionally, the facility did not maintain cleanliness standards for kitchen equipment. The dome drying rack was found to be rusty and dirty, which was confirmed by both DA 3 and the Dietary Supervisor (DS). The DS admitted that there was no cleaning schedule for the dome drying rack, and it should be free from rust and debris to ensure health and safety. The facility's policies indicated that personal items should be stored separately from food and that effective maintenance management is essential for sanitation, but these were not followed.
Inaccurate MDS Coding for Language Preference
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident's language preference, which is a federally mandated resident assessment tool. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including heart failure and hypotension. The resident's quarterly MDS inaccurately indicated that their preferred language was English, despite the resident's actual preference being Turkish. This discrepancy was discovered during an observation and interview where the resident was found speaking Turkish over the phone and was unable to communicate effectively in English. Further observations revealed that a Certified Nursing Assistant (CNA) was unable to communicate with the resident due to the language barrier, confirming the resident's limited English proficiency. The MDS Coordinator acknowledged the error in coding the resident's preferred language and admitted that the MDS should have been accurately coded to reflect the resident's current assessment and preference. The facility's policy and procedure for resident assessment, revised in 2019, mandates that the resident assessment coordinator ensures timely and appropriate assessments, which was not adhered to in this case.
Failure to Create Baseline Care Plan for Resident
Penalty
Summary
The facility failed to create a baseline care plan for a resident upon their admission, which was necessary to address the resident's immediate care needs within 48 hours. The resident, who was admitted and readmitted with conditions including Parkinson's disease, communication deficits, chronic non-pressure ulcers, and a stage three pressure ulcer, had severely impaired cognitive abilities and was dependent on staff for various activities. Despite these needs, the baseline care plan was not completed, as confirmed by the Director of Nursing during a review and interview. The absence of a baseline care plan was acknowledged by the Director of Nursing, who stated that it should have been completed to guide staff in providing appropriate care based on the resident's immediate needs. The facility's policy, revised in December 2016, mandates the development of a baseline care plan within 48 hours of admission to ensure the resident's immediate care needs are met. The failure to adhere to this policy placed the resident at risk of an interruption in care.
Failure to Develop Individualized Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident who was prescribed Haloperidol, an antipsychotic medication. The resident, who was admitted with diagnoses of depression and dementia, had severely impaired cognition and required significant assistance with daily activities. Despite these needs, there was no clinical documentation indicating that a care plan was initiated and implemented to manage the use of Haloperidol, as required by the facility's policy and procedure. Interviews with the facility's Infection Prevention Nurse and Director of Nursing confirmed the absence of a comprehensive care plan tailored to the resident's specific needs for the use of Haloperidol. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of completing the required comprehensive assessment, but this was not done, potentially affecting the resident's treatment and care related to the medication.
Failure to Monitor Catheter for Signs of Infection
Penalty
Summary
The facility failed to properly assess and monitor a resident's indwelling catheter for the presence of white sediments, which could indicate a urinary tract infection (UTI). The resident, who was admitted with spinal stenosis and essential hypertension, had an indwelling catheter as part of their care plan. The care plan required staff to monitor and report any signs of UTI, such as changes in urine color, clarity, and odor, to the physician. However, during an observation, it was noted that the resident's catheter tubing and drainage bag contained white sediments, which were not reported or documented as required by the facility's policy. The Infection Prevention Nurse acknowledged the presence of white sediments and stated that it could be a sign of infection, requiring the tubing to be flushed and the physician to be notified. The Director of Nursing confirmed that the resident's catheter should have been monitored every eight hours for signs of infection, but there was no documentation of such monitoring. The facility's policy on catheter care emphasized the need to observe and report signs of urinary tract infection immediately, but this was not adhered to in the case of the resident.
Failure to Update Daily Nursing Staff Posting
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the posting of actual nursing hours within two hours of the start of each shift. On a tour conducted on 11/7/24, it was observed that the nursing hours posted in the facility's entrance lobby were for the previous day, 11/6/24, instead of the current date. During an interview, the Director of Staff Development (DSD) acknowledged that the Daily Nursing Staff Posting (DNSP) should have been updated to reflect 11/7/24 and admitted that the facility's policy was not followed. The DSD explained that the night shift staff were responsible for updating the DNSP, but this was not done. A review of the facility's P&P, revised in July 2016, confirmed that the DNSP should be updated within two hours of the beginning of each shift and posted in a prominent location accessible to residents and visitors.
Failure to Verify Resident Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 301, had the capacity to understand and make decisions before signing a Resident-Facility Arbitration Agreement (AA). Resident 301, who was admitted with diagnoses including pneumonia and End Stage Renal Disease, was assessed to have severely impaired cognitive skills for daily decision-making. The Minimum Data Set (MDS) indicated that the resident sometimes understood others and was sometimes self-understood, but was dependent on others for personal hygiene and transfers. Furthermore, the History and Physical (H&P) report confirmed that Resident 301 did not have the capacity to understand and make decisions. Despite these assessments, the Admission Coordinator allowed Resident 301 to sign the AA without verifying the resident's capacity to do so. The Admission Coordinator admitted to not checking the MDS assessment and H&P before allowing the resident to sign the legal document. An observation conducted later showed that Resident 301 was unable to communicate when asked questions, further indicating the resident's lack of capacity to make informed decisions. This oversight had the potential to result in the resident being unable to make an informed decision and having their rights denied.
Failure to Follow Isolation Precautions for MRSA-Infected Resident
Penalty
Summary
The facility failed to adhere to its Policy and Procedures regarding Isolation - Categories of Transmission-Based Precautions for a resident diagnosed with methicillin-resistant staphylococcus aureus (MRSA) infection. The resident, who had moderately impaired cognition and required assistance with daily activities, was placed on Contact and Droplet Precautions. However, during an observation, a Licensed Vocational Nurse (LVN) was seen administering medication to the resident without wearing the required personal protective equipment (PPE), such as gloves and a gown, which was necessary to prevent the spread of infection. Interviews with the LVN, the facility's Infection Preventionist Nurse, and the Director of Nursing confirmed that the staff was aware of the need to wear PPE when entering the resident's room. The facility's policy, dated 10/2018, clearly stated that staff and visitors should wear a disposable gown upon entering the room and remove it before leaving to avoid contamination. Despite this, the LVN did not follow the protocol, which had the potential to transmit infectious microorganisms and increase the risk of infection for other residents in the facility.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure that a functioning call light system was available for a resident, identified as Resident 17, which could potentially delay the provision of needed care and services. Resident 17, who was readmitted to the facility with diagnoses including heart failure and hypotension, had the capacity to understand and make decisions, and required partial assistance for personal hygiene and transfers. During an observation, it was noted that Resident 17's call light was not functioning, and the resident's roommate confirmed that the call light had been non-functional for a couple of months. Both a Certified Nursing Assistant and a Licensed Vocational Nurse verified that the call light was not working, emphasizing the importance of a functioning call light for timely response to the resident's needs. The Maintenance Supervisor indicated that there was a Maintenance Log for reporting equipment issues, but no issue regarding Resident 17's call light was documented. The Maintenance Supervisor also noted a lack of a checklist or system to ensure all equipment was checked, and acknowledged a communication failure between the nursing staff and the maintenance department. The facility's policy stated that residents should have a means to call staff for assistance from their bed and other areas, but this was not adhered to in the case of Resident 17.
Deficiency in Abuse Prevention Policy Regarding Resident's Money Handling
Penalty
Summary
The facility failed to include specific guidelines in its Abuse Prevention Policy and Procedure on how staff should handle residents' property, particularly money, to prevent financial abuse. This deficiency was identified during a review of the facility's policies and procedures, which lacked detailed instructions on managing residents' financial matters. The absence of such guidelines contributed to a situation where staff members received and cashed personal checks from a resident, leading to potential financial abuse. The deficiency involved a resident who was cognitively intact and had a history of chronic obstructive pulmonary disease, chronic pain syndrome, and major depressive disorder. The resident's family member reported that the resident had signed checks to facility staff, which was inappropriate. Photocopies of the checks showed significant amounts of money were given to a Certified Nursing Assistant and an Activity Aide, who were no longer employed at the facility, except for the CNA who was suspended pending investigation. Interviews with various staff members, including Licensed Vocational Nurses and the Social Services Director, confirmed that it was against facility policy for staff to accept money or gifts from residents. The facility's Administrator acknowledged that the CNA involved felt uncomfortable taking the money and recognized the act as financial abuse, despite the resident's alleged consent. The facility's existing Abuse Prevention Policy did not provide specific actions for handling residents' money, which contributed to the deficiency.
Failure to Ensure Timely Podiatry Referral for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the care of fingernails and toenails for one resident, identified as Resident 4. This deficiency was observed when the facility did not ensure that the assigned Licensed Vocational Nurses (LVNs) notified the Social Services Director (SSD) to refer Resident 4 to a podiatrist for the cleaning and trimming of long and overgrown toenails. Resident 4, who was admitted with diagnoses including gout, infection of an amputation stump, and peripheral vascular disease, was dependent on assistance for various activities of daily living, including lower body dressing and putting on/taking off footwear. The resident's care plan, which was untitled, indicated that staff should inspect the resident's feet daily and refer them to a podiatrist for foot care needs, including toenail trimming. During an observation and interview, it was noted that Resident 4's left toenails were long, overgrown, and yellow, and the resident expressed concern about the risk of infection. LVN 7 acknowledged the condition of the toenails and stated the need to inform the SSD to schedule a podiatrist appointment. The Director of Nursing (DON) confirmed the importance of keeping toenails clean and trimmed to prevent infection and injury, and stated that CNAs were responsible for inspecting toenails and informing the LVN and SSD when trimming was needed. The facility's policy, revised in 2018, emphasized the importance of regular nail care to prevent infections and injuries, particularly for diabetic residents or those with circulatory impairments, whose nails should not be trimmed by staff unless permitted otherwise.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for falls. The resident, who had a history of falls and was diagnosed with conditions such as generalized muscle weakness, type II diabetes mellitus, and encephalopathy, experienced an unwitnessed fall. Despite being assessed as confused and needing a sitter, the necessary order for one-to-one supervision was not obtained by the Licensed Vocational Nurses (LVNs) involved. The resident's care plan indicated several risk factors for falls, including cognitive impairment and the use of cardiac and anti-hypertensive medications. After the fall, the resident was found to be confused and experiencing hallucinations, yet the LVNs did not update the care plan or complete the necessary documentation to secure a sitter. The Medical Doctor (MD) was informed of the fall but not of the resident's confusion or the need for a sitter, which could have prevented further incidents. Interviews with the nursing staff revealed a lack of communication and understanding of the process for obtaining a sitter. The Director of Nursing confirmed that the LVNs should have obtained a physician's order for a sitter following the fall. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision, which was not adhered to in this case.
Failure to Reassess Pain Management
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) reassessed the pain level of a resident after administering acetaminophen for mild pain, as per the facility's policy and procedure. The resident, who had a history of gout, infection of an amputation stump, and peripheral vascular disease, was admitted with acute pain related to amputation. The care plan for the resident included goals for adequate pain relief and interventions such as administering analgesia and monitoring its effectiveness. On the day of the incident, the resident complained of mild pain and was given acetaminophen. However, the LVN did not reassess the resident's pain level within the required 30 minutes to one hour after administration. Later, the resident reported experiencing severe pain, rated 9 out of 10, and stated that no one had checked if the pain medication was effective. The LVN acknowledged the failure to reassess the pain level and recognized that the resident's pain could worsen without proper evaluation. The Director of Nursing confirmed that the facility's process required reassessment of pain medication effectiveness within one hour of administration. The facility's policy indicated that nursing staff should assess pain whenever there is a significant change in condition or worsening of existing pain. The failure to follow this protocol resulted in unrelieved pain for the resident and placed them at risk for psychosocial harm.
Expired CNA Certification Leads to Deficiency
Penalty
Summary
The facility failed to ensure that one of its certified nursing assistants (CNA 1) had an active CNA certification while employed and performing resident care. This deficiency was identified during an interview and record review, where it was revealed that CNA 1 worked on multiple dates with an expired CNA certificate. The Director of Nursing (DON) acknowledged this oversight, admitting that they did not verify the certification status before scheduling CNA 1 for work. The facility's policy and procedure, titled 'Credentialing of Nursing Service Personnel,' requires nursing personnel to present verification of their license or certification prior to employment and annually by February 1st. However, the DON admitted to failing to adhere to this policy, resulting in CNA 1 working without a valid certification. This lapse in following established procedures had the potential to lead to inadequate and unsafe resident care due to a knowledge, training, and certification deficit.
Failure to Notify Resident and Responsible Party of Room Changes
Penalty
Summary
The facility failed to notify a resident and the resident's responsible party prior to room or bed changes, as required by the facility's policy and procedure. The resident, who had diagnoses including difficulty walking and end-stage renal disease, was transferred multiple times between rooms without documented evidence of notification. Interviews with the Infection Preventionist Nurse, Social Services Director, and Director of Nursing confirmed the lack of documentation and notification for these room changes. The resident's medical records indicated that the resident had the capacity to understand and make decisions, although later assessments showed moderately impaired cognition. Despite this, the facility's policy required advance written notice of room changes, which was not provided. The resident expressed that he did not remember being notified about the room changes and did not want to be moved. The facility's policy clearly stated that all parties involved in a room change should receive advance written notice, including the reasons for the change, but this procedure was not followed.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate care and necessary services to prevent pressure ulcers and promote healing. Specifically, the licensed nurses did not set Resident 3's low air loss (LAL) mattress settings accurately based on the resident's weight or comfort. The mattress was observed to be set at 240 lbs, while Resident 3's actual weight was 119 lbs. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an interview and observation. The Director of Nursing (DON) acknowledged that setting the mattress at the correct weight is crucial for wound healing. Additionally, the nursing staff did not turn and reposition Resident 3 every two hours as indicated in the resident's care plan. Resident 3 reported that she had not been turned since the morning, and this was confirmed during an observation and interview. The care plan specifically required turning and repositioning every two hours to prevent further skin breakdown. The facility also failed to provide timely incontinent care to Resident 3 after a bowel movement. Multiple observations showed that Resident 3 had to wait for extended periods before receiving incontinent care, resulting in soiled conditions that could exacerbate her pressure ulcers. The DON and other staff members acknowledged the importance of timely incontinent care and proper communication among staff to ensure that residents' needs are promptly addressed.
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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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