Glendora Grand, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 805 W. Arrow Hwy., Glendora, California 91740
- CMS Provider Number
- 056079
- Inspections on file
- 47
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Glendora Grand, Inc during CMS and state inspections, most recent first.
A resident with a history of stroke, mobility impairment, and cognitive deficits did not receive physician-ordered ambulation five times per week as part of a restorative nursing program. Despite orders and facility policy, documentation and staff interviews confirmed that the ambulation was not provided, resulting in decreased mobility for the resident.
A CNA and an LVN documented inaccurate information in a resident's medical record regarding the level of assistance needed for bed mobility and transfers. Both staff members later acknowledged the documentation was incorrect, as the resident required only limited assistance rather than being fully dependent. The resident had a history of stroke, difficulty walking, and traumatic brain disorder, and was assessed as moderately cognitively impaired.
A resident with a history of stroke and traumatic brain disorder was discharged without adequate arrangements for enteral feeding formula and without assessment or training of the caregiver in safe transfer techniques. Facility staff did not verify the caregiver's ability to provide necessary care, and essential supplies were not provided at discharge.
Four residents with cognitive and/or physical impairments were found without accessible call lights, despite facility policy and care plans requiring call lights to be within reach. Observations showed call lights placed out of reach—such as behind headboards or on the non-functional side—while staff interviews confirmed the importance of accessibility and acknowledged the lapses.
Ten residents reported not knowing where to find the facility's latest survey results or how deficiencies had been corrected. Interviews with the DON and Administrator revealed that the responsibility for posting survey results was with the Administrator, who was unaware of the residents' lack of knowledge. Facility policy states residents have the right to access survey results and plans of correction, but this information was not effectively communicated.
Two residents with indwelling Foley catheters and severe cognitive impairment were not properly assessed or monitored for sediments, hematuria, or cloudy urine as ordered by physicians and outlined in care plans. Nursing staff failed to document required shift assessments, and in one case, visible white sediments were present in the catheter tubing without evidence of timely intervention. Facility policy required such monitoring and reporting, but these procedures were not followed.
Licensed staff did not follow physician orders for a resident's gastrostomy tube feeding rate, administering a higher rate than prescribed, and failed to implement or communicate an RD's recommendation for multivitamins and minerals for another resident. Both deficiencies involved residents with significant care needs and were not in accordance with facility policy or physician directives.
Three residents receiving oxygen therapy did not receive care in accordance with professional standards: one resident lacked a required oxygen concentrator in the room for PRN use, another had nasal cannula tubing improperly stored when not in use, and a third was administered oxygen without a physician's order or required cautionary signage. These deficiencies were confirmed by staff and were not in line with facility policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors observed that six large trash bins in multiple facility buildings were left uncovered and overfilled, contrary to facility policy. Staff interviews, including with the KM, MS, DON, and IPN, confirmed that trash bin lids should remain closed at all times for infection control and sanitation, but space limitations and overfilling led to open lids.
A nurse failed to perform required hand hygiene during medication administration for a resident with neurological conditions, and another resident with a G-tube had a feeding valve that was left uncapped and visibly dirty, contrary to facility policy. Staff interviews and policy reviews confirmed that proper infection control procedures were not followed, placing both residents at risk for infection.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, as required by regulation.
A deficiency was cited for not ensuring a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and to formulate an advance directive. The report does not provide further details about the specific circumstances or individuals involved.
A resident with impaired cognition and incontinence was exposed when an RN failed to close the privacy curtain while checking a foley catheter, leaving the resident's upper legs visible to others. Both the RN and DON confirmed that privacy should have been maintained according to facility policy.
A registered nurse was hired before the required OIG background check was completed, as facility staff followed a practice of conducting background checks after hiring, contrary to facility policy. Interviews with the DSD, DON, and ADM confirmed that background checks should be completed prior to employment to screen for abuse or criminal history.
Two residents with dementia and schizophrenia experienced significant behavioral changes resulting in psychiatric hospitalization and readmission, but the facility did not complete required MDS comprehensive assessments within 14 days as mandated. Documentation and staff interviews confirmed these were significant changes in condition, yet the assessments were not updated or reported to CMS in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions was observed with unkempt hair and dirty feet, despite a care plan requiring assistance with ADLs and scheduled showers. Staff confirmed the resident's disheveled state, and facility policy required regular hygiene support, but the necessary care was not provided.
A resident with cognitive impairment and behavioral risks was found with unsupervised cigarettes in their room, despite facility policy requiring nursing staff to control smoking materials for residents needing supervision. Staff interviews revealed inconsistent enforcement of the smoking policy, resulting in a potential fire hazard.
A resident with severe cognitive impairment and behavioral risks was not provided with the required 1:1 supervision as outlined in their care plan. The assigned staff left the resident unsupervised in their room, resulting in a fall from a wheelchair and injuries that required emergency medical attention. Facility records and staff interviews confirmed the supervision requirement was known but not followed at the time of the incident.
Two residents with diabetes had care plans that included blood glucose monitoring and specific glycemic targets, but there were no corresponding physician orders for routine bedside blood sugar checks. Nursing staff and the DON confirmed the care plans' requirements, yet the lack of physician orders meant the interventions could not be properly implemented.
A resident with a history of suicidal ideation was readmitted from a hospital without proper assessment, documentation, or care planning for their mental health needs. The Social Services Director did not record the resident's recent suicidal thoughts or notify nursing staff, and no care plan or monitoring was initiated, despite facility policy requiring these actions for residents with such risk factors.
A resident with cognitive impairment developed an infected wound on the wrist due to embedded bracelets after nursing staff failed to perform a full body skin assessment, despite noticing a foul odor. The wound was only discovered when EMS arrived and removed the bracelets, revealing the infection. Facility policy requiring skin assessments after changes in condition was not followed by the LVN and RN.
A resident with intellectual disabilities and limited mobility did not receive daily body checks as required by their care plan and facility policy. Staff failed to identify the source of a foul odor, and a full body assessment was not performed, resulting in an infected wound on the resident's wrist caused by an embedded rubber band.
A resident with intellectual disabilities and mobility limitations developed an infected wound on the left wrist that went unnoticed and untreated after an LVN and RN failed to perform a full body assessment or escalate concerns when a persistent foul odor was detected. Facility policy required such assessments and reporting, but these were not followed, resulting in the wound only being discovered after hospital transfer.
A resident with Parkinson's and dementia repeatedly refused podiatric care, leading to osteomyelitis and hospitalization. The facility failed to notify the resident's physician or family and did not implement alternative interventions as per the care plan. Staff were unaware of the ongoing refusals, and a change in condition was not documented promptly, contributing to the resident's preventable condition.
A resident with Parkinson's and dementia repeatedly refused podiatric treatment, leading to hospitalization for osteomyelitis. The facility failed to notify the physician and family as required by policy, despite the resident's inability to make medical decisions and documented refusals throughout the year.
A resident with Parkinson's and dementia repeatedly refused podiatric treatment, but the facility failed to notify the physician or implement alternative interventions as required by the care plan. Despite documented refusals over a year, the Social Service Director and DON were unaware, and no actions were taken to address the refusals, violating the facility's policy for comprehensive care plans.
A resident with Parkinson's disease and dementia repeatedly refused podiatry care, and the facility failed to communicate this to the resident's physician and family. The care plan addressing refusal of care was not implemented, and licensed nurses did not inform the physician about the resident's toenail condition during weekly assessments. This led to the resident being hospitalized for right toe osteomyelitis.
A resident with schizophrenia and anxiety disorder, assessed as at risk for elopement, was transferred from a secured to an unsecured unit. The resident went missing after being last seen in the hallway and was not found despite extensive searches. The unsecured unit had multiple exit doors, some of which were not alarmed or locked, allowing the resident to potentially exit undetected.
A resident with a history of wandering and confusion left a secured unit unsupervised due to a janitor unlocking the door, allowing the resident to leave with a rideshare driver without a staff chaperone. The resident, who was scheduled for an ophthalmologist appointment, did not check in and was reported missing. The facility failed to follow its policy requiring staff accompaniment for residents at risk of elopement.
The facility failed to provide adequate pressure ulcer care for three residents, leading to the development and worsening of ulcers. A resident at risk for ulcers did not receive prescribed treatments, resulting in new and worsening ulcers. Another resident's low air loss mattress was incorrectly set, risking skin breakdown. A third resident did not receive consistent treatment for a stage 4 ulcer, potentially delaying healing.
The facility failed to ensure call lights were within reach for two residents, both at high risk for falls due to conditions like dementia and muscle weakness. Observations revealed that the call lights were inaccessible, contrary to the care plans and facility policy. Staff interviews confirmed the oversight, indicating a lapse in maintaining safety and accessibility for residents needing assistance.
The facility failed to implement its smoking policy for a resident identified as an unsafe smoker, who was found with cigarettes despite requiring supervision. Additionally, the facility did not ensure proper positioning for another resident with dysphagia during meals, as observed when the resident's neck was hyperextended contrary to physician orders. These deficiencies highlight lapses in policy adherence and communication among staff.
The facility failed to prevent UTIs in two residents with Foley catheters. One resident's urine output was not monitored for UTI signs, and the physician was not notified of changes. Another resident's catheter bag was improperly positioned on the floor, risking contamination. Staff acknowledged these oversights, which contradicted the facility's catheter care policy.
The facility failed to follow its respiratory care procedures for two residents. A resident with respiratory failure had a suction canister with sputum that was not replaced, risking inaccurate monitoring. Another resident with COPD had an undated humidifier bottle, risking reduced oxygen therapy effectiveness. Both instances reflect non-compliance with facility policies.
The facility failed to implement gradual dose reductions and monitor psychotropic medication use for three residents. A resident on Risperdal and Lexapro did not have a GDR attempted since the medications were ordered, and another resident on Lexapro did not have a GDR attempted despite limited social interaction not being an adequate indication for continued use. Additionally, a resident's target behavior and side effects for Ativan use were not monitored every shift as required.
The facility failed to ensure kitchen staff were trained and evaluated for competency in following guidelines for chlorine paper testing and sanitizer use. Staff did not adhere to correct procedures, leading to potential unsanitized dishware and ineffective surface sanitization. There was no competency evaluation for key staff, and not all attended training sessions.
The facility's kitchens were found to have multiple sanitation and food safety deficiencies, including dust and dirt buildup in freezers and refrigerators, rusted storage racks, improper storage of dented cans, and inadequate cleaning of equipment. Staff practices, such as wearing inappropriate jewelry and not following sanitizer guidelines, further contributed to the potential health risks for residents.
The facility failed to properly dispose of garbage and refuse, with overflowing and uncovered trash bins observed outside Kitchens 1 and 3. The Dietary Area Manager noted the health risks posed by exposed trash, while the Environmental Services Manager confirmed that trash pickup was insufficient to prevent overflow. Facility policies and the Food Code 2017 require covered receptacles to prevent contamination.
The facility failed to provide Speech Therapy (ST) evaluations as ordered for three residents with swallowing, communication, and cognitive concerns. Despite physician's orders, these residents only received Therapy Screens, which are not comprehensive evaluations. The Director of Rehabilitation and the Speech Therapist confirmed the oversight, highlighting the importance of following physician's orders to ensure residents receive necessary care.
The facility did not ensure its arbitration agreements included a venue selection convenient for both the facility and residents, affecting three residents with cognitive impairments. The facility's policy lacked this regulatory requirement, acknowledged by the administrator.
A facility failed to document and implement hospice services for a resident with severe cognitive impairment. The Hospice Health Aide did not document care provided, and the Licensed Vocational Nurse visits were not accurately recorded or completed according to the physician's orders. The facility's policy required proper communication and documentation of hospice interventions, which was not adhered to.
The facility failed to maintain three laundry dryers in a safe and sanitary condition, with thick patches of brown/black material observed on the dryers' drums. This posed a risk of cross-contamination and potential fire hazard due to obstructed ventilation. The Environmental Service Manager acknowledged the issue, which was contrary to the facility's maintenance policies requiring daily inspection and cleaning.
The facility failed to properly dispose of soiled gauze, adhere to PPE protocols for Contact Isolation Precautions, and follow COVID-19 guidance in yellow zones. A soiled gauze was left in a resident's room, an RNA did not change PPE after exiting a resident's room, and staff did not wear full PPE, including face shields, in yellow zones. These actions were confirmed through observations and interviews with staff.
A resident's room in an LTC facility was found to have peeling paint and a black stain on the floor, which were not reported to maintenance until a surveyor's visit. The resident had moderately impaired cognition and lacked decision-making capacity. The facility's policy required staff to report such issues, but the Director of Maintenance was unaware of the problem until informed by the DON during the survey.
A resident with anxiety and dementia, prescribed Ativan, did not have an individualized care plan developed by the LTC facility. Despite the resident's impaired cognition and need for assistance with daily activities, the facility failed to create a care plan addressing the use of Ativan, as confirmed by the RN Supervisor and DON. This was contrary to the facility's policy requiring a person-centered care plan within seven days of the MDS assessment.
A resident with a history of diabetes and renal disease had a care plan for hip scratches that was not updated when the condition worsened. Despite facility policy requiring care plan revisions after assessments, the plan was not revised when the scratches became macerated and white, potentially delaying treatment. The DON acknowledged the oversight.
A resident was nearly given contaminated medications after an LVN dropped pills on the floor and returned them to the medication cup. The incident was stopped by a surveyor. The resident had heart failure and a malignant kidney tumor, requiring partial assistance. The facility's policy mandates discarding dropped medications to prevent contamination.
A resident with chronic conditions and impaired cognition was found to have unclean, yellow, and long toenails, indicating a failure in timely foot care. Despite being seen by a podiatrist in May, the resident's toenails were not trimmed as needed, and the Social Services Designee was not informed until late July. The facility's policy required nail care to be provided as needed, but this was not adhered to, leading to a deficiency in care.
Failure to Implement Physician-Ordered Ambulation for Resident
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve a resident's range of motion and mobility by not implementing a physician's order for ambulation. The resident, who had a history of cerebral infarction, difficulty walking, and traumatic brain disorder, was admitted and later readmitted to the facility. Assessment records indicated the resident required supervision or assistance for daily activities and had moderate cognitive impairment. A physician's order was in place for a Restorative Nursing Assistant (RNA) to ambulate the resident five times a week using a front wheel walker, as part of a restorative nursing program following discharge from rehabilitation services. Despite the physician's order, record reviews and staff interviews confirmed that the resident did not receive the prescribed ambulation in the hallway five times a week. Documentation for August, September, and October did not show evidence that the ambulation was provided as ordered. The RNA confirmed that the ambulation was not performed as required. The facility's policy stated that restorative services should be provided to maintain or improve residents' abilities, but this was not followed for the resident in question, resulting in a decrease in the resident's ability to walk.
Inaccurate Documentation of Resident Assistance Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of two sampled residents when both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) documented inaccurate information regarding the resident's level of assistance needed for bed mobility and transfers. Specifically, the CNA documented that the resident was dependent on staff for transfers, mobility, getting up in a chair, and ambulation on several dates, but later admitted that this was inaccurate and that the resident actually required only limited assistance for these activities. Similarly, the LVN documented in the resident's discharge summary that the resident was dependent on staff for bed mobility and transfers, but also acknowledged this was inaccurate. The resident involved had a history of cerebral infarction, difficulty walking, and a traumatic brain disorder, and was assessed as moderately impaired in cognitive skills. The Minimum Data Set indicated the resident required supervision or touch assistance for activities such as dressing, bathing, toileting, and personal hygiene. The facility's policy required that all medical records be complete and accurate to reflect the care and services provided, but this was not followed, resulting in incomplete and inaccurate documentation in the resident's medical record.
Failure to Ensure Safe Discharge Preparation and Caregiver Training
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge of a resident who required enteral feeding and assistance with transfers. Specifically, the facility did not arrange for the resident's enteral feeding formula to be readily available upon discharge, providing only a one- to two-day supply and leaving the caregiver to obtain additional formula independently. Additionally, the facility did not assess or verify the caregiver's ability to safely transfer and care for the resident, nor did it provide training or instruction on safe transfer techniques. The resident's caregiver reported not being aware of the resident's inability to get out of bed without assistance and did not receive training or incontinence supplies upon discharge. Interviews with facility staff confirmed that there was no assessment of the caregiver's competence in transferring the resident, and discharge instructions did not include necessary training or arrangements for ongoing care needs. The facility's policy required orientation and documentation to ensure safe discharge, but this was not followed in this case. The resident had a history of cerebral infarction, traumatic brain disorder, and required assistance with activities of daily living, making these omissions significant in the context of the resident's care needs.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four sampled residents, as required by its own policy and care plans. Observations and interviews revealed that residents with significant cognitive and physical impairments did not have access to their call lights, which are essential for requesting assistance. For example, one resident with severely impaired cognition and high fall risk was found unable to reach the call light, which was stuck behind the headboard. Nursing staff confirmed the call light was not accessible and acknowledged the importance of keeping it within reach. Another resident with hemiplegia and severely impaired cognition was observed unable to reach the touch call light, which was placed above the resident's non-functional side. Staff interviews confirmed that the call light should have been placed near the resident's dominant, functional hand. Similarly, a resident with a left hand contracture and severe cognitive impairment had the call light placed on the side of the contracted hand, making it inaccessible. Staff confirmed the resident could only use the right hand and that the call light should have been placed accordingly. A fourth resident, with moderate cognitive impairment and mobility issues, was found sitting in a wheelchair with the call light wedged behind the bed and out of reach. The resident stated they could not access the call light when not in bed and would have to yell for help. Staff interviews consistently indicated that call lights should always be within reach, and the facility's policy required staff to ensure accessibility with each interaction. The failure to follow these procedures was observed across all four cases.
Failure to Inform Residents of Survey Results and Corrections
Penalty
Summary
Ten residents who attended a resident council meeting reported being unaware of the availability and location of the facility's latest survey results, as well as how the facility addressed previously identified deficiencies. During interviews, both the DON and the Administrator acknowledged that posting the survey results was the Administrator's responsibility. The Administrator was unaware that residents did not know where to find the survey results or how to access them, despite stating that the results were discussed during resident council meetings. A review of the facility's policy and procedure on Resident Rights confirmed that residents have the right to examine the most recent survey results and any plan of correction in effect. However, all ten residents interviewed indicated they had not been informed about the location or availability of these documents, nor about the facility's corrective actions following the last survey. This lack of communication resulted in residents not being fully informed of the facility's survey findings or the steps taken to address deficiencies.
Failure to Monitor and Document Catheter Assessments for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters were properly assessed and monitored for the presence of sediments, hematuria, and cloudy urine as required by physician orders and the residents' care plans. For two residents with significant cognitive impairment and dependence on staff for activities of daily living, there was no documentation that licensed staff assessed or monitored the catheter tubing and drainage bags for signs of infection or complications every shift, as ordered. One resident with a history of obstructive uropathy, benign prostatic hyperplasia, and prior urinary tract infection had a physician order to monitor the Foley catheter tubing and bag for sediments, hematuria, and cloudy urine every shift. However, review of the medical record and interviews with nursing staff confirmed that there was no documentation of these assessments being performed. The care plan for this resident also required staff to observe for signs and symptoms of UTI, but this was not carried out as documented. Another resident with chronic kidney disease and BPH had a Foley catheter in place and was similarly dependent on staff. During observation, white sediments were noted in the catheter tubing, which staff acknowledged could indicate infection. Despite this, there was no evidence that regular monitoring and assessment were documented as required. Facility policy and procedure required observation for complications and reporting of findings, but these were not followed for the residents in question.
Failure to Administer Tube Feeding as Ordered and Implement Dietitian Recommendations
Penalty
Summary
Licensed nursing staff failed to administer gastrostomy tube (GT) feeding to a resident as ordered by the physician and as outlined in the facility's policy and procedure for enteral nutrition. The resident, who had diagnoses including Parkinson’s disease and dysphagia, was dependent on staff for all activities of daily living and required continuous GT feeding at a specific rate. Observations revealed that the feeding was administered at 65 ml/hr instead of the ordered 60 ml/hr. Both the LVN and DON confirmed that the physician’s order was not followed, and the RD noted that the resident had experienced significant weight gain over the past six months, with the feeding rate being a contributing factor. In a separate incident, the facility did not implement or communicate the registered dietitian’s (RD) recommendation for another resident to start multivitamins and minerals. The resident, who had severe cognitive impairment and was dependent on staff for daily care, had a nutrition screening indicating the need for multivitamins. However, this recommendation was not included in the dietary recommendations form, nor was it communicated to the resident’s physician. Interviews with nursing staff and the DON confirmed that the RD’s recommendation was not followed up, and there was no documentation that the physician had been notified. The facility’s policies and procedures required that enteral nutrition be provided as ordered by the physician and that all dietary recommendations from the RD be reviewed by the physician and documented by nursing staff. In both cases, the required processes were not followed, resulting in deficiencies related to the administration of nutrition and communication of dietary recommendations.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary care and services for three residents receiving oxygen therapy by not adhering to professional standards of practice. For one resident with a PRN oxygen order due to COPD and other chronic conditions, there was no oxygen concentrator machine set up in the room, despite the order requiring oxygen to be available as needed. Both the CNA and RN Supervisor confirmed the absence of the equipment, and the DON stated that all residents with continuous or PRN oxygen orders should have a concentrator set up and a cautionary sign posted outside the room, as per facility policy. Another resident, with a history of pneumonia and asthma, had a physician's order for PRN oxygen therapy. During observation, the resident's nasal cannula tubing was found hanging on the oxygen concentrator with the prongs touching the handle, rather than being stored in a plastic bag when not in use. Both the RN and DON confirmed that the tubing should be stored in a bag for infection control, in accordance with the facility's policy and procedure for oxygen administration. A third resident, diagnosed with COPD and anemia, was observed receiving oxygen at 2.5 liters per minute via nasal cannula. However, there was no physician's order for this oxygen administration, and no sign was posted outside the resident's door to indicate oxygen was in use or to prohibit smoking. The RN confirmed the absence of a physician's order and signage, both of which are required by the facility's policy to ensure safe and accurate oxygen therapy.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Noncompliance with Drug Labeling and Storage Requirements
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Improper Disposal of Garbage and Refuse Due to Uncovered Trash Bins
Penalty
Summary
The facility failed to properly cover six out of ten large trash bins with lids as required by its own policy and procedure on garbage disposal. During a facility tour and observation, surveyors found two large trash bins in the Lodge Building, three in the Manor Building, and one in the Center Building area outside in the parking lot with open lids, all of which were full of trash bags. Staff interviews confirmed that the trash bin lids should be kept closed at all times to maintain sanitation and prevent cross contamination. The Kitchen Manager stated that the kitchen area in the Center Building had insufficient space for daily trash, leading to overfilled bins and open lids. The Maintenance Supervisor also acknowledged that overfilled bins prevented lids from closing, which could attract rodents and flies. Further interviews with the DON and Infection Prevention Nurse confirmed that trash bins should be covered with lids at all times for infection control, to prevent bad odors, and to keep out rodents and other animals. The facility's policy and procedure on garbage disposal specifies that refuse containers and dumpsters kept outside should have tightly fitting lids and be kept covered when not being loaded. The failure to keep trash bin lids closed was directly observed and confirmed by multiple staff members as not sanitary and not in compliance with facility policy.
Failure to Follow Infection Control Protocols During Medication Administration and G-Tube Care
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene during medication administration for a resident with multiple diagnoses, including dry eye syndrome, epilepsy, and Parkinson’s disease. The LVN did not sanitize or wash hands before entering the resident’s room, after exiting the room, before donning gloves, or after removing gloves, despite handling medications and administering eye drops. The LVN acknowledged the lapse in hand hygiene during an interview, and the facility’s policies clearly required hand hygiene at these points to prevent infection. Another deficiency was observed with a different resident who had a gastrostomy tube (G-tube) for enteral feeding and was dependent on staff for all activities of daily living. The resident’s [NAME] valve, used to maintain a closed system for tube feeding, was found to be uncapped, with visible dry, black, and brown crust and formula residue inside the connector port. The valve was only wrapped with a towel rather than being properly covered with a cap. Staff interviews confirmed that the valve should have been kept clean and covered, and that the facility had replacement covers available. The facility’s policies required proper cleaning and maintenance of medical devices to minimize infection risk. Both deficiencies were confirmed through direct observation, staff interviews, and review of facility policies and procedures. The failures to follow established infection prevention and control protocols placed the residents at risk for the spread of infection and cross-contamination. The facility’s own policies outlined the necessary steps for hand hygiene and device maintenance, which were not followed in these instances.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support residents in making their own choices regarding their care or daily life, as required by regulation. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions of staff, the events that occurred, or the medical history or condition of the resident(s) involved. No further factual observations or resident-specific information are included in the report.
Failure to Provide Privacy During Catheter Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide privacy for a resident during a foley catheter check. The RN did not close the privacy curtain while pulling up the resident's gown to check the catheter securement device, resulting in the resident's upper legs being exposed to a roommate and the hallway. The RN acknowledged that the privacy curtain should have been closed prior to providing care and treatment to maintain the resident's privacy. The resident involved had chronic kidney disease, benign prostatic hyperplasia, and was incontinent of bowel and bladder due to impaired cognition. The care plan for this resident specifically indicated that nursing staff should provide privacy during activities of daily living. Both the RN and the Director of Nursing confirmed during interviews that the privacy curtain should be closed to protect the resident's dignity and bodily privacy during care, as outlined in the facility's policy.
Failure to Complete Pre-Employment OIG Background Check
Penalty
Summary
The facility failed to conduct a required Office of Inspector General (OIG) background check for one of four randomly selected employees, a registered nurse, prior to hire. According to interviews and record reviews with the Director of Staff and Development (DSD), the Director of Nursing (DON), and the Administrator (ADM), the facility's practice was to hire applicants before completing background checks, contrary to the facility's own policy and procedure. The DSD confirmed that the background check for the registered nurse was performed after the hiring date, following instructions from the previous DSD. Both the DON and ADM acknowledged during interviews that background checks should be completed prior to hiring to ensure applicants do not have a history of abuse or criminal records. Review of the facility's policy titled "Abuse, Neglect and Exploitation" indicated that screening for a history of abuse, neglect, exploitation, or misappropriation of resident property must be conducted on potential employees, contracted staff, students, volunteers, and consultants before hire. The policy specifies that background, reference, and credential checks are required prior to employment. The failure to follow this policy resulted in the hiring of an employee before confirming their eligibility through the OIG database.
Failure to Complete Timely MDS Assessments After Significant Change in Condition
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) comprehensive assessments within the federally required time frames for two residents who experienced significant changes in condition. Both residents had histories of dementia and schizophrenia, and each exhibited new or worsening behavioral symptoms that led to acute psychiatric hospitalizations and subsequent readmissions to the facility. Documentation, including SBAR forms and progress notes, indicated that these behavioral changes were significant departures from each resident's baseline condition. Despite this, the MDS assessments did not reflect a significant change of condition, and comprehensive assessments were not completed within 14 days of the residents' readmissions as required. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the changes in the residents' mental and behavioral status constituted significant changes in condition, necessitating timely MDS comprehensive assessments. The facility's own policy also required completion of such assessments within 14 days after determination of a significant change. The failure to complete and report these assessments in a timely manner resulted in inaccurate and delayed reporting of the residents' health status to CMS.
Failure to Maintain Resident Hygiene and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus, schizophrenia, and adult failure to thrive was not kept clean, as observed on 8/5/2025. The resident was found lying in bed with an oily, unkempt ponytail and the bottoms of both bare feet covered with black dirt. Multiple staff, including a CNA and an LVN, confirmed the resident's disheveled appearance and dirty feet during interviews and observations. The resident's care plan indicated a need for assistance with activities of daily living (ADLs), including personal hygiene and bathing, and interventions were in place to encourage participation and maintain cleanliness. Despite these documented needs and scheduled showers, the resident was not provided adequate hygiene, as evidenced by their appearance during the survey. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, and the DON confirmed that staff were expected to provide hygiene every shift. The failure to ensure the resident was kept clean constituted a deficiency in providing care and assistance with ADLs.
Failure to Enforce Smoking Policy for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement its smoking policy and procedure for a resident with significant cognitive impairment and behavioral issues. The resident, who had diagnoses including schizoaffective disorder, schizophrenia, and traumatic brain injury, was assessed as having moderately impaired cognition and was determined to be a danger to self or others while smoking. The resident's care plan indicated a risk for self-injury related to smoking and a tendency to hoard cigarettes, with interventions requiring staff to explain and enforce the facility's smoking policy. Despite these documented risks and interventions, the resident was found with two cigarettes in their possession in their room, which was not in accordance with the facility's policy that required nursing staff to maintain control of smoking materials for residents needing supervision. Interviews with staff revealed inconsistent practices regarding the handling of cigarettes, with a certified nurse assistant stating that residents were usually given one cigarette per day and could keep cigarettes in their rooms, while a licensed vocational nurse and the director of nursing confirmed that residents were not allowed to keep cigarettes or lighters. The facility's written policy specified that smoking materials for residents requiring supervision should be maintained by nursing staff. The failure to follow this policy resulted in the resident having unsupervised access to cigarettes, creating a potential fire hazard within the facility.
Failure to Provide Required 1:1 Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with intellectual disabilities, autistic disorder, and schizoaffective disorder, who was assessed as having severely impaired cognitive skills and a history of impulsive and self-injurious behaviors, was not provided with the required one-on-one (1:1) supervision as indicated in their care plan. The care plan, established by the interdisciplinary team, specified that the resident should receive 1:1 supervision for 10 hours daily due to their impaired cognition and behavioral risks. On the day of the incident, the assigned staff member left the resident unsupervised in their room for approximately 30 seconds, during which time the resident fell from their wheelchair. As a result of being left unsupervised, the resident sustained a laceration above the left eyebrow, abrasions to the left elbow and forearm, and a bruise under the left eye. The injuries required emergency medical attention, and the resident was transferred to a general acute care hospital for further evaluation and wound management. Staff interviews confirmed that the resident was known to require constant supervision due to their behavioral tendencies and risk of harm, and that the assigned staff was aware of the supervision requirement but failed to maintain it at the time of the fall. Facility records, including progress notes, care conference documentation, and staff interviews, consistently indicated that the resident's need for 1:1 supervision was well established and communicated among the care team. The facility's policy on safety and supervision emphasized the importance of implementing and communicating specific interventions to prevent accidents, but in this instance, the intervention was not carried out as required, directly leading to the resident's fall and subsequent injuries.
Failure to Align Diabetes Care Plans with Physician Orders
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two of three sampled residents with diabetes mellitus, as required by physician orders and facility policy. For both residents, the care plans included goals to maintain blood glucose levels within a specified range and interventions such as monitoring blood glucose and observing for signs of hypo- or hyperglycemia. However, neither resident had an active physician's order for routine bedside blood sugar monitoring, which was a key component of the care plan interventions. Resident 4 was admitted and readmitted with a diagnosis of diabetes mellitus type 2 and diabetic polyneuropathy. The resident's care plan specified blood glucose monitoring and maintaining levels between 70 and 150 mg/dl, but the order summary report showed no physician order for routine blood sugar checks. Interviews with nursing staff confirmed that the care plan called for monitoring, but this was not supported by physician orders. Similarly, Resident 6, who had severe cognitive impairment and required assistance with activities of daily living, had a care plan with similar goals and interventions for diabetes management. The order summary report for this resident also lacked a physician order for routine blood glucose monitoring or for monitoring signs and symptoms of hypo- or hyperglycemia. Nursing staff and the DON acknowledged the importance of care plans in guiding resident care, but the necessary physician orders to implement the care plan interventions were not present.
Failure to Assess, Document, and Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of suicidal ideation. Upon readmission from an acute care hospital, the resident's prior episode of suicidal ideation, including a stated plan to overdose on medication, was not accurately assessed or documented by the Social Services Director (SSD) or the admitting licensed nurse. The resident's medical records from the hospital indicated recent suicidal thoughts, feelings of hopelessness, and a history of aggressive behavior, but this information was not incorporated into the facility's assessment or care planning process. The SSD conducted an interview with the resident after readmission and asked about current suicidal thoughts, to which the resident denied any intent. However, the SSD did not document this conversation or the resident's history of suicidal ideation in the Social Service History & Initial Assessment. The assessment form's section for history of suicidal ideation/gestures was left blank, and the SSD did not notify nursing staff or initiate an interdisciplinary team meeting as required by facility policy. The Director of Nursing (DON) confirmed that no assessment, care plan, or monitoring for suicidal ideation was completed for the resident, despite the documented history and recent hospital evaluation. Interviews with facility staff, including the DON, SSD, and a registered nurse, revealed a consensus that the lack of assessment, documentation, and care planning for suicidal ideation could result in potential or actual harm to the resident. Facility policies required assessment for suicidality upon admission, thorough documentation, and the development of a care plan with appropriate interventions for residents with a history of suicidal ideation. These steps were not followed, and the resident's risk factors were not addressed in the care plan or through ongoing monitoring.
Plan Of Correction
F 740 Behavioral Health Services 483.40 Resident 1 was discharged to acute hospital for evaluation of his aggressive behavior on 5/6/25. All residents in house census as of 5/16/25 were reviewed by the DON and RN/LVN supervisors. Review was initiated on 5/16/25 to ensure that residents with a history of suicidal ideations have been assessed, care planned, and monitored. Review was completed on 5/22/25. NO other residents were affected. Social services department and licensed nurses were in serviced by the DON on 5/15 and 5/19/25 regarding Behavioral Health Services; Social services and licensed nurses are to accurately assess and document suicidal ideation upon admission; develop a care plan, and monitor the suicidal ideation behavior. Every other month, licensed staff and Social services department will be given an in-service regarding Behavioral Health Services by the DON. RN/LVN supervisors will monitor compliance during weekly admissions review using the suicidal ideation admission review log to ensure that residents' suicidal ideations have been assessed upon admission, care planned, and behavior is being monitored. Any findings will be corrected immediately and will be given to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.
Failure to Assess Resident's Skin Leads to Infected Wound from Embedded Bracelets
Penalty
Summary
Licensed nursing staff failed to perform a full body skin assessment on a resident who had a history of mild intellectual disabilities and moderate cognitive impairment. The resident required partial to moderate assistance with activities of daily living and had no documented skin conditions prior to the incident. On one occasion, a Licensed Vocational Nurse (LVN) noticed a foul odor coming from the resident but did not identify its source, did not conduct a full body assessment, and did not notify a supervisor or Registered Nurse (RN) about the issue. The following day, the LVN again noticed the odor and informed the RN, who instructed the LVN to provide the resident with another shower, despite the resident having already received one the previous day. Neither the LVN nor the RN performed a full body skin assessment as required by facility policy, which mandates such assessments after a change in condition or when a new wound is identified. The facility's Director of Nursing confirmed that the staff did not follow the established policy for skin assessments. Emergency medical services were called, and upon their arrival, EMTs discovered that the resident had bracelets, including a hospital band and beaded bracelets, embedded in the left wrist, causing a wound that was infected and emitting a strong odor. The bracelets were removed by the EMTs, and the wound was noted to be infected with discharge. The failure of the nursing staff to assess the resident's skin and identify the embedded bracelets led to the development of the infected wound.
Plan Of Correction
F 684 Quality of Care CFR(s): 483.25 Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. RN1 and LVN 1 were given a one-on-one in-service and 1:1 Skills and Policy review by the DON on 4/11/25. Disciplinary action was given by the DON to the RN1, LVN1, and the CNAs who were assigned to Resident 1. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any residents affected with the findings. Skin/Body checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses on 4/9/25, 4/11/25, and 4/28/25 regarding Skin assessment Policy upon admission/readmission, change of condition, and as needed. DSD in-serviced CNAs on 4/9/25 regarding skin and body assessment including reporting to licensed nurses for any changes. A follow-up in-service to CNAs, LVNs, and RNs was given on 4/25/25 by the DSD. To monitor compliance, the DON and/or Designee will conduct random skin assessment reviews to licensed nurses on a weekly basis. Any issues will be addressed and corrected immediately. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.
Failure to Implement Comprehensive Care Plan and Daily Body Checks
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident by not performing daily body checks as required by the resident's care plan and the facility's own policies. The resident had a history of mild intellectual disabilities, limited mobility, and was at risk for developing pressure ulcers, as documented in the care plan and Minimum Data Set (MDS). The care plan specifically included interventions such as daily body checks for redness and open areas, keeping the skin clean and dry, and protecting the skin from moisture. Despite these documented needs and interventions, staff did not consistently perform or document daily body checks. A Licensed Vocational Nurse (LVN) assigned to the resident noticed a foul odor but did not conduct a full body assessment, stating it was outside their scope of practice. The LVN reported the odor to a Registered Nurse (RN), but the only action taken was to provide another shower, even though the odor persisted. The Director of Nursing (DON) confirmed that the facility's policy required full body skin assessments by licensed or registered nurses, particularly for residents at risk of pressure ulcers, and that this protocol was not followed in this case. As a result of the failure to follow the care plan and perform required skin assessments, the resident developed an infected wound on the left wrist, which was later identified at an acute care hospital as an embedded rubber band causing infection. The lack of adherence to the care plan and facility policy directly contributed to the development and delayed identification of the wound.
Plan Of Correction
F 656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. Care plan reviewed and revised by the RN supervisor on 3/28/25. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any resident affected with the findings. Body/skin checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses regarding Comprehensive Care Plan Implementation on 4/9, 4/11, and 4/28. At least quarterly, every 10th, DON will in-service regarding Comprehensive Care Plan Implementation. Weekly, during IDT care plan meetings, MDS nurse, RN/LVN supervisors assigned, and Social Services designee will review the care plan of residents on schedule to ensure that body/skin assessment was performed as written in the care plan. Findings will be corrected and will be reported to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
Licensed nursing staff failed to properly assess and respond to a foul odor detected from a resident on two consecutive days. An LVN assigned to the resident noticed a foul smell but did not perform a full body assessment, citing it as outside their scope of practice, nor did they notify a supervisor or RN on the first day. The following day, after the smell persisted, the LVN informed an RN, who instructed the LVN to give the resident another shower, despite the LVN's report that a shower had already been given and the odor remained. The resident in question had a history of mild intellectual disabilities and mobility issues, and required varying levels of assistance with daily activities. The resident's most recent assessment did not indicate any skin conditions. However, when the resident was later evaluated at a hospital, a rubber band embedded in the left wrist was found to be infected, which had gone unnoticed and untreated by facility staff. Facility policy required licensed or registered nurses to perform full body skin assessments upon admission, readmission, and as needed, including after a change in condition or the identification of new skin issues. The Director of Nursing confirmed that LVNs are expected to report unusual findings to RNs for further assessment, but was unaware of the wound until the resident was transferred to the hospital. The failure of both the LVN and RN to assess the resident's skin condition and follow facility policy led to the deficiency.
Plan Of Correction
Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c) Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. RN1 and LVN 1 were given a one-on-one in-service and 1:1 Skills and Policy review by the DON on 4/11/25 regarding Skin assessment Policy. Disciplinary action was given by the DON to the RN1, LVN1, and the CNAs who were assigned to Resident 1. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any residents affected with the findings. Skin/Body checks were completed on 4/30/25. No other residents were affected. Monthly, Skin assessment in-service will be given by the DON and DSD to licensed nurses and CNAs. To monitor compliance, the DON and/or designee will conduct random Skin assessment reviews to licensed nurses on a weekly basis. Any issues will be addressed and corrected immediately. Skills competency training and evaluation by return demonstration will be done annually and as needed by the DON and/or designee and DSD to the licensed nurses and CNAs. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.
Failure to Provide Adequate Foot Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate foot care and treatment to a resident, leading to a significant health issue. The resident, who had a history of Parkinson's disease and dementia, repeatedly refused podiatric treatment throughout 2024. Despite these refusals, the facility did not notify the resident's physician or family, nor did they implement alternative interventions as outlined in the resident's care plan. This lack of action resulted in the resident developing osteomyelitis, a serious bone infection, which required hospitalization and intravenous antibiotics. The resident's care plan indicated that staff should monitor for noncompliance and notify the physician for possible treatment, as well as refer the resident for psychological consultation if necessary. However, the facility's staff, including licensed nurses and the Social Service Director, failed to follow these protocols. The resident's toenails were noted to be mycotic and hypertrophic, yet no treatment was provided due to the resident's refusal. The facility's policies required notification of the physician and family after repeated refusals, but this was not done. Interviews with staff revealed a lack of communication and awareness regarding the resident's condition. The Director of Nursing was unaware of the resident's year-long refusal of podiatric care, and the Social Service Director did not inform the nursing staff of the ongoing refusals. Additionally, a change in the resident's condition was not documented in a timely manner, delaying necessary medical intervention. This series of inactions and communication failures contributed to the resident's hospitalization for a preventable condition.
Failure to Notify Physician and Family of Treatment Refusal
Penalty
Summary
The facility failed to notify the physician and responsible party of a resident's repeated refusal of podiatric treatment, as required by their policies and procedures. The resident, who was diagnosed with Parkinson's disease and dementia, was unable to make medical decisions and had a history of refusing treatment and medications. Despite the resident's refusal of podiatric care throughout 2024, the licensed nurses did not inform the resident's physician or family, which was a requirement under the facility's policy. The resident's condition deteriorated, leading to a transfer to a General Acute Care Hospital for intravenous antibiotics to treat osteomyelitis in the right toe. The resident's toenails were noted to be mycotic, hypertrophic, and painful, with repeated refusals for toenail debridement documented. The facility's staff, including the Social Services Designee and Director of Nursing, were unaware of the resident's continued refusal of podiatric care, and the necessary notifications to the physician and family were not made. Interviews with staff revealed that the facility's policy required notification of the physician and family after three refusals of treatment, but this was not followed. The Director of Nursing acknowledged the lack of awareness and communication regarding the resident's refusal of care. The facility's policies clearly outlined the need for notification in cases of significant changes in a resident's condition, but these were not adhered to, resulting in the resident's hospitalization.
Failure to Implement Care Plan for Resident's Podiatric Treatment Refusals
Penalty
Summary
The facility failed to implement the care plan for a resident, identified as Resident 4, by not notifying the resident's physician about repeated refusals to receive podiatric treatment. Resident 4, who was admitted with diagnoses including Parkinson's disease and dementia, was noted to refuse treatment and medications, including podiatric care, as per the care plan. The care plan required staff to monitor for noncompliance and notify the physician for possible treatment, but this was not done. Resident 4's nursing assessments and podiatric consultation notes indicated repeated refusals of toenail debridement over a year, resulting in untreated mycotic and hypertrophic toenails. Despite the care plan's directive to notify the physician and involve family or staff in decision-making, the Social Service Director and Director of Nursing were unaware of the ongoing refusals, and no alternative interventions were attempted. The facility's policy required comprehensive care plans to include measurable objectives and timeframes, with attempts to address treatment refusals documented. However, the licensed nurses were not informed of Resident 4's refusals, and the necessary notifications to the physician and other relevant parties were not made, leading to a failure in implementing the care plan as required.
Failure to Address Resident's Refusal of Podiatry Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to a resident, identified as Resident 4, by not implementing its policies and procedures regarding changes in a resident's condition or status and comprehensive care plans. Resident 4 repeatedly refused treatment by a podiatrist, and this refusal was not communicated to the resident's physician or family. The care plan addressing the refusal of care and treatment was not implemented, and licensed nurses did not inform the resident's physician about the condition of the resident's toenails during weekly nursing assessments. Resident 4, who was admitted with diagnoses including Parkinson's disease and dementia, was at risk for clinical or social decline due to refusals of care, including podiatry treatment. The resident's care plan indicated that family members and staff should assist in decision-making and inform the resident of the risks and consequences of their choices. Despite this, the facility did not take appropriate actions when the resident refused podiatry care throughout 2024, leading to a lack of communication with the resident's physician and family. The failure to address Resident 4's refusal of podiatry care resulted in the resident being transferred to a General Acute Care Hospital for treatment of right toe osteomyelitis. The facility's policies required that significant changes in a resident's condition be communicated to the physician and family, but this was not done. The Director of Nursing and Social Service Director were unaware of the resident's repeated refusals, and the necessary interventions were not implemented, leading to the resident's hospitalization.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as at risk for wandering and elopement. The resident, who had a history of schizophrenia and anxiety disorder, was initially admitted to a secured unit due to wandering behavior. However, the resident was later transferred to an unsecured unit, Station 6, which had multiple exit doors, some of which were not alarmed or locked. This transfer occurred despite the resident's known risk factors and a physician's order to admit the resident to a secured unit. On the evening of the incident, the resident was last seen walking in the hallway by the nurses' station and later listening to the radio in their room. The staff, including a CNA and LVN, noticed the resident's absence at 8:45 pm and initiated a search within the facility and surrounding areas. Despite these efforts, the resident was not found, and a missing person report was filed with the local police department. The facility's emergency code for a missing resident was activated, and staff searched extensively, but the resident remained missing. Interviews with staff revealed that the kitchen exit door, located near a vending machine frequently used by the resident, was not alarmed at the time of the incident. This door was not visible from the main hallway or the nurses' station, potentially allowing the resident to exit the facility undetected. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and systematic monitoring, which was not effectively implemented in this case, leading to the resident's elopement.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as at risk for elopement. The incident involved a resident with a history of diabetes mellitus and schizophrenia, who was admitted to the secured unit due to wandering behavior and confusion. Despite being scheduled for an ophthalmologist appointment, the resident left the facility unsupervised with a rideshare driver, without the presence of a staff chaperone as required by the facility's policy. The deficiency occurred when a janitor unlocked the door of the secured unit, allowing the resident to leave with the rideshare driver. The staff responsible for accompanying the resident to the appointment was not present at the scheduled pick-up time. The facility's policy required that residents in the secured unit be accompanied by a staff member for any outside appointments, but this protocol was not followed, leading to the resident's unsupervised departure. The facility's failure to ensure that the resident was accompanied by a staff chaperone resulted in the resident not checking in at the ophthalmologist's office and subsequently being reported missing. The facility's staff, including the Administrator and Director of Nursing, were unable to locate the resident, prompting the filing of a missing person report with the local police department. The incident highlighted a lapse in the facility's supervision and monitoring procedures for residents at risk of elopement.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and worsening of pressure ulcers. Resident 228, who was at risk for pressure ulcers due to limited mobility and moist skin, did not receive the prescribed treatments for open wounds and unstageable pressure ulcers on multiple occasions. The treatment nurses failed to notify the medical doctor of the development of new pressure ulcers and did not implement the care plan for impaired skin integrity. As a result, Resident 228 developed an avoidable unstageable pressure ulcer on the right hip and a worsening ulcer on the left hip. Resident 231 was at risk for pressure ulcers due to severe cognitive impairment and required substantial assistance with daily activities. The facility staff failed to set the low air loss mattress to the correct setting based on the resident's weight, which could potentially lead to skin breakdown. The mattress was set at 325 pounds, while the resident weighed 158 pounds, indicating a lack of adherence to the manufacturer's recommendations and facility policy. Resident 80, who had severe cognitive impairment and was dependent on all activities of daily living, did not receive the prescribed treatment for a stage 4 pressure ulcer on the sacrococcyx for several days. The treatment administration record was left blank for multiple days, indicating missed treatments. The failure to provide consistent wound care had the potential to delay the healing of the pressure ulcer.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in care. Resident 81, who was admitted with osteoarthritis, muscle weakness, and dementia, had a care plan indicating a high risk for falls and required assistance with activities of daily living. During an observation, it was noted that Resident 81's call light was dangling and out of reach, which the resident confirmed, stating they could not access it without assistance. Staff interviews corroborated that the call light should have been clipped to the bed for easy access, as per the facility's policy. Similarly, Resident 25, who was admitted with muscle weakness and unspecified dementia, was also identified as high risk for falls. The care plan for Resident 25 included ensuring the call light was within reach. However, during an observation, the call light was found on the floor, out of reach, and not accessible to the resident. Staff interviews confirmed that the call light should have been within reach to allow the resident to call for assistance promptly. The facility's policy on call light accessibility was not adhered to, as evidenced by the observations and staff interviews. Both residents were at high risk for falls, and the failure to ensure call lights were within reach could lead to delayed assistance and potential harm. The deficiency was identified through observations, interviews, and a review of the residents' records, highlighting a lapse in maintaining safety and accessibility for residents in need of assistance.
Failure to Implement Smoking Policy and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to implement its smoking policy for Resident 100, who was observed with a pack of cigarettes despite being identified as an unsafe smoker requiring supervision. Resident 100, diagnosed with schizophrenia, schizoaffective disorder, and anxiety, had a care plan indicating a risk for self-injury related to smoking. The care plan required that smoking materials be maintained by nursing staff, yet during an observation, the resident was found with cigarettes in their possession. Interviews with staff confirmed that cigarettes should be kept by LVNs and only provided to residents during supervised smoking times. The facility also failed to ensure proper positioning for Resident 80 during meals, which is crucial to prevent aspiration. Resident 80, who has dementia and dysphagia, was observed with their neck hyperextended while eating, contrary to physician orders requiring the head of the bed to be elevated at 90 degrees during feeding. A registry CNA assisting the resident was unaware of this requirement, and the care plan for dysphagia did not include specific instructions for proper positioning during meals. Interviews with nursing staff highlighted the importance of correct positioning and the need for this information to be communicated to all staff, including registry staff. These deficiencies indicate a lack of adherence to established policies and procedures, potentially compromising resident safety. The facility's failure to supervise Resident 100's smoking and to ensure Resident 80's proper positioning during meals could lead to significant health risks, as noted in the observations and interviews conducted during the survey.
Failure to Prevent UTIs in Residents with Foley Catheters
Penalty
Summary
The facility failed to provide necessary care to prevent urinary tract infections (UTIs) for two residents with Foley catheters. For one resident, the licensed staff did not monitor urine output for signs of UTI, such as cloudy urine and sediments, and failed to notify the physician promptly. This oversight was acknowledged by a registered nurse who admitted to being too busy to inform the physician. Additionally, a certified nursing assistant focused only on the urine output amount and did not check for changes in color or sediments until instructed by the nurse. For the second resident, the facility did not ensure proper positioning of the Foley catheter bag, which was observed on the floor. A certified nursing assistant was unsure about the correct positioning, and a licensed vocational nurse confirmed that the bag should not be on the floor due to infection risks. The facility's policy and procedure for catheter care also indicated that the catheter bag should be kept off the floor to prevent contamination and infection.
Failure to Follow Respiratory Care Procedures
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding respiratory care for two residents, leading to potential health risks. For Resident 67, who was admitted with respiratory failure and dysphagia, the facility did not remove or replace the suction canister after use, leaving a moderate amount of thick, yellow sputum in the canister. This oversight was observed by a Licensed Vocational Nurse (LVN) who acknowledged the need for the canister to be emptied after use. The failure to do so could result in inaccurate monitoring of the resident's secretions, as staff would not know how long the sputum had been in the container. The facility's policy required the suction bottle to be cleaned every shift and changed weekly or as needed. For Resident 653, who had chronic obstructive pulmonary disease and asthma, the facility did not date the humidifier bottle used with the resident's oxygen machine. This was observed by an LVN, who noted that the absence of a date could lead to the use of an old humidifier bottle, potentially reducing the effectiveness of the oxygen therapy. The facility's policy required the humidifier bottle to be changed every 72 hours or as recommended by the manufacturer. Both instances reflect a failure to follow established procedures, which could compromise the residents' respiratory care.
Failure to Implement Gradual Dose Reductions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents on psychotropic drugs were free from unnecessary medication. For Resident 198, the licensed staff did not attempt a gradual dose reduction (GDR) for Risperdal and Lexapro since the medications were ordered on 6/8/21. The resident was readmitted with the same medication orders, and there was no documented evidence of a past or recent failed attempt of GDR to justify that it would be clinically contraindicated. For Resident 210, the staff did not attempt a GDR for Lexapro since it was ordered on 3/27/23. The resident was readmitted with diagnoses including dementia and diabetes mellitus. The staff believed that GDR was not indicated after several psychotropic medications had been discontinued, but acknowledged that limited social interaction was not an adequate indication for continued use of Lexapro. Resident 22's target behavior and side effects for Ativan use were not monitored every shift as required. The resident was admitted with diagnoses including anxiety and dementia, and the physician order required monitoring for adverse side effects and target behavior every shift. However, there was no documented monitoring for specific shifts, and the Director of Nurses confirmed the lack of documentation, emphasizing the need for monitoring to assess medication effectiveness and potential harm.
Deficiencies in Kitchen Staff Training and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in following manufacturer's guidelines for chlorine paper testing and smartpower sink and surface cleaner sanitizer. Two staff members, a Dietary Aide and the Dietary Account Manager, did not adhere to the correct procedures for testing chlorine sanitizer concentration. The Dietary Aide incorrectly shook the test strip for 4 seconds and compared it to the color chart, while the Dietary Account Manager placed the test strip on wet trays instead of dipping it in water, as per the manufacturer's guidelines. This deviation from the guidelines could result in inaccurate readings of chlorine concentration, potentially leading to unsanitized dishware. Additionally, the facility did not follow the manufacturer's guidelines for the smartpower sink and surface cleaner sanitizer. The staff failed to check the temperature of the testing solution, which should be above 65°F, as required by the guidelines. The Director of Maintenance confirmed that water temperature checks were not conducted daily, and the Maintenance Worker did not record the results of temperature checks in the log. This oversight could lead to ineffective sanitization of kitchen surfaces, increasing the risk of cross-contamination. The report also highlighted that there was no competency evaluation for the Dietary Aide and the Dietary Account Manager, despite their job descriptions requiring them to maintain sanitation and safety standards. The Registered Dietitian confirmed that the Dietary Account Manager had not been evaluated for competency because she had not been in the facility for a year. Furthermore, the facility's in-service lesson plan indicated that staff were instructed on testing procedures, but attendance records showed that not all staff, including the Dietary Aide, attended these sessions.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in both of its kitchens, leading to potential health risks for residents. Observations revealed that Freezer A and B in Kitchen 1 had significant dust and dirt buildup, with food debris present on the bottom shelves and vents. The reach-in refrigerator in Kitchen 1 also had dirt buildup on its vents. Additionally, stainless steel racks used for kitchen utensil storage and in the dry storage area were found to be rusted, which could contribute to foodborne illnesses. Dented cans were improperly stored with non-dented cans in both kitchens, and bulk condiment containers had dirt buildup on their lids. Further issues were identified with the equipment and utensils used in the kitchens. The reach-in refrigerator in Kitchen 2 had ice buildup and dirt debris, while the dry storage wooden racks had cereal debris. The ice machine in Kitchen 1 had hard water buildup, and its internal parts had a slimy brownish buildup. The resident's refrigerator was not maintained at the correct temperature, and pans in Kitchen 2 had burned dirt debris. Kitchen utensils storage also had food debris, and staff were not following the manufacturer's guidelines for testing chlorine concentration for the dish machine. Staff attire and practices also contributed to the deficiencies. A dietary aide was observed wearing dangling and beaded bracelets while handling food, which is against the facility's policy. The facility's policy on jewelry was not adhered to, as staff were only allowed to wear plain bands. Additionally, the facility did not have a proper cleaning schedule for some equipment, such as the plate warmer, and staff were not following the manufacturer's guidelines for the use of sanitizers, which could lead to inaccurate readings and ineffective disinfection of kitchen surfaces.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the dumpster areas outside Kitchen 1 and Kitchen 3. Four gray trash bins outside Kitchen 1 were overflowing and not completely closed, while one of two black trash bins outside Kitchen 3 was also not fully covered. The Dietary Area Manager (DAM) acknowledged that the trash bins should be completely covered and expressed concerns about the health implications for residents. The DAM indicated that it was the janitor's responsibility to maintain the cleanliness of the dumpster areas. Additionally, the dumpster areas outside Kitchens 1 and 3 were not maintained free from trash, soiled gloves, and other debris. The DAM noted the presence of a trash bag on the ground, soiled gloves, and other trash in the surrounding areas, emphasizing the importance of cleanliness to prevent the spread of infections. The Environmental Services Manager (EVSM) confirmed that trash was picked up daily except Sundays, but acknowledged that the bins should not be overflowing to avoid attracting insects and rodents. The facility's policies and procedures, as well as the Food Code 2017, require that trash receptacles be covered with tight-fitting lids to prevent contamination.
Failure to Provide Speech Therapy Evaluations as Ordered
Penalty
Summary
The facility failed to provide Speech Therapy (ST) evaluations as ordered by physicians for three residents with swallowing, communication, and cognitive concerns. Resident 147, who was readmitted with diagnoses including encephalopathy, cirrhosis, and COPD, had a physician's order for an ST evaluation upon readmission. However, the resident only received a Therapy Screen, which is not equivalent to a comprehensive ST evaluation. The Director of Rehabilitation (DOR) and the Speech Therapist (ST 1) confirmed that the ST evaluation was not conducted as ordered, which could potentially result in negative outcomes for the resident. Similarly, Resident 198, who was readmitted with dysphagia and a G-tube malfunction, also had a physician's order for an ST evaluation. Despite this, the resident did not receive the evaluation, only a Therapy Screen. Both the DOR and ST 1 acknowledged the oversight, emphasizing the importance of following physician's orders to ensure residents receive necessary care and services to reach their highest functional level. Resident 280, admitted with dysphagia, metabolic encephalopathy, and COPD, was also supposed to receive an ST evaluation as per physician's orders. However, the evaluation was not performed, and the order was discontinued by a Registered Nurse without notifying the physician. ST 1 admitted to not conducting the evaluation and failing to inform the physician about the discontinuation. The facility's policy requires that ST services follow physician's orders, which was not adhered to in these cases.
Failure to Ensure Convenient Venue in Arbitration Agreements
Penalty
Summary
The facility failed to ensure its Resident-Facility Arbitration Agreement (AA) included the selection of a venue convenient to both the facility and the residents or their responsible parties. This deficiency was identified for three residents, each with moderately impaired cognitive skills and requiring varying levels of assistance for daily activities. The facility's policy and procedure for the Binding Arbitration Agreement did not include a provision for selecting a mutually convenient venue, which is a regulatory requirement. During the review, it was found that the arbitration agreements for the residents did not have written language providing for the selection of a convenient venue. The facility's administrator acknowledged this omission and stated that the facility's policy did not require the selection of a convenient venue for both parties involved in the arbitration agreement. This oversight placed the residents at risk for unjust arbitration and potential delays in arbitration hearings.
Deficiency in Hospice Service Documentation and Implementation
Penalty
Summary
The facility failed to ensure proper documentation and implementation of hospice services for a resident on hospice care. The resident, who had severe cognitive impairment and was dependent on all activities of daily living, did not have documented services provided by the Hospice Health Aide (HHA) during visits. The Hospice and Nursing Facility Services Agreement required the HHA to document care provided, but the flow sheet for the resident only indicated a regular visit without details of the care given. This lack of documentation was confirmed by a registered nurse, who stated that the Hospice Book should contain all relevant documents and communication between the hospice and the facility. Additionally, the facility did not accurately document hospice Licensed Vocational Nurse (LVN) visits. The LVN flow sheet showed a visit on one date, but there were four undocumented vital signs without dates, making it impossible to verify additional visits. The registered nurse confirmed that the LVN visits were not completed according to the hospice visit calendar or the physician's orders, which required skilled nurse visits twice a week. The facility's policy indicated the need for communication and documentation of hospice interventions, but this was not followed, leading to the deficiency.
Deficient Laundry Dryer Maintenance
Penalty
Summary
The facility failed to maintain three laundry dryers in a safe, operating, and sanitary condition, which was observed during a survey. The Environmental Service Manager (EVSM) noted multiple thick patches of brown/black material on the inner walls of the dryers' drums. The EVSM acknowledged that these patches were dirty and did not know their origin. The presence of these patches was identified as a potential source of cross-contamination and infection risk when drying residents' clothes. Additionally, the EVSM recognized that the patches could pose a fire hazard by obstructing the drum holes, which are essential for heat and moisture ventilation. The facility's policies and procedures for washer and dryer maintenance, as well as laundry maintenance, were reviewed and indicated the need for daily inspection and cleaning of laundry equipment to prevent such hazards. However, these procedures were not followed, leading to the observed deficiencies.
Infection Control Deficiencies in PPE Usage and Disposal
Penalty
Summary
The facility failed to properly dispose of soiled gauze in a resident's room, which was observed during a concurrent observation and interview with a Licensed Vocational Nurse (LVN). The soiled gauze dressing was left next to the resident's head on the bed, potentially causing the spread of infection. The LVN acknowledged that the gauze should have been disposed of and suggested it might have been left by the wound doctor. The Infection Prevention Nurse (IPN) confirmed that the failure to clean up after wound care could spread infection and emphasized the expectation for staff to follow proper infection control protocols. In another incident, a Restorative Nursing Aide (RNA) failed to remove an isolation gown and gloves and perform hand hygiene after exiting a resident's room who was on Contact Isolation Precautions. The RNA transported the resident into the hallway without changing PPE, which was confirmed during an interview. The Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) both stated the importance of following proper infection control procedures to prevent cross-contamination and the spread of infection. The facility's policy on Transmission-Based Precautions was reviewed, indicating the need for PPE to be donned upon room entry and discarded before exiting. Additionally, the facility did not adhere to the Public Health Nurse's guidance for COVID-19 precautions in yellow zones. Observations revealed that PPE carts lacked face shields, and staff were not wearing full PPE, including face shields, when entering rooms in these zones. Interviews with staff confirmed the absence of face shields in PPE carts and the incorrect PPE usage. The facility's policy on COVID-19 prevention was reviewed, which required full PPE, including face shields, for staff entering rooms of residents with suspected or confirmed SARS-CoV-2 infection.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not addressing peeling paint on the walls and a black stain on the floor in the resident's room. The resident, who was admitted with diagnoses including muscle weakness, anxiety disorder, and insomnia, had moderately impaired cognition and lacked the capacity to make decisions. During an observation, the Director of Nursing (DON) confirmed the presence of peeling paint and a black stain on the floor, acknowledging that these issues had not been reported to the Maintenance Department until the surveyor's visit. Interviews with the DON and the Director of Maintenance (DM) revealed that the facility's policy required staff to report environmental issues, such as peeling paint and stains, to the Maintenance Supervisor. However, the DM was unaware of the issues in the resident's room until informed by the DON during the survey. The facility's policy and procedure emphasized the importance of maintaining a safe, clean, and homelike environment, which was not upheld in this instance.
Failure to Develop Individualized Care Plan for Resident on Ativan
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident who was prescribed Ativan for anxiety. The resident, who had diagnoses of anxiety and dementia, was admitted and readmitted to the facility with severely impaired cognition affecting daily decision-making. The Minimum Data Set (MDS) assessment indicated the resident required varying levels of assistance with daily activities, including eating, hygiene, and dressing. Despite these needs and the prescription of Ativan to manage anxiety symptoms such as yelling and screaming, the facility did not create a care plan to address the use of Ativan and ensure appropriate care and interventions. During a review of the resident's medical records, it was confirmed by the Registered Nurse Supervisor that no care plan had been developed for the management of Ativan. The Director of Nursing also acknowledged the absence of a comprehensive care plan tailored to the resident's specific needs. The facility's policy on Comprehensive Care Plans, revised in March 2023, mandates the development of a person-centered care plan within seven days of completing the comprehensive MDS assessment, which was not adhered to in this case.
Failure to Revise Care Plan for Resident's Skin Injury
Penalty
Summary
The facility failed to revise the care plan for Resident 228 when a change in the condition of a skin injury was observed. Resident 228, who has a medical history including type two diabetes mellitus, end-stage renal disease, and dependence on renal dialysis, was readmitted to the facility with mild cognitive impairments. The resident's care plan, initially addressing open scratches on the right hip, included an intervention for staff to notify the Medical Doctor if treatment was ineffective. However, when the scratches appeared macerated and white in color, indicating a change in condition, the care plan was not updated. During a review of the Non-Pressure Sore Skin Problem Report, it was noted that the change in the condition of the scratches occurred on 7/24/2024. The Director of Nursing confirmed that the care plan should have been revised to ensure appropriate treatment was provided. The facility's policy on comprehensive care plans requires that they be reviewed and revised after each comprehensive and quarterly MDS assessment, with objectives and timeframes to meet the resident's needs. The failure to update the care plan potentially delayed necessary care and treatment for Resident 228's skin injury.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the safe administration of medications during an observation involving a resident. During the medication administration, a Licensed Vocational Nurse (LVN) prepared 13 medications for a resident and accidentally dropped three pills on the floor. Instead of discarding the contaminated pills, the LVN picked them up and placed them back into the medication cup, which was then handed to the resident. The surveyor intervened before the resident could consume the contaminated medications. The resident involved had been admitted to the facility with diagnoses including heart failure and a malignant neoplasm of the right kidney. The resident required partial assistance for personal hygiene and transfers. The Director of Nursing confirmed that the facility's policy required nurses to discard any medications that fell on the floor to prevent contamination, aligning with professional standards of practice. The facility's policy on medication administration emphasized the importance of preventing contamination or infection during the process.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, identified as Resident 42, who was observed to have unclean, yellow, and long toenails on both feet. This deficiency was noted during an observation and interview conducted on July 30, 2024, where the resident expressed a desire for shorter toenails, indicating that no one had trimmed them. The resident's toenails were described by a Licensed Vocational Nurse (LVN) as yellow, thick, long, and surrounded by dry skin. The resident had been seen by a podiatrist on May 21, 2024, but the facility's policy required nail care to be provided as needed between scheduled visits. The resident, who had diagnoses including Chronic Kidney Disease, dementia, and schizophrenia, was noted to have moderately impaired cognition and required assistance with personal hygiene. Despite the facility's policy and the resident's needs, the Social Services Designee (SSD) was not informed by the nursing staff about the resident's long toenails until July 30, 2024. The Director of Social Services confirmed that the last podiatry consult was in May, and the facility's policy indicated that nail care should be provided as needed, highlighting a lapse in communication and care coordination within the facility.
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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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