Greenfield Care Center Of Fairfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, California.
- Location
- 1260 Travis Blvd, Fairfield, California 94533
- CMS Provider Number
- 055189
- Inspections on file
- 41
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Greenfield Care Center Of Fairfield during CMS and state inspections, most recent first.
A resident with pneumonia and acute/chronic respiratory failure, normally cognitively intact and full code, developed hypoxia, shortness of breath, and altered level of consciousness. An LN found the resident repeatedly saying the same sentence, with O2 sat in the low 80s on supplemental O2, increased the O2 flow, and called the on-call physician, who ordered an ER transfer via non-emergency transport. The resident was transferred without documented escalation to a non-rebreather mask and without calling 911, despite facility policy and the DON’s and NP’s statements that O2 sat below 88% with decreased consciousness requires activation of emergency response/911. ER records later showed a GCS of 7 and intubation for acute respiratory failure, and the facility’s policies and the state Nursing Practice Act require initiation of emergency procedures based on such observed abnormalities.
A resident with multiple medical and cognitive issues was not permitted to return to the facility after a hospital transfer, despite not exhibiting behaviors that endangered herself or others. Facility staff cited safety concerns due to the resident's confusion and attempts to leave, but there was no physician documentation or evidence that the facility could not meet her needs. The refusal to readmit led to the resident remaining in the hospital unnecessarily.
A resident with confusion, impaired mobility, and a history of wandering was inaccurately assessed as low risk for elopement, resulting in the absence of a wander guard and insufficient supervision. The resident left the facility unnoticed, crossed a busy street, and was found wandering at another location, exposing her to significant health hazards.
Surveyors found that the facility did not have a required remote manual stop station for its propane emergency power supply system and could not provide documentation of a four-hour load test, as confirmed by observation, record review, and staff interview. These deficiencies affected all residents and smoke compartments.
Surveyors observed that a relocatable power tap was connected to another relocatable power tap at the nursing station, in violation of electrical safety codes. Maintenance staff were unaware of this connection, and the deficiency affected multiple residents and a smoke compartment.
A long-term care facility failed to administer medications timely for several residents, leading to severe pain and potential health risks. Delays were due to late orders, missing prescriptions, and administrative issues, affecting residents' comfort and well-being.
Four residents did not receive prescribed pain medications as ordered due to delays in order transcription, lack of valid prescriptions, and medication unavailability, leading to unnecessary pain, emotional distress, and impaired comfort, activity, and sleep.
The facility failed to properly dispose of garbage, as the dumpster was observed overflowing and unable to close, which could attract pests. This was confirmed by a kitchen staff member and the facility's RD, who emphasized the importance of keeping dumpster lids closed. The facility's policy requires garbage to be stored in a manner inaccessible to vermin, with dumpsters kept closed.
The facility failed to protect resident privacy by improperly disposing of meal tray tickets containing personal and medical information. Staff routinely discarded these tickets into regular trash, which was then taken to unsecured dumpsters, risking unauthorized access to sensitive information. The facility's policy required shredding of these tickets, but this was not followed, affecting 54 residents.
Two residents in an LTC facility did not receive appropriate pain management as per physician orders and facility policy. One resident with multiple diagnoses, including osteoarthritis and chronic pain syndrome, received inconsistent pain medication, leading to severe pain and distress. Another resident with a fracture and neuralgia received medication for moderate pain instead of severe pain, contrary to orders. The facility's policies emphasize adherence to prescriber orders, which was not followed, resulting in unnecessary pain and emotional distress.
The facility failed to provide timely pharmaceutical services, resulting in residents not receiving prescribed medications on time. Delays were due to late receipt of orders by the pharmacy and subsequent delivery issues. Residents with chronic conditions experienced adverse effects, and the facility did not follow procedures for medication delivery and accountability, increasing risks of drug diversion.
The facility had a medication error rate of 10% due to improper administration practices. Two residents received Polyethylene Glycol powder with insufficient water, contrary to manufacturer instructions. Additionally, a resident's G tube was not flushed between medications, violating protocol. These errors contributed to the facility's high error rate.
A facility failed to safely store medications in Medication Cart C, where unused medications from a discharged resident and an expired narcotic were found. A nurse acknowledged the error and removed the medications. The DON stated that nurses are expected to check expiration dates and remove expired or unused medications. The facility's policy requires disposal of such medications according to laws.
The facility failed to fill a full-time Dietary Manager/Supervisor position with a qualified individual after the current manager went on medical leave. A kitchen staff member without the necessary training and qualifications was placed in the role, potentially risking the nutritional status of 60 residents. The part-time RD confirmed the lack of proper credentials for the acting manager, and the facility Administrator acknowledged the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 residents. The sanitizing solution was below effective concentration, and a dietary aide worked without a beard cover. Food items were improperly stored and labeled, with some lacking use-by dates. Dishware was stored wet, and some cookware was unsanitary. These practices could lead to foodborne illness, as confirmed by the Registered Dietician.
The facility failed to maintain effective infection control, with staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene. A resident on EBP received wound care without required PPE, and another resident's family member provided care without PPE. Additionally, staff failed to perform hand hygiene during medication administration, and glucometers were not properly disinfected. The Infection Preventionist and Director of Nursing confirmed these lapses, highlighting the need for adherence to infection control protocols.
The facility failed to conduct mandatory Effective Communications in-services for direct care staff, affecting 60 residents. The Director of Staff Development confirmed that no communication training was included in the 2024/2025 In-Service Calendar, and none had been conducted in 2024 or 2025. This failure contradicts the facility's policy to develop and improve staff skills through ongoing in-service training.
The facility did not provide training on resident rights and facility responsibilities to indirect staff members, as confirmed by the Director of Staff Development. The in-service training calendar for 2024/2025 lacked this essential training, despite the facility's policy requiring ongoing development for all personnel. This oversight affected a census of 60 residents.
The facility failed to conduct mandatory training on its QAPI program for all staff, as confirmed by the DSD during a review of the 2024/2025 in-service calendar. The absence of QAPI training sessions was contrary to the facility's policy on ongoing staff development, potentially leading to poor communication and compromised resident care.
The facility did not conduct required behavioral health training for staff, as confirmed by the Director of Staff Development (DSD) during a review of the 2024/2025 In-Service Calendar. An in-service on the needs of aged and ill patients was scheduled but not conducted, violating the facility's policy for ongoing staff development.
Two residents with significant physical and cognitive impairments were left without appropriate or functional call light systems. One was unable to use the standard call light due to limited hand mobility, and the other was given a nonfunctional alternative after being moved to a room with a broken call light. Staff and maintenance confirmed the deficiencies, and facility policy required prompt repair or replacement of call systems.
The facility failed to maintain dignity and respect for three residents. A resident was humiliated by a CNA's demeaning comments about her use of a commode. Two residents with severe cognitive impairments were assisted with meals in a disrespectful manner, as CNAs stood over them instead of sitting. The inappropriate actions were acknowledged by the CNAs and confirmed by the Director of Nursing.
The facility failed to ensure accessible call light systems for three residents, leading to potential unmet needs. A resident with multiple sclerosis had a call light out of reach due to a contracted hand. Another resident with hemiplegia was without a call light while on a Geri chair, and a third resident with cerebral infarction had a call light on the floor. Staff confirmed these deficiencies, which contradicted care plans and facility policy.
The facility failed to provide a written transfer agreement with a local GACH, as required by federal regulations. The DON was unable to produce the agreement during multiple interviews, acknowledging the requirement but failing to locate it. This deficiency could potentially risk residents' continuity of care and treatment.
A resident's Foley catheter drainage bag was observed on the floor, contrary to the facility's infection control policy. Staff confirmed that this practice increases infection risk, as the policy requires the bag to be kept off the floor to prevent bacterial contamination.
The facility failed to ensure call lights were within reach for two residents, leading them to yell for help. Staff confirmed the call lights were inaccessible, which is against facility policy. The deficiency involved residents with muscle weakness, neuromuscular dysfunction, hyperlipidemia, and anemia.
A resident experienced a 22-day delay in UTI treatment, risking acute kidney failure, while three others missed critical medications due to pharmacy delays. One resident with respiratory issues was transferred to higher care after missing medications, and another with heart conditions missed doses for two days. The DON acknowledged failures in medication administration and pharmacy delivery adherence.
The facility failed to notify two residents and their Responsible Parties (RPs) of changes in their medical conditions or treatment plans. One resident with severe cognitive impairment was not informed about changes in skin condition, while another resident was not notified about the extension of intravenous antibiotic therapy. Staff interviews confirmed the facility did not follow its policy of notifying residents and RPs, violating their rights and potentially impacting care quality.
A facility failed to ensure timely administration of insulin for a diabetic resident and did not implement a nurse practitioner's treatment plan for another resident. The insulin was administered late on multiple occasions, and the NP's recommendations for pressure ulcer prevention were not followed. Staff interviews confirmed the importance of adhering to orders, but the facility's policies were not followed, leading to deficiencies in resident care.
A licensed nurse in an LTC facility reused an alcohol wipe on a resident's abdomen after administering insulin, contrary to infection control protocols. The resident, dependent on staff for care and with a history of diabetes, requested the site be wiped again, leading the nurse to reuse the wipe due to a lack of extras. Staff interviews confirmed this practice poses a risk of infection, violating the facility's infection prevention policy.
The facility failed to ensure all CNAs were CPR certified, as required by policy. Interviews revealed that four CNAs lacked CPR certification and were unfamiliar with emergency procedures, relying on licensed nurses for assistance during emergencies. The DSD confirmed the absence of a CPR team, and the facility's policy indicated that key clinical staff should maintain CPR certification.
A resident with a history of heart transplant did not receive Tacrolimus as prescribed, with a staff member administering an incorrect dose without a prescriber's order and failing to conduct required weekly lab tests. The facility's policy on medication orders was not followed, compromising safe care delivery.
A resident with severe cognitive impairment and high fall risk experienced a fall due to the facility's failure to consistently implement a non-skid mesh intervention on the wheelchair. Despite recommendations from the Director of Rehabilitation, the mesh was missing, and staff were unaware of its necessity, leading to the resident's fall and subsequent injuries.
A resident with cognitive impairment was physically assaulted by another resident, resulting in injuries. The incident was witnessed by a CNA, and the aggressor admitted to hitting the victim due to noise. The facility's policy states residents should be free from abuse, but the altercation occurred nonetheless.
A resident with heart failure and pressure ulcers experienced respiratory distress, indicating pneumonia onset. Despite a chest x-ray confirming pneumonia and orders for antibiotics and aspiration evaluation, the facility failed to implement a care plan with necessary interventions like oxygen administration and aspiration monitoring. The resident was transferred to the hospital without consistent intervention implementation, contrary to facility policies.
The facility failed to prevent and treat pressure ulcers for three residents, leading to the development and worsening of wounds. One resident developed a Deep Tissue Injury and a Stage 4 pressure ulcer due to improper monitoring and treatment. Another resident's left heel pressure ulcer was not identified or treated, causing pain and discomfort. A third resident did not receive wound dressing changes as ordered, and his heels were not floated, leading to a wound infection.
The facility failed to implement an effective fall management program for three residents with dementia, leading to multiple fall incidents and injuries. The facility did not follow care plans, address causal factors, or provide adequate supervision, resulting in falls that caused significant injuries, including a head contusion and femur fracture.
The facility failed to provide adequate pain management for four residents, leading to repeated pain and discomfort during care and treatment. Residents with severe contractures, pressure ulcers, and post-surgical conditions were not given pain medication as needed, resulting in visible signs of pain and inadequate pain relief.
The facility failed to assess, monitor, and provide necessary care for two residents, leading to severe health complications. One resident developed a deep tissue injury and an open wound that worsened, resulting in an above-the-knee amputation. Another resident experienced severe constipation and a small bowel obstruction, leading to an emergency hospital transfer.
The facility failed to post the contact information for the State Survey and Certification agency, leaving six residents uninformed about their right to file complaints about their care. Staff members confirmed the absence of this information, and residents expressed frustration and sadness over not knowing how to contact the State.
The facility failed to ensure that 28 out of 35 rooms met the required 80 square feet per resident in multiple-occupancy rooms. Rooms with two beds provided only 71.5 square feet per resident, and rooms with four beds also provided 71.5 square feet per resident. The Administrator admitted that the application for a room waiver had not been sent to the California Department of Public Health.
The facility failed to treat residents with respect and dignity, as evidenced by unlicensed staff neglecting residents' needs and displaying poor attitudes. Additionally, the facility did not follow its laundry policy, leading a resident to mistrust the service and wear only a patient gown due to lost personal clothes.
The facility failed to ensure accurate MDS assessments for two residents. One resident's right above-the-knee amputation was not documented, and another resident's healed pressure ulcer was inaccurately reported as unhealed. The MDS Coordinator confirmed these inaccuracies, emphasizing the importance of accurate assessments for proper care planning.
The facility failed to develop and implement person-centered care plans for two residents, leading to multiple falls for one resident and inadequate pain management for another post-amputation. The care plans were generic and did not address specific risks or provide necessary interventions, resulting in potential harm and discomfort.
The facility failed to meet professional nursing standards for five residents, leading to multiple deficiencies. Two residents with pressure ulcers had improperly inflated mattresses, one resident did not receive pain medication as prescribed, another resident's neurological condition was not adequately assessed, and a resident expressing suicidal ideations was not monitored as required.
A resident with multiple health conditions did not receive scheduled showers, leading to poor personal hygiene. Despite being scheduled for showers twice a week, the resident only received bed baths and partial baths during the review period. Staff admitted to not providing the showers, and no complaints were reported to the DSD.
The facility failed to provide activities to meet the needs and preferences of four residents, resulting in feelings of loneliness, isolation, and depression for one resident. Despite care plans indicating preferences for TV and music, these activities were not facilitated, leaving residents without interaction or entertainment.
The facility failed to provide appropriate ROM treatment for two residents, leading to pain and potential worsening of contractures. One resident did not have a hand roll applied as ordered, and the other did not consistently receive RNA services. Documentation and communication issues between departments contributed to these deficiencies.
The facility failed to provide appropriate respiratory care for two residents. One resident did not receive continuous oxygen therapy as ordered, and there was no documentation of respiratory assessments. Another resident received oxygen therapy above two liters per minute without a required humidifier, risking nasal dryness and bleeding.
The facility failed to maintain adequate staffing levels for CNAs and Licensed Nurses, leading to delayed care and resident complaints. Residents reported long wait times for assistance, and staff acknowledged the negative impact of short staffing on resident safety and care quality.
Failure to Initiate Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate emergency treatment and care according to physician orders, resident preferences, and established policies when a resident experienced acute respiratory distress and altered mental status. The resident had been re-admitted with diagnoses including pneumonia and acute and chronic respiratory failure with hypoxia and had a POLST indicating full code status. An MDS assessment documented intact cognition at baseline. On the date of the incident, an SBAR noted hypoxia, altered level of consciousness, and shortness of breath. According to the nurse’s notes, at approximately 9 p.m. a licensed nurse entered the resident’s room to administer bedtime medications and found the resident awake, able to take medications, but repeatedly saying the same sentence. The nurse documented that when asked if he was okay, the resident opened his eyes and then closed them again. The resident’s O2 saturation was 84% on 3 L O2 via nasal cannula; the nurse increased the oxygen to 4 L, but the O2 saturation remained low at 82–83%. The nurse contacted the on-call physician at 9:30 p.m., obtained an order to send the resident to the emergency room for hypoxia, and arranged a non-emergency transport that arrived at 9:45 p.m., with transfer out at 10 p.m. There was no documentation that staff changed the nasal cannula to a non-rebreather mask. In interviews, the licensed nurse stated she noted the resident’s difficulty breathing, continuous oxygen use, low O2 saturation, and behavior not consistent with baseline, and that she called the on-call physician, who ordered transfer to the ER. The DON stated that respiratory distress with O2 saturation below 88% and decreased level of consciousness requires activation of the emergency response system by calling 911, and confirmed that the resident’s condition warranted a 911 transfer. The nurse practitioner, after reviewing the case and ER records, stated the resident should have been transferred via 911 due to hypoxia, altered responsiveness, and continued desaturation despite oxygen, and noted that ER records showed a GCS of 7 on arrival and subsequent intubation for acute respiratory failure. The facility’s policies on Emergency Procedures and Change of Condition require immediate medical care and initiation of emergency procedures, including calling 911 and providing first aid until emergency personnel arrive, and the California Nursing Practice Act requires initiation of emergency procedures based on observed abnormalities. The failure to call 911 and initiate an emergency response in accordance with these standards constituted the deficiency.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, in violation of federal requirements for permitting residents to return to the facility following a hospital stay or therapeutic leave. The resident, who had been admitted with multiple diagnoses including stroke, depression, and muscle weakness, was described as friendly but disoriented, requiring staff assistance for personal care, eating, transfer, and ambulation. After admission, the resident eloped from the facility and was found at another facility across the street. Upon return, the resident was placed on one-on-one supervision and later sent to the emergency room for evaluation. Despite repeated requests from the hospital, the facility refused to readmit the resident, citing concerns about the resident's safety due to confusion, agitation, and a tendency to attempt to leave the facility. Interviews with facility staff, including the Administrator and DON, revealed that the decision to refuse readmission was based on the belief that the resident was not safe at the facility, particularly given its proximity to a busy street. However, staff interviews and documentation indicated that the resident did not exhibit physical aggression, agitation, or behaviors that endangered herself or others. The resident was described as confused, talking about wanting new slippers, and attempting to get up from her wheelchair, but not combative or aggressive. The facility's own policies required that discharges or refusals to readmit be based on documented evidence that the resident's needs could not be met or that the resident posed a danger to themselves or others, with physician documentation supporting such decisions. In this case, there was no documentation from a physician indicating that the resident's needs could not be met or that transfer was necessary. The DON acknowledged the lack of clinical records supporting the decision and agreed that interventions such as a wander guard and adequate supervision might have prevented the elopement and subsequent transfer. The failure to permit the resident's return resulted in the resident remaining unnecessarily in the hospital while awaiting placement.
Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, muscle weakness, difficulty walking, and acute encephalopathy caused by stroke, was admitted to the facility. The resident was documented as confused, disoriented to time, place, and person, and required staff assistance for personal care, eating, transfer, and ambulation. Despite these factors, the facility's elopement assessment rated the resident as low risk for elopement, which was later acknowledged by the Director of Nursing to be inaccurate. On the day following admission, the resident was observed by a licensed nurse standing by her room door with a walker, expressing confusion and searching for slippers. Later that day, a concerned citizen notified facility staff that the resident had been found wandering in the parking lot of another facility across a busy street. The resident had left the facility without staff knowledge, crossed a dangerous roadway, and was found confused and wearing only socks, insisting she needed to buy new slippers. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the resident had no wander guard in place due to the inaccurate elopement assessment. Staff acknowledged that the resident was confused, wandered frequently, and required significant redirection and supervision. The facility's own policy required identification and intervention for residents with exit-seeking behavior, but these procedures were not effectively implemented, resulting in the resident's unsupervised elopement and exposure to significant health hazards.
Failure to Maintain Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) in accordance with regulatory requirements. During a tour and review of records, it was observed that the facility did not have a remote manual stop station for its five-kilowatt propane EPSS. The absence of this stop station was confirmed through observation and interview with the Maintenance Staff, who stated they were unaware of the requirement for such a device. Additionally, the facility was unable to provide documentation of a required four-hour load test for the EPSS when requested. The Maintenance Staff confirmed that no such documentation was available for review. This indicates that the facility did not perform or could not verify the performance of the four-hour load test as required by NFPA 110 standards. These deficiencies affected all 57 residents and three smoke compartments within the facility. The lack of a remote manual stop station and the absence of documentation for the four-hour load test were directly observed and confirmed through staff interviews and record review.
Plan Of Correction
K 918 - Electrical Systems - Essential Electric System. Continue A. 1. C. Bates Electric company installed the remote manual stop station for the five-kilowatt propane EPSS on 4/11/25. 2. The annual service and the four-hour load bank test for the generator is scheduled on 4/18/25 by the C and D Power company. B. There is only one generator in the building. No other concerns with this deficient practice. C. The Administrator provided an in-service on 4/14/25 to the Maintenance Staff regarding the requirements of the Life and Safety findings K 918 Electrical Systems - Essential Electric System including but not limited to: 1. Remote manual stop station for the five-kilowatt propane EPSS. 2. The Administrator provided an in-service to the Maintenance Staff regarding the annual service and the four-hour load bank test for the facility generator. D. Monitoring 1. Maintenance Staff will monitor and test the remote manual stop station for the five-kilowatt propane EPSS once a month during generator test and by the facility contracted vendor that provides service to do the four-hour load bank test for the generator. It will be recorded on the "Generator Log." 2. The Maintenance Staff and Administrator will monitor to make sure that the annual service and the four-hour load bank test for the generator is conducted annually by the facility contracted vendor for the generator preventative maintenance. A log will be maintained to record the annual generator service on the "Generator Log." The log will be kept by the Maintenance Staff and is available for inspection when requested. E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice of K 918 Electrical Systems and Essential Electric System; remote manual stop for the generator is maintained and the four-hour generator load test is performed annually. Completion Date: April 18, 2025
Improper Use of Relocatable Power Taps in Nursing Station
Penalty
Summary
During a facility tour, surveyors observed a deficiency related to the improper use of electrical equipment and wiring. Specifically, at the nursing station, a relocatable power tap was found connected to another relocatable power tap, which is not compliant with NFPA 101 and NFPA 70 standards. The maintenance staff, when interviewed, stated that he was not aware that the relocatable power taps were connected to each other. This non-compliant use of electrical equipment was found to affect 16 out of 57 residents and one of three smoke compartments. The report documents that the facility failed to ensure that electrical equipment, including power strips and extension cords, was used in accordance with applicable codes and standards. The improper connection of power taps was directly observed by surveyors, and the maintenance staff's lack of awareness contributed to the deficiency. No information about corrective actions or follow-up measures is included in the report.
Plan Of Correction
K 920 Electrical Equipment - Power Cords and Extensions A. The Maintenance Supervisor immediately removed the relocatable power tap that was connected to another relocatable power tap being used at the nursing station. The two relocatable power taps are now both connected directly to the electrical power outlet. The facility is now in compliance with the use of a relocatable power tap. B. The Maintenance Staff made rounds in the facility and checked the extension cords and electrical equipment in the building to ensure compliance. No other problems were identified, same as this deficient practice. C. The Administrator provided an in-service to the Maintenance Staff regarding compliance with this deficiency regarding proper use of extension/power cords and to ensure compliance with the use of relocatable power taps; (plug directly to the wall electrical outlet and not with another power tap). D. The Maintenance Staff will monitor appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. It will be documented on the "Extension Cord Monitoring Log." E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice, such as appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. Completion Date: April 18, 2025
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications for nine residents, leading to significant discomfort and potential health risks. Residents experienced delays in receiving prescribed medications due to late orders, lack of valid prescriptions, and administrative oversights. For instance, Resident 265 did not receive morphine sulfate on time, resulting in severe pain and sleep disturbances. Similarly, Resident 60 and Resident 267 faced delays in receiving their medications, which posed risks to their health conditions. The report highlights multiple instances where medication orders were either sent late to the pharmacy or lacked necessary authorizations, causing delays in delivery. Resident 264's pain medication was not administered for several days due to a missing valid prescription, leading to severe pain and limited daily activities. Resident 266 also experienced delays in receiving pain and respiratory medications, resulting in severe pain and potential breathing difficulties. Additionally, the facility's failure to administer medications as per physician's orders and professional standards was evident in the case of Resident 48, where a licensed nurse did not safely administer medications via a gastrostomy tube. These deficiencies indicate systemic issues in medication management and order processing within the facility, adversely affecting residents' well-being and comfort.
Failure to Provide Timely Pain Medication Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that four residents received their prescribed pain medications in accordance with physician orders, resulting in significant medication errors. For each resident, there were delays or omissions in administering pain medications such as morphine sulfate, pregabalin, Qulipta, and buprenorphine. These failures were due to issues such as delayed transcription and faxing of medication orders to the pharmacy, lack of valid prescription orders, and the absence of certain pain medications in the facility's emergency kit. In several cases, the pharmacy did not receive the necessary orders in a timely manner, which led to delays in medication delivery and administration. Residents affected by these deficiencies had medical histories that included fractures, neuralgia, neuritis, osteoarthritis, chronic pain, migraines, and diabetes with neuropathy. Upon admission, these residents experienced moderate to severe pain, as documented in their clinical records and pain assessments. The medication administration records (MARs) showed that scheduled doses of pain medications were marked as held and not given, and progress notes indicated that medications were not available or pending delivery from the pharmacy. Interviews with residents confirmed that they experienced severe pain, difficulty sleeping, and emotional distress due to not receiving their pain medications as ordered. Staff interviews and record reviews revealed that delays in processing and transmitting medication orders contributed to the problem. The admissions coordinator acknowledged that it could take several hours for nurses to transcribe and fax orders, and that issues with electronic transmission from hospitals further complicated timely medication access. The facility's policies required prompt verification, transcription, and communication of medication orders, but these procedures were not consistently followed, resulting in residents experiencing unnecessary pain and discomfort.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during an inspection of the kitchen and garbage dumpster area. The dumpster was found to be overflowing, preventing the lid from closing, which was acknowledged by a kitchen staff member. This situation was confirmed during an interview with the facility's Registered Dietitian, who stated that dumpster lids should be closed to prevent attracting pests. A review of the facility's policy on food-related garbage disposal indicated that all garbage and food waste should be kept in containers and stored in a manner inaccessible to vermin, with outside dumpsters kept closed.
Improper Disposal of Resident Meal Tray Tickets
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tray tickets. During observations and interviews, it was noted that Dietary Aide 2 and Cook 2 routinely discarded used resident meal tray tickets into the regular kitchen trash, which was then taken to the dumpsters outside the facility. The dumpsters were observed to be overflowing and unsecured, posing a risk of unauthorized access to the residents' protected health information. The meal tray tickets contained sensitive information such as residents' names, room numbers, diet orders, and other personal details. The facility's policy required that resident meal tray tickets be shredded when no longer needed, but this procedure was not followed. The Registered Dietician confirmed that the tickets should be shredded to comply with HIPAA regulations. Observations on subsequent days revealed that identifiable information from residents was still being discarded improperly, indicating a systemic issue with the facility's handling of confidential information. This failure affected 54 out of 60 residents who consumed facility-prepared meals, exposing their personal and protected health information to potential unauthorized access.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management services for two residents, Resident 264 and Resident 265, as per professional standards, facility policy, and physician orders. Resident 264, who was admitted in February 2025, had multiple diagnoses including osteoarthritis, diabetes mellitus, neuropathy, chronic pain syndrome, and major depressive disorder. Despite having an intact cognition and experiencing frequent pain that affected her daily activities, Resident 264 did not receive her prescribed pain medications consistently upon admission. Her medication administration records indicated that she received oxycodone for moderate pain and hydrocodone-acetaminophen for severe pain, contrary to the physician's orders. Resident 265, admitted in February 2025, had a moderately impaired cognition and diagnoses including a fracture of the left humerus, neuralgia, and neuritis. Her care plan indicated a need for pain management due to her fracture. However, her medication administration records showed that she received hydrocodone-acetaminophen for moderate pain, although it was prescribed for severe pain. This inconsistency in medication administration was confirmed by a licensed nurse, who acknowledged the risk of over-medication or drug dependence when the medication was given for moderate pain. The Director of Nursing confirmed that staff should adhere to physician orders when administering medications. The facility's policies on pain management and medication administration emphasized the importance of following prescriber orders to ensure safe and effective pain management. The failure to adhere to these policies and physician orders resulted in unnecessary pain and emotional distress for the residents, affecting their physical comfort and psychosocial well-being.
Delayed Medication Administration and Policy Non-Compliance
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of its residents, as evidenced by multiple instances where residents did not receive their prescribed medications in accordance with physician orders. Residents, including those with diabetes mellitus, respiratory conditions, and other chronic illnesses, experienced delays in receiving critical medications such as metformin, insulin glargine, and various inhalers. These delays were often due to late receipt of medication orders by the pharmacy and subsequent delayed deliveries, which were not aligned with the facility's policy of timely medication administration. The report highlights specific cases where residents were adversely affected by these delays. For instance, a resident with diabetes did not receive metformin on time, posing a risk of elevated blood sugar levels. Another resident with chronic obstructive pulmonary disease did not receive their inhaler, leading to difficulty breathing. In several cases, the facility's emergency medication kit did not contain the necessary medications, further exacerbating the issue. Interviews with residents revealed dissatisfaction and discomfort due to the lack of timely medication administration. Additionally, the facility's procedures for medication delivery and accountability were not followed. Medication delivery manifests were not signed by two licensed staff members, which is a requirement for accountability. Furthermore, the facility did not adhere to its policies and procedures for the destruction of controlled medications, increasing the risk of drug diversion. These systemic issues contributed to unsafe and untimely medication use, as well as potential risks to resident health and safety.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 10%, which is above the acceptable threshold of 5%. During observations, it was noted that Licensed Nurse 2 and Licensed Nurse 3 did not follow the manufacturer's directions for reconstituting Polyethylene Glycol powder, as they used less than the recommended 4 to 8 ounces of water. This error affected Resident 48 and Resident 16, as the medication was not prepared according to the guidelines, potentially impacting its effectiveness. Additionally, during a medication administration observation, Licensed Nurse 2 administered four medications via a gastrostomy tube to Resident 48 without performing water flushes between medication boluses or after the final medication. The Director of Nursing and the Director of Staff Development confirmed that the facility's protocol and evidence-based practice require flushing the G tube with water between each medication to ensure proper medication delivery. This oversight in following the correct procedure for G tube medication administration contributed to the facility's high medication error rate.
Unsafe Medication Storage in Med Cart
Penalty
Summary
The facility failed to ensure the safe storage of medications, as observed during an inspection of Medication Cart C. Unused medications from a discharged resident were found stored in the bottom drawer of the cart, including Pantoprazole 40 mg tablets and Nifedipine 30 mg tablets. Additionally, an expired narcotic, Morphine Sulfate Oral Solution, was also found in the same drawer. Licensed Nurse 4 acknowledged that these medications should not have been stored there and proceeded to remove them immediately. The Director of Nursing stated that the expectation is for licensed nurses to check expiration dates during medication counts and to remove any expired medications or those belonging to discharged residents from the cart. The facility's policy on labeling and storing medications indicates that medications no longer in use or expired should be disposed of according to Federal and State Laws. These failures had the potential to contribute to unsafe medication use and storage, as well as the potential for diversion.
Inadequate Staffing in Dietary Management
Penalty
Summary
The facility failed to ensure that a full-time Dietary Manager/Supervisor position was filled appropriately when the current Dietary Manager went on medical leave in mid-November 2024. During this period, a kitchen staff member, who lacked the necessary training and qualifications, was placed in the role to cover for the Dietary Manager. This staff member, referred to as CK 1, acknowledged not having the regulatory training and certification required for the Dietary Manager/Supervisor position. The facility employs a part-time Registered Dietician (RD) who works on a consultant basis and is present at the facility only once a week. The RD confirmed that CK 1 was covering the Dietary Manager/Supervisor role without the required credentials, which could potentially risk the residents' nutritional status. Interviews with the facility Administrator (ADM) and the part-time RD revealed that the facility was aware of the absence of a qualified full-time Dietary Manager/Supervisor. The ADM acknowledged the differences in roles and qualifications between CK 1 and the Dietary Manager/Supervisor, and admitted that CK 1 did not have the necessary regulatory training and credentials. The facility's job descriptions outlined the qualifications required for the Dietary Supervisor role, which CK 1 did not meet. This situation had the potential to impact the nutritional needs of the facility's 60 residents adversely.
Sanitation Deficiencies in Kitchen Affecting Resident Safety
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 out of 60 residents who received food from the kitchen. During an observation, it was found that the sanitizing solution used in the kitchen was below the manufacturer's minimum effective concentration, posing a risk for foodborne illness. The acting Dietary Manager confirmed the issue and acknowledged the need for a new solution. Additionally, a dietary aide was observed working in the kitchen without a beard cover, which was against the facility's policy and could negatively impact the kitchen's sanitary conditions. Further inspection revealed that food items were not stored properly. A clear plastic bin containing Jello was found with an unsealed lid, and an opened box of pancake mix was not tightly sealed. The facility's Registered Dietician acknowledged that these practices could compromise the kitchen's sanitary conditions. Moreover, food items were not labeled with use-by dates, including a partial loaf of bread and a box of pancake mix, which were only marked with the date they were opened or received. This lack of proper labeling was against the facility's policy and could lead to the use of expired food. The inspection also uncovered unsanitary conditions in the storage of dishware. Food preparation and storage bins were stored wet and stacked, preventing them from air drying and increasing the risk of bacterial growth. Cooking and baking pans were found with blackened debris that could not be removed, indicating they were unsanitary. The Registered Dietician confirmed that these practices could lead to foodborne illness and acknowledged the need for proper drying and replacement of cookware that could not be cleaned effectively.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Resident 13, who was on EBP due to an indwelling catheter and a wound on the left knee, received wound care from the Staff Development Director without the required gown. This was confirmed by the Infection Preventionist, who stated that proper PPE, including gowns, masks, and gloves, was necessary to prevent the spread of infection. Resident 17, who was on EBP due to a gastric tube, received care from his wife without the use of PPE. The Infection Preventionist confirmed that all caregivers, including family members, should wear PPE when providing direct care to residents on EBP. Additionally, Resident 53, who had a severe sepsis diagnosis and was on EBP due to a urinary catheter and feeding tube, was repositioned by staff without the required PPE. The Director of Nursing confirmed that staff should wear gowns and gloves when repositioning residents on EBP to prevent cross-contamination. Furthermore, several licensed nurses failed to perform hand hygiene before and after medication administration, as observed with multiple residents. The Director of Nursing and the Infection Preventionist emphasized the importance of hand hygiene in preventing infections. Additionally, a licensed nurse did not properly disinfect glucometers between uses, lacking understanding of the necessary dwell time for disinfectants to be effective. This oversight was acknowledged by the Infection Preventionist, who was unaware of the dwell time requirements and planned to address this issue with the nursing staff.
Failure to Conduct Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that Effective Communications in-services were conducted as mandatory training for direct care staff, affecting a census of 60 residents. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield did not include any communication in-service training. The DSD acknowledged that no communication training had been conducted in 2024 or 2025. The facility's policy, revised in January 2025, stated that the in-service training program is intended for the development and improvement of staff skills, with classes scheduled by the in-service coordinator. However, the absence of communication training indicates a failure to adhere to this policy, potentially impacting the quality of care provided to residents.
Indirect Staff Not Trained on Resident Rights
Penalty
Summary
The facility failed to ensure that indirect staff members, who do not provide direct resident care, were educated on the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was confirmed that the 2024/2025 in-service training calendar did not include training on resident rights and facility responsibilities for indirect staff. The facility's policy on in-service training, revised in January 2025, states that the training program is intended for the development and improvement of skills for all personnel, yet this training was not conducted for indirect staff members, affecting a census of 60 residents.
Failure to Conduct Mandatory QAPI Training
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program, which is essential for maintaining and improving safety and quality in nursing homes. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 in-service calendar for the facility did not include any QAPI training sessions. Furthermore, the DSD admitted that no such training had been conducted in 2024 or 2025. The facility's policy on in-service training, revised in January 2025, emphasizes the importance of ongoing training programs for staff development and skill improvement, yet this policy was not adhered to in the case of QAPI training. This deficiency had the potential to result in poor communication among staff, a lack of awareness of facility updates, insufficient collaborative work, and compromised resident care, as the staff was not adequately informed about the QAPI program.
Failure to Conduct Behavioral Health Training
Penalty
Summary
The facility failed to conduct staff training on behavioral health, which was required as part of their facility assessment. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD). The review of the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield revealed that an in-service training on the problems and needs of aged, chronically ill, acutely ill, and disabled patients was scheduled for April 2024 but was not conducted. The DSD confirmed this omission. Additionally, the facility's policy and procedure for the In-Service Training Program, revised in January 2025, stated that the facility is committed to developing an effective in-service training program to improve the skills of all personnel. However, the planned training was not executed, leading to a deficiency in staff preparedness to care for residents with behavioral health issues.
Failure to Provide Functional Call Light Systems for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of two residents by not ensuring they had access to appropriate and functional call light systems. One resident, who was dependent on staff for all activities of daily living and had severe cognitive and physical impairments, was provided with a standard call light button that he was unable to use due to his inability to move his fingers. Multiple staff members confirmed that the resident could not operate the call light and required an alternative system, such as a soft touch pad, but this was not provided. Another resident, who was bedbound and at high risk for falls and decline in activities of daily living, was moved to a new room where the call light system was broken. As an alternative, the resident was given a blue string to pull for assistance, but the string was tangled with bed wires and was not functional. The resident was unable to use this makeshift system to call for help, and staff confirmed that the alternative provided was not a functional call light system. Maintenance records indicated the call light was reported as broken, but the issue was not resolved at the time of observation. Facility policy required that residents be provided with a means of communication with nursing staff and that defective call lights be promptly reported and repaired or replaced. Despite these policies, both residents were left without effective means to request assistance, as confirmed by staff interviews and direct observation.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain dignity and respect for three residents. Resident 160, who had no cognitive impairment, was humiliated when CNA 2 made demeaning comments about her use of a commode instead of the restroom. CNA 2 acknowledged the inappropriate nature of her comments, which left Resident 160 feeling embarrassed and disrespected. The Director of Staff Development confirmed the interaction was inappropriate. Additionally, two residents with severe cognitive impairments, Resident 45 and Resident 6, were assisted with meals in a manner that lacked respect. Both residents were reclined in Geri chairs while CNAs stood over them during meal assistance. CNA 6 and CNA 3 admitted to standing over the residents, acknowledging that they should have been seated to promote respect. The Director of Nursing confirmed the inappropriate positioning of the CNAs, which was contrary to the facility's policy on treating residents with dignity and respect.
Inaccessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for three residents, leading to potential unmet needs and communication barriers for assistance. Resident 13, who has multiple sclerosis and generalized muscle weakness, was observed with a call light button out of reach due to his contracted right hand. Both the resident and a licensed nurse confirmed the inaccessibility of the call light, which contradicted the care plan that required the call light to be within easy reach. Resident 48, diagnosed with hemiplegia, epilepsy, and dysphagia, was found without a call light within reach while lying on a Geri chair. The call light was tied to the bed's side rail, making it inaccessible. Both a family member and staff confirmed the resident's inability to reach the call light, emphasizing the need for it to be on the left side due to the resident's right-side paralysis. Resident 263, with cerebral infarction, diabetes mellitus, and atherosclerosis, was observed with the call light button on the floor, out of reach. The resident's care plan also required the call light to be within easy reach. Staff confirmed the call light's inaccessibility, which was against the facility's policy that mandates call lights to be within reach when residents are in bed.
Failure to Provide Written Transfer Agreement with Local Hospital
Penalty
Summary
The facility failed to ensure there was a written transfer agreement with a local General Acute Care Hospital (GACH), as required by federal regulations. During an interview on March 12, 2025, the Director of Nursing (DON) was unable to provide a copy of the facility's transfer agreement with a local hospital upon request. Despite multiple follow-up interviews on the same day and the following day, the DON confirmed that she was still unable to locate the transfer agreement. The DON acknowledged the requirement for such an agreement but was unable to produce it, potentially placing residents at risk for inadequate continuity of care and treatment.
Infection Control Lapse with Foley Catheter Management
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for a resident with a Foley catheter. During an observation, it was noted that the resident's Foley catheter drainage bag was left on the floor, which is against the facility's policy. The resident confirmed that this was a recurring issue, indicating a lapse in maintaining proper infection control practices. Interviews with staff, including an unlicensed staff member, the Director of Staff Development, and the Director of Nursing, confirmed that the drainage bag should not be on the floor as it increases the risk of infection. The facility's policy explicitly states that catheter tubing and drainage bags should be kept off the floor to prevent bacterial contamination, yet this protocol was not followed, putting the resident at risk for a urinary tract infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that two out of six sampled residents had their call lights within reach, which is essential for residents to communicate with staff when they need assistance. Resident 1, admitted with muscle weakness and neuromuscular dysfunction of the bladder, did not have his call light within reach, as it was found on the floor by the foot of his bed. Resident 2, admitted with hyperlipidemia and anemia, had her call light wrapped around the left side rail of her bed, making it inaccessible. Both residents reported having to yell for help due to the unavailability of their call lights. During observations and interviews, staff members, including Unlicensed Staff A, Licensed Staff B, and the Director of Staff Development, acknowledged that the call lights were not within reach and confirmed that this was not acceptable practice. The facility's policy and procedure on call lights, revised in January 2024, states that call lights should only be out of reach during resident care and must be placed within reach immediately after care or when the resident is back in bed. The Director of Nursing also emphasized the importance of having call lights within reach to prevent delays in care and ensure resident safety.
Delayed Treatment and Medication Unavailability in LTC Facility
Penalty
Summary
The facility failed to provide timely and appropriate care for four residents, leading to significant health risks. One resident experienced a 22-day delay in the treatment of a urinary tract infection. The resident was admitted with a history of urinary tract infections, diabetes, acute kidney failure, and high blood pressure. A urinalysis with culture and sensitivity was ordered, but the antibiotic treatment was not prescribed until 11 days after the test results were available, despite the nurse practitioner visiting the facility multiple times during this period. This delay in treatment posed a risk of acute kidney failure for the resident. Three other residents did not receive their prescribed medications due to unavailability, which had the potential to result in serious health issues. One resident, with a history of respiratory failure and COPD, did not receive medications for high blood pressure, fluid overload, and breathing problems. This resident became anxious and was eventually transferred to a higher level of care. Another resident, with a history of atrial flutter and transient ischemic attack, missed doses of medications for high blood pressure and stroke prevention over two days. A third resident, with a history of high blood pressure and heart failure, did not receive medications for blood pressure and potassium supplementation due to pharmacy delivery delays. The Director of Nursing acknowledged the medication administration failures and the lack of timely delivery from the pharmacy. The facility's policies required timely specimen collection and medication administration, but these were not followed, leading to the deficiencies. The DON noted that the pharmacy had scheduled delivery times to ensure medications were available, but these were not adhered to, resulting in residents missing critical medications.
Failure to Notify Residents and RPs of Changes in Condition
Penalty
Summary
The facility failed to notify residents and their Responsible Parties (RP) of changes in their medical conditions or treatment plans, leading to deficiencies in care. For Resident 2, who has severe cognitive impairment and multiple health issues including Parkinson's Disease and Bipolar disorder, the facility did not inform the RP about changes in the resident's skin condition. Despite the presence of scattered scabs, open wounds, and other skin issues, there was no documentation or communication to the RP about these changes, which is a violation of the resident's rights as per facility policy. Similarly, Resident 3, who is cognitively intact and self-responsible, was not informed about the extension of his intravenous antibiotic therapy. The resident was initially supposed to receive the therapy until a certain date, but the treatment was extended without notifying him or explaining the reason for the extension. This lack of communication led to the resident feeling frustrated and upset, as he was unaware of the changes in his treatment plan. Interviews with various staff members, including the Director of Nursing and Licensed Nurses, confirmed that the facility did not follow its policy of notifying residents and their RPs about changes in condition or treatment. The facility's policy clearly states that it is the residents' right to be informed and involved in their care planning and treatment decisions. The failure to communicate these changes not only violated the residents' rights but also potentially impacted the quality of care they received.
Failure to Follow Physician and NP Orders
Penalty
Summary
The facility failed to ensure that a Licensed Nurse (LN A) followed the Physician's Order for administering long-acting insulin to a resident with diabetes mellitus. The insulin was supposed to be administered at 9 a.m., but LN A injected it at 11:18 a.m. on one occasion, and there were multiple instances where the insulin was administered late on other dates. During interviews, LN A admitted to not following the prescribed administration time, and other staff members, including LN B and the Infection Preventionist (IP), confirmed that administering medication late could pose a safety risk to the resident. The Director of Nursing (DON) also emphasized the importance of timely medication administration as per Physician's Orders. The facility also failed to follow the nurse practitioner's (NP) treatment plan and recommendations for another resident. The resident's Electronic Treatment Administration Record (ETAR) did not reflect the NP's treatment plan, which included the use of an alternating pressure pad (APP) and heel protectors to prevent pressure ulcers. Observations revealed that the resident was not using these devices, and interviews with staff, including LN B, the IP, and the DON, confirmed that the NP's treatment plan was not implemented. The DON acknowledged that the NP's recommendations should have been followed to prevent further skin breakdown. The facility's policy and procedure documents indicated that medications and treatments should be administered in accordance with prescriber orders. However, the failure to adhere to these policies resulted in deficiencies in the care provided to the residents. The staff, including the Director of Staff Development (DSD) and LN E, recognized that the NP's treatment plan and recommendations were considered valid orders and should have been followed, but they were not carried out as required.
Improper Reuse of Alcohol Wipe After Insulin Injection
Penalty
Summary
The facility failed to adhere to proper infection control protocols when a licensed nurse (LN) reused an alcohol wipe on a resident's abdomen after administering insulin. The resident, who was admitted with diagnoses including Diabetes Mellitus, chronic pain, and hyperlipidemia, was dependent on staff for all care. During an observation, LN A was seen using an alcohol wipe to clean the resident's abdomen before injecting insulin. After the injection, the resident requested the site be wiped again, and LN A reused the same alcohol wipe, acknowledging that it was not acceptable practice and citing a lack of extra wipes as the reason. Interviews with other staff members, including another licensed nurse, the infection preventionist, and the director of nursing, confirmed that reusing an alcohol wipe is against infection control protocols due to the risk of cross-contamination and infection. The facility's policy on infection prevention emphasizes the importance of educating staff and ensuring adherence to proper techniques, which was not followed in this instance.
Lack of CPR Certification Among CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) were trained and certified in Cardiopulmonary Resuscitation (CPR), which is a critical life-saving procedure. During interviews, it was revealed that four CNAs did not have CPR certifications and were not familiar with the facility's policy and procedure for CPR. The Director of Staff Development (DSD) acknowledged that some CNAs were not CPR certified and stated that these CNAs would seek a licensed nurse in the event of a resident experiencing a heart attack or breathing failure. The Director of Nursing (DON) confirmed that CNAs without CPR certification would be unable to assist residents during emergencies such as cardiac or respiratory arrest. Interviews with individual CNAs further highlighted the deficiency. CNA 2 admitted to not being CPR certified and unable to identify cardiac or respiratory arrest, indicating she would look for a licensed nurse or supervisor during an emergency. CNA 3 and CNA 4 also confirmed their lack of CPR certification and uncertainty about the facility's emergency procedures. The DSD confirmed the absence of a designated CPR team within the facility. A review of the facility's policy and procedure document indicated that key clinical staff, including non-licensed personnel, should obtain and maintain CPR certification, which was not adhered to in this case.
Failure to Adhere to Medication Orders and Monitoring Protocols
Penalty
Summary
The facility failed to ensure that services met professional standards for a resident who was admitted with multiple diagnoses, including dementia and a history of heart transplant. The resident was prescribed Tacrolimus to prevent organ transplant rejection, with specific instructions for dosage and weekly lab monitoring. However, Licensed Staff B administered Tacrolimus 0.5 mg without a prescriber's order and altered the prescribed dose without consulting the transplant coordinator, as required by the hospital discharge orders. Additionally, the facility did not conduct the weekly Tacrolimus lab tests as ordered, with only three lab results documented over a three-month period. Interviews with staff revealed that there was no documented evidence of a prescribed order for the 0.5 mg dose, and the Nurse Practitioner confirmed that she did not authorize such a change. The Director of Nursing acknowledged the absence of a written order and emphasized the expectation for verbal orders to be documented immediately. The facility's policy required medication orders to be recorded and signed by an authorized prescriber, which was not adhered to in this case. This oversight in medication administration and monitoring compromised the safe delivery of care to the resident.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement a non-skid mesh intervention for a resident, who was at high risk for falls due to severe cognitive impairment, epilepsy, and muscle weakness. The resident, who mobilized using a wheelchair, experienced an unwitnessed fall resulting in injuries, including a skin tear and pain in the lower back and right knee. The fall risk assessment indicated a high risk for falls, and the resident's care plan did not include the recommended intervention of a non-skid mesh to prevent sliding from the wheelchair cushion. Interviews and observations revealed that the non-skid mesh was missing from the resident's wheelchair at the time of the fall and during subsequent checks. The Director of Rehabilitation had recommended the use of the non-skid mesh on multiple occasions, but it was not implemented. Staff members, including CNAs and the Director of Nursing, acknowledged the absence of the mesh and were unaware of its necessity, despite it being a bright blue and easily noticeable item. The facility's policy on fall management emphasized the importance of consistent intervention to minimize fall risks, which was not adhered to in this case.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect Resident 2 from abuse when Resident 1 physically assaulted him. Resident 1, who was cognitively intact, punched Resident 2 in the face while he was sleeping, resulting in a swollen upper lip, scratches on the right forearm, and scratches on the left-hand middle finger. This incident was witnessed by a Certified Nursing Assistant (CNA 1), who reported that Resident 1 was yelling at Resident 2 to stop making noise with his dentures before the altercation. The Director of Nursing (DON) confirmed that Resident 1 admitted to hitting Resident 2 because of the noise. Resident 2, who had severely impaired cognition due to conditions such as epilepsy, dementia, and depression, was unable to defend himself during the incident. The Social Services Director (SSD) acknowledged that the altercation was abusive. The facility's policy on abuse, neglect, and mistreatment clearly states that physical abuse includes hitting, and each resident should be free from abuse. Despite this policy, the facility did not prevent the altercation, resulting in Resident 2 being subjected to abuse.
Failure to Implement Care Plan for Resident with Pneumonia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced a change in condition indicating the onset of pneumonia. The resident, who was admitted with diagnoses of heart failure and pressure ulcers, showed signs of respiratory distress on June 1, 2024. An SBAR Communication Form documented the resident's shortness of breath, and a chest x-ray confirmed mild airspace disease in the right lower lung, indicative of pneumonia. The resident's Nurse Practitioner was informed and ordered a chest x-ray and antibiotics, and recommended an evaluation by a speech language therapist for aspiration risk. Despite these actions, the facility did not create a care plan to address the resident's pneumonia, including necessary interventions such as administering supplemental oxygen, elevating the head of the bed, and monitoring for aspiration during meals. The Director of Nursing confirmed these interventions were appropriate but were not documented in the resident's care plan. The Medication Administration Record and Treatment Administration Record showed no consistent implementation of these interventions before the resident was transferred to the hospital on June 5, 2024. The facility's policies required individualized care plans and interventions for residents with pneumonia, which were not followed in this case.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, monitor, and provide wound care treatment to prevent the development and worsening of pressure ulcers for three residents. Resident 21 was not monitored properly while wearing a Pressure Relief Ankle Foot Orthosis (PRAFO), and there was no documentation to show that he was turned and repositioned every two hours as required. Additionally, the facility did not identify or treat Resident 21's pressure ulcer on his coccyx in a timely manner, leading to its progression from a Stage 2 to a Stage 4 ulcer. The facility also failed to ensure that Resident 21's low air loss mattress was set correctly according to his weight, which contributed to the development of a Deep Tissue Injury (DTI) on his right heel and a Stage 4 pressure ulcer on his coccyx. The facility's documentation was inconsistent and inaccurate, further complicating the treatment process for Resident 21's pressure ulcers. The Director of Nursing (DON) confirmed that the pressure ulcers were facility-acquired and that the lack of proper care and documentation contributed to their development and worsening. Resident 21 reported pain and discomfort due to the pressure ulcers and stated that he was not being turned and repositioned regularly, nor was he receiving consistent incontinence care. The facility's failure to follow its own policies and procedures for pressure ulcer prevention and treatment resulted in significant harm to Resident 21. Resident 33's left heel pressure ulcer was not identified or treated by the facility, leading to pain and discomfort for the resident. The facility did not have a doctor's order to treat the wound, and there was no documentation of a skin assessment for the left heel. The lack of monitoring and treatment had the potential to worsen the wound. Resident 33 was also not turned and repositioned every two hours as required, and his heels were not floated properly, which contributed to the development of the pressure ulcer. The facility's failure to implement appropriate interventions and monitor Resident 33's condition resulted in inadequate care and potential harm. Resident 122 did not receive wound dressing changes as ordered by the physician, and his heels were not floated to prevent pressure ulcers. The facility also failed to provide an appropriate pressure-reducing surface for his bed. These failures contributed to a wound infection and potentially prevented the healing of Resident 122's wounds. The facility's lack of adherence to physician orders and nursing standards of practice resulted in inadequate care and increased the risk of complications for Resident 122.
Failure to Implement Effective Fall Management Program
Penalty
Summary
The facility failed to develop and implement an effective fall management program for three residents with dementia. For Resident 38, the facility did not follow the fall care plan, failed to address causal factors such as poor balance and comprehension, and did not revise the care plan to reduce the likelihood of future falls. These failures led to six fall incidents between June 2023 and January 2024, with the most recent fall resulting in a head contusion and emergency department visit. Staff interviews revealed that Resident 38 was often unsupervised despite being a high fall risk, and the care plan was not individualized to address her specific needs. For Resident 13, the facility did not collaborate with the physician to identify pertinent interventions after falls on two occasions and did not have the pharmacist complete a Medication Regimen Review. The facility also failed to review and re-evaluate the fall care plan for effectiveness. These failures resulted in a fall that led to a hospitalization with a diagnosis of a laceration, bruise, and femur fracture. Staff interviews indicated that Resident 13 was not adequately supervised or provided with necessary incontinence care, contributing to the fall incidents. Resident 26 also experienced repeated falls due to the facility's failure to provide one-on-one supervision as part of the fall care plan. The report highlights that the facility's policies and procedures for fall risk intervention and monitoring were not consistently followed, leading to multiple fall incidents and injuries among the residents. Staff interviews consistently pointed out the lack of supervision and inadequate implementation of care plans as significant factors contributing to the residents' falls.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for four residents, leading to repeated pain and discomfort during care and treatment. Resident 33, who had severe contractures and pressure ulcers, was not given pain medication before receiving care, resulting in visible signs of pain such as grimacing and physical aggression. Despite reports from staff about the resident's pain, there was no routine order for pain medication, and the resident's pain was not adequately addressed during care and wound treatment. Resident 21, who had an above-the-knee amputation, was not offered pain medication after returning to the facility post-surgery. The resident reported feeling pain and discomfort but was scared to ask for pain medication due to a history of drug use. The facility's records showed that the resident did not receive scheduled pain medication, and the NP acknowledged that the resident could be experiencing phantom limb pain. Residents 35 and 122 were not given pain medication before wound treatment as ordered by their physicians. Resident 35 experienced pain during wound treatment, and the medication's effectiveness had worn off by the time of the procedure. Resident 122, who had a Stage 4 pressure ulcer, reported severe pain and was not pre-medicated before dressing changes. The facility's policies on pain management and pressure ulcer prevention were not followed, leading to inadequate pain relief for these residents.
Failure to Monitor and Provide Necessary Care for Residents
Penalty
Summary
The facility failed to assess, monitor, and provide necessary care and services for two residents, leading to severe health complications. Resident 21, who was at high risk for wounds due to Diabetes Mellitus, developed a facility-acquired deep tissue injury on his right heel and an open wound on his right lateral lower leg. Despite the identification of these wounds, nursing staff did not adequately assess and monitor the wounds, resulting in the worsening of the condition. This led to Resident 21 being transferred to the hospital, where he was diagnosed with Osteomyelitis and gangrene, ultimately requiring an above-the-knee amputation. Resident 61, who was nonverbal and had a history of stroke, hemiplegia, and hemiparesis, was dependent on staff for bowel management. Nursing staff failed to monitor for signs of constipation, did not administer medication per physician orders, and did not notify the physician or family about the constipation. This resulted in Resident 61 experiencing projectile vomiting and abdominal distention, leading to an emergency hospital transfer. At the hospital, Resident 61 was diagnosed with a small bowel obstruction, severe constipation, acute kidney injury, and hypernatremia. The deficiencies in care for both residents were evident through the lack of proper wound assessment and documentation for Resident 21 and the failure to follow bowel management protocols for Resident 61. These actions and inactions by the nursing staff directly contributed to the severe health outcomes experienced by both residents.
Failure to Inform Residents of State Complaint Procedures
Penalty
Summary
The facility failed to post the contact information for the State Survey and Certification agency, which is responsible for determining whether healthcare providers meet federal certification standards to participate in Medicaid and Medicare programs. This information was not made available to residents, as observed during interviews and record reviews. Six residents, including Resident 14 and Resident 34, were not informed of their right to file a complaint with the State about the care they were receiving at the facility. Anonymous Residents 1, 2, 3, and 4 also stated they did not know where the state information postings were located or how to formally complain to the State about their care. During interviews, various staff members, including Unlicensed Staff R, the Activity Director, Licensed Staff S, and the Infection Preventionist, confirmed that the State contact information was not posted anywhere in the building. They acknowledged the importance of this information being readily available to residents, as it is their right to know how to file a complaint about their care. The Administrator and the Director of Nursing (DON) also confirmed the absence of a policy and procedure on required notices and admitted that the State contact information was not posted in the facility. Resident 14 expressed anger and frustration over not being informed of his right to contact the State, while Resident 34 felt saddened by the lack of information. The failure to provide this essential information left residents feeling uninformed about their rights and how to address their concerns about the care they were receiving. This deficiency highlights a significant lapse in the facility's responsibility to ensure residents are aware of their rights and the proper channels to file complaints about their care.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 28 out of 35 rooms met the required 80 square feet per resident in multiple-occupancy rooms. Specifically, 24 rooms with two beds each measured only 143 square feet, providing 71.5 square feet per resident, and four rooms with four beds each measured 286 square feet, also providing 71.5 square feet per resident. During an interview, the Administrator admitted that the application for a room waiver had not been sent to the California Department of Public Health. The Administrator also mentioned that some room adjustments had been made in the past, converting four-bed rooms to three-bed rooms. The deficiency was identified through observations, interviews, and record reviews, highlighting the potential impact on residents' personal space and mobility.
Failure to Treat Residents with Respect and Dignity and Follow Laundry Policy
Penalty
Summary
The facility failed to employ staff who treat residents with respect and dignity, as evidenced by multiple incidents involving unlicensed staff members. Resident 18's family member reported that an unlicensed staff member repeatedly failed to change Resident 18's soiled briefs despite being informed and called multiple times. Resident 31 indicated that an unlicensed staff member was combative, had a bad attitude, and did not clean her properly, and that complaints to leadership were ignored. Resident 12 experienced neglect when Unlicensed Staff Q turned off a bed alarm without acknowledging her or addressing her concerns, leading Resident 12 to avoid using the call light due to such interactions. The facility also failed to follow its policy regarding laundry services, resulting in Resident 7 refusing to wear anything other than a patient gown due to mistrust in the laundry services. Resident 7 reported that her personal clothes were not returned from the laundry, despite being labeled, and she often found other residents wearing her clothes. The Laundry Aide confirmed that clothes were supposed to be labeled by staff, but some clothes were found unlabeled, making it difficult to return them to the appropriate residents. The facility's policy required nursing staff to inventory and label residents' personal possessions upon admission and any additional items brought in after admission, but this was not consistently followed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately completed for two residents. For Resident 21, the MDS dated [DATE] did not address his right above-the-knee amputation, which occurred on 1/28/24. Despite a 5-day assessment being completed on 2/07/24, the amputation was not captured in the MDS assessment. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that a Significant Change in Status Assessment was not completed to reflect Resident 21's current condition. For Resident 40, the MDS dated [DATE] inaccurately indicated the presence of an unhealed pressure ulcer without specifying its stage. The MDS Coordinator confirmed that the pressure ulcer on Resident 40's right ankle had healed on 12/03/23, making the assessment inaccurate. The MDS Coordinator emphasized the importance of accurate assessments in guiding staff to develop appropriate care plans for residents. The job description for the MDS Assessment Nurse also highlighted the necessity of complete and accurate documentation.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to significant deficiencies in their care. For Resident 38, the facility did not address the causal factors of fall incidents and failed to implement relevant, consistent, and individualized interventions to prevent future falls. Despite multiple falls between June 2023 and January 2024, the care plans remained generic and did not provide specific interventions based on the resident's risk and cause of falls. Staff interviews confirmed that the fall care plans were not followed, and the resident was often unsupervised, leading to further falls and potential injuries. Resident 21's care plan did not address how the resident would be kept free from pain and discomfort after a right leg amputation. The care plan lacked interventions for pain management, and there was no scheduled pain medication ordered for the resident. Interviews with the MDS Coordinator and the DON revealed that the care plan did not include pain assessment and management, which could have resulted in the resident experiencing pain and discomfort post-amputation. The facility's policies and procedures for fall risk intervention and care planning were not adhered to, resulting in inadequate care for the residents. The fall care plans were not updated to address the root causes of falls, and the amputation care plan did not include necessary pain management interventions. These deficiencies highlight the facility's failure to provide individualized and effective care plans for its residents, leading to potential harm and discomfort.
Failure to Meet Professional Nursing Standards
Penalty
Summary
The facility failed to meet professional nursing standards for five residents, leading to multiple deficiencies. For Residents 35 and 33, who had pressure ulcers, the facility did not properly inflate their Low Air Loss (LAL) mattresses according to their weights. This oversight was confirmed during observations and interviews with staff, who admitted that the mattresses were not set correctly, potentially worsening the residents' pressure ulcers. Additionally, excessive linens were found under Resident 35, which defeated the purpose of the pressure-relieving mattress. Resident 35 also did not receive pain medication according to the doctor's orders. The resident was given a lower dose of Morphine Sulfate than prescribed for her reported pain levels, as verified through record reviews and staff interviews. This failure in pain management could have led to unnecessary pain and discomfort for the resident. For Resident 12, the facility's licensed nurses failed to appropriately assess a neurological condition related to an intracranial hemorrhage. Despite the resident's caregiver reporting significant changes in the resident's mental status, the nurses did not document or act on these changes adequately. The resident was eventually transferred to a higher level of care, where she was diagnosed with an intracranial hemorrhage requiring surgical intervention. Additionally, Resident 47, who expressed suicidal ideations, was not monitored every 15 minutes as per physician orders. The facility staff did not follow the policy for emergent transfer, placing the resident at risk of self-harm or death.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that Resident 21 received showers on his scheduled days, which were Tuesdays and Fridays. Despite being scheduled for showers twice a week, Resident 21 reported that he never received a shower and felt grimy and dirty as a result. Observations confirmed that Resident 21 had white flakes around his mouth, indicating poor personal hygiene. Interviews with the resident and staff revealed that the resident had not received his scheduled showers and instead received complete bed baths on four days and a partial bath on one day during the review period from 3/01/24 to 3/24/24. The staff admitted to not providing the showers and stated they would give a bed bath if they did not have time for a shower, but there was no record of any showers being given during this period. Resident 21, who has diagnoses including Diabetes Mellitus, morbid obesity, and hemiplegia, is dependent on staff for showering and personal hygiene. The Minimum Data Set (MDS) indicated that Resident 21 had a BIMS score of 15, showing he is cognitively intact and aware of his hygiene needs. Despite this, the facility's documentation and staff interviews confirmed that the resident's scheduled showers were not provided, and no complaints from the resident were reported to the Director of Staff Development (DSD). The facility's policy on showers, revised in January 2024, emphasizes the importance of promoting cleanliness and relaxation, but this policy was not followed in the case of Resident 21.
Failure to Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide activities to meet the needs and preferences of four residents, resulting in feelings of loneliness, isolation, and depression for Resident 12. Resident 12, who has a history of surgical amputation, major depression, and heart disease, requested a television in her room to alleviate her isolation. Despite her request, the facility did not provide a television, and the Activity Director indicated that residents must purchase their own if one is not already installed in their room. This lack of accommodation left Resident 12 without any interaction or entertainment, exacerbating her feelings of isolation and depression. Resident 21, who is cognitively intact and has diagnoses including diabetes mellitus and morbid obesity, was observed lying in bed with his television off and no other activities provided. Although his care plan indicated he enjoyed watching TV and listening to music, these preferences were not met. The Activity Director stated that Resident 21 preferred to stay in bed and received one-on-one visits, but there was no evidence of other activities being provided to him, such as books or magazines. Resident 33, who has severe cognitive impairment and a history of hemiplegia and contractures, was frequently observed lying in bed with his television and radio off. Despite his care plan indicating he enjoyed listening to the radio and watching TV, these activities were not facilitated by the staff. Similarly, Resident 40, who has a BIMS score of 5 and diagnoses including hemiplegia and congestive heart failure, was observed lying in bed with his television unplugged and no music playing. The lack of available power outlets for his TV further limited his access to preferred activities, contributing to his inactivity and potential social isolation.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to ensure that two residents, Resident 33 and Resident 5, received appropriate treatment and services to maintain joint mobility and prevent further decrease in Range of Motion (ROM). Resident 33, who was admitted with diagnoses including hemiplegia and contractures of the left hand and knee, did not have a hand roll applied to his left hand as ordered by the physician. Multiple observations confirmed the absence of the hand roll, and interviews with staff revealed inconsistencies in the application of the hand roll and the provision of passive ROM exercises. Resident 33 exhibited signs of pain during care, such as grimacing and physical aggression, indicating that the ROM exercises were causing discomfort and were not being managed appropriately by the staff. The Director of Rehabilitation acknowledged the importance of ROM exercises to prevent worsening contractures but noted that staff were instructed to stop if the resident showed signs of pain, which was not consistently followed. Resident 5, who had a history of paraplegia and multiple contractures, was supposed to receive restorative nursing assistant (RNA) services for passive ROM exercises and positioning to prevent further contractures. However, documentation revealed that Resident 5 had not been consistently receiving these services. The Director of Rehabilitation and the Director of Nursing both confirmed that Resident 5 should have been on the RNA program, but there was a lack of documentation to support that the services were provided. The RNA Weekly Assessments and Treatment Authorization Requests (TAR) showed inconsistencies, with some documents indicating that Resident 5 was not on the RNA program while others suggested that services were provided. The Director of Staff Development also confirmed that there was a disconnect in communication between the nursing and therapy departments, leading to missed orders and inconsistent documentation. The facility's policies and procedures for RNA referrals and joint mobility assessments were not followed, resulting in inadequate care for both residents. The failure to provide consistent and appropriate ROM exercises and positioning led to pain and the potential for further contractures. The discrepancies in documentation and communication between departments contributed to the deficiencies in care, highlighting a systemic issue within the facility's management of restorative nursing services.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 33 and Resident 35. Resident 33, who had diagnoses including Hemiplegia, Hemiparesis, Congestive Heart Failure, and Anxiety Disorder, was not receiving oxygen therapy as per the doctor's order for continuous oxygen at two liters per minute. Multiple observations over several days showed Resident 33 without oxygen therapy, and there was no documentation of respiratory assessments by the nursing staff. The Director of Nursing confirmed that the nurses did not follow the doctor's order and failed to monitor and document signs of respiratory distress when Resident 33 was not on oxygen therapy. Resident 35, diagnosed with Dementia and Chronic Obstructive Pulmonary Disease, was observed receiving oxygen therapy at three liters per minute without a pre-filled humidifier attached to the oxygen concentrator. The facility's policy required a humidifier for oxygen flow above two liters per minute to prevent nasal discomfort and bleeding. Observations confirmed the absence of the humidifier, and the Infection Preventionist acknowledged the risk of nasal dryness and bleeding due to this oversight. The facility's failure to adhere to the prescribed oxygen therapy and lack of proper respiratory assessments for Resident 33, along with the omission of a required humidifier for Resident 35, demonstrated a significant lapse in providing appropriate respiratory care. These deficiencies were confirmed through observations, staff interviews, and record reviews, highlighting the facility's non-compliance with physician orders and internal policies regarding respiratory care.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels for Certified Nursing Assistants (CNAs) and Licensed Nurses, resulting in complaints and potential risks to resident safety. For 20 out of 30 days in January 2024, the facility did not meet the required number of CNAs, and for two days, it did not meet the required number of Licensed Nurses. This inadequacy led to residents experiencing delays in care, with some residents having to wait for extended periods before their call lights were answered. One resident reported having to transfer herself to a wheelchair and seek help independently due to the lack of timely staff response during a COPD attack. Interviews with residents and staff highlighted the negative impact of short staffing. Residents expressed frustration and concern over frequent falls and long wait times for assistance. Staff members acknowledged the challenges posed by inadequate staffing, noting that it led to hurried care, increased risk of accidents, and delayed or missed care. One staff member mentioned that the facility's reluctance to offer overtime contributed to the staffing issues. The facility's staffing guidelines required a specific number of CNAs and Licensed Nurses based on the census, but these guidelines were not consistently met. The administrator confirmed the use of a staffing guideline but did not provide an explanation for the staffing shortfalls. The facility's policy stated the importance of adequate staffing to meet residents' needs, but the observed staffing levels did not align with this policy, leading to compromised resident care and safety.
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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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