Herman Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 2295 Plummer Avenue, San Jose, California 95125
- CMS Provider Number
- 555831
- Inspections on file
- 33
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Herman Health Care Center during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia, schizoaffective disorder bipolar type, a history of substance abuse, moderately impaired cognition, and no decision-making capacity was identified on admission as being at risk for elopement and exhibited wandering behavior. Despite this, staff did not develop or implement a person-centered care plan or document any specific interventions, monitoring, or supervision strategies to address elopement risk, even though facility policy required such measures for residents at risk of wandering or elopement. The resident was last seen walking in the courtyard and later could not be found anywhere on the premises; staff believed the resident likely climbed a perimeter fence in the dark, and multiple staff, including CNAs, an LVN, and the DON, acknowledged that there was no continuous or scheduled supervision in place to prevent the resident from leaving and that the resident remained missing.
Two residents with neurological and psychiatric conditions were administered quetiapine nightly over several months without documented evidence that non-pharmacological interventions were attempted first, as required by facility policy. The DON confirmed that staff did not document any non-drug approaches prior to giving the antipsychotic medication.
The facility failed to follow its discharge planning process for two residents with dementia and cognitive impairment, resulting in discharges to shelters without documented care plans, IDT notes, or evidence of referrals and preparation. Both residents lacked support and resources post-discharge, with one later found homeless and hospitalized.
The facility did not provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of two residents with cognitive impairments. In both cases, discharge notices were sent to the ombudsman's office on the day of discharge, rather than concurrently with notice to the residents and their representatives, as required by facility policy.
A female resident with moderate cognitive impairment and multiple psychiatric diagnoses was left unsupervised with a male resident, also cognitively impaired, resulting in her being found unclothed from the waist down in his bed while he stood nearby with his belt buckle undone. A CNA, after being threatened by the male resident, left the room without separating the residents or ensuring the female resident's safety, and no staff remained to supervise. Facility staff confirmed that the situation could have been prevented with proper supervision and adherence to abuse prevention policies.
A resident with a high fall risk due to a femur fracture and dementia experienced multiple falls in the facility. Despite being identified as needing substantial assistance and supervision, the resident was observed walking independently, leading to injuries. The facility's fall prevention plan was not effectively implemented, compromising the resident's safety.
A resident was physically abused by another resident during an argument over a chair, resulting in a minor injury. The facility's investigation confirmed the incident, which violated the facility's abuse prevention policy.
A resident with multiple diagnoses did not receive medications as ordered, as indicated by blank entries in the EMAR for several dates. Interviews with the RN supervisor and DON confirmed that the medications were not administered, and the facility's policy for medication administration and documentation was not followed.
The facility failed to follow psychiatric and medication recommendations for two residents. A resident did not receive follow-up on a PNP's medication and blood test recommendations, nor was a response from a consulting pharmacy pursued. Another resident did not receive a recommended psychiatric follow-up. These oversights were confirmed by the RN supervisor and DON.
The facility did not complete and submit 5-day investigative reports for abuse allegations made by three residents, as required by its policy. Interviews with the DON and Administrator confirmed the absence of these reports, which should have been sent to the CDPH within five working days. This failure indicates a lapse in following the facility's procedures for abuse reporting and investigation.
Two residents did not receive medications as ordered due to blank EMAR documentation, indicating non-administration. The facility's use of registry nurses contributed to this issue, as confirmed by the DON. The facility's policy for safe and timely medication administration was not followed.
A facility failed to provide and document scheduled showers for a resident dependent on staff for bathing due to a chronic medical condition. Over a one-month period, there was no documentation of showers, bed baths, or refusals, confirmed by the CNA and DON. The resident, who was cognitively intact, reported not being showered regularly according to her schedule.
The facility failed to provide care according to professional standards when nursing staff did not order medications timely for two residents, resulting in missed doses of Hydroxyzine and Clozapine. LVN A confirmed the medications ran out and were not reordered in time, contrary to the facility's policy requiring medications to be reordered five days in advance.
The facility failed to ensure proper use of bed rails for 40 residents, lacking documentation for routine maintenance, informed consents, and attempts at alternatives. Observations and staff interviews confirmed that bed rail assessments and care plans were not completed as required by facility policy.
The facility failed to ensure food safety and proper storage, with issues including ice buildup in the refrigerator gasket, stained and damaged kitchen equipment, and outdated snacks in the unit refrigerator. These deficiencies were confirmed by various staff members and had the potential to cause food contamination and illness.
The facility failed to maintain respect and dignity for seven residents by standing while feeding, not covering urinary bags, exposing a resident during care, referring to a resident disrespectfully, and not providing a privacy curtain. Staff confirmed these actions were against the facility's policies.
The facility failed to ensure informed consent was obtained or verified before administering psychotropic medications to three residents. The DON confirmed the absence of required consent forms in the medical records, despite the facility's policy mandating such documentation.
The facility failed to ensure that residents' call light buttons were within reach, affecting five residents. Observations revealed that call lights were either placed in inaccessible locations or were broken, and no alternative means of communication were provided, contrary to the facility's policy.
The facility failed to complete and transmit MDS discharge assessments and death tracking records in a timely manner for three residents. The assessments were not signed by an RNC and were not transmitted to CMS within the required timeframes, resulting in non-compliance with federal regulations.
The facility failed to develop and implement individualized care plans for five residents, including those with COPD, mood disorders, and wandering behaviors. Staff did not follow care plans or document required checks, leading to unmet care needs.
The facility failed to provide an ongoing activity program that met the needs, interests, and preferences of five residents. Observations and interviews revealed that the care plans for these residents were not followed, and there was a lack of documented activities, leading to unmet physical, mental, and psychosocial needs.
The facility failed to administer prescribed antibiotics to a resident, did not address another resident's significant sleep disturbances, and did not follow physician orders for oxygen administration and PICC line care for other residents. These deficiencies were confirmed through observations, interviews, and record reviews.
The facility failed to ensure nursing staff were competent in using the charting system before their first shift. Interviews and record reviews revealed that new staff, including registry staff, did not receive adequate training and had to rely on other staff for assistance, leading to potential issues in documentation of patient care, assessments, and medication administration.
The facility failed to post direct care staffing numbers and nursing staff responsible for direct care to residents for two consecutive days in each of the three halls. Observations revealed no staff schedule or direct patient care hours were posted. The DON was unaware of the missing information, which should have been posted according to the facility's policy.
The facility failed to provide adequate pharmaceutical services, resulting in missed doses, late medication administration, and discrepancies in controlled medication audits. Residents were affected by the unavailability of medications, incomplete documentation, and delayed emergency kit replacement.
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly medication regimen review and conducted an interim or immediate MRR for three residents. This included not evaluating whether a resident's multiple falls were medication-related, not managing diabetes medications properly, and not monitoring for signs and symptoms related to anticoagulant and aspirin use.
The facility had a medication error rate of 14.29% when five medication errors occurred out of 35 opportunities during the medication administration for a resident. Errors included administering incorrect eye drops, not administering Depakote and levothyroxine as prescribed, and failing to administer Miralax and fluticasone nasal spray. The DON confirmed that medications should be given within one hour of the ordered time.
The facility failed to ensure proper medication storage and labeling. A medication refrigerator was found unlocked and its temperature was not monitored twice daily. Additionally, issues were found with unlabeled eye drops, expired test strips, improperly stored Lorazepam, and incorrectly dated insulin pens. The DON acknowledged these deficiencies.
The facility failed to ensure garbage was properly contained when one of the receptacles' lids was not tight-fitting and could not close. The maintenance director confirmed the defective lid, acknowledging it could attract pests. This violates the FDA's 2022 Food Code and the facility's own policy requiring tight-fitting lids on garbage containers.
The facility failed to maintain an infection prevention and control program. A dietary staff member did not change gloves between tasks, and a nurse did not clean a nasal cannula before use. Additionally, the nurse did not follow proper infection control procedures during medication administration, including not wearing gloves and not sanitizing equipment.
The facility failed to document essential details regarding a resident's transfer to the hospital, including the date and time of transfer, destination, mode of transportation, and a summary of the resident's condition. Interviews with staff confirmed the missing documentation, which is required by the facility's policy.
The facility failed to accurately assess and complete the MDS for two residents, compromising the ability to develop resident-centered care plans. One resident's hospice care status was not indicated, and another resident's weight loss status was incorrectly coded.
The facility failed to follow their Policy and Procedure for the Preadmission Screening and Resident Review (PASRR) for a resident with multiple diagnoses, including paranoid schizophrenia. The required annual PASRR Screening was not completed, and the Administrator incorrectly believed it was unnecessary if the resident was readmitted without a significant change in condition.
The facility failed to ensure a safe environment for two residents. Broken glass from a wall clock was not cleaned up for five hours, posing a risk to Resident 81, who has cognitive impairment. Additionally, a wet sheet was placed on the floor near Resident 40's bed, presenting a fall risk for the resident with dementia. Both incidents contradict the facility's safety policies.
A resident with acute osteomyelitis, type 2 diabetes with diabetic neuropathy, and bipolar disorder did not receive prescribed Norco for pain management from 2/02/2024 to 2/13/2024, despite experiencing severe pain. The medication was unavailable due to a pending physician's signature, and the facility's policy on pain management was not followed.
The facility failed to ensure that two residents were free from unnecessary medications. One resident received multiple diabetes medications without proper monitoring or a care plan, while another received Lovenox and aspirin without monitoring for adverse effects and had insulin orders without a hypoglycemia protocol.
The facility did not update its bed safety policy, last revised in December 2007, after completing a recertification survey's POC. The DON acknowledged the need for quarterly reviews due to changing regulations, while the ADM confirmed the policy was reviewed but not updated. This failure had the potential to compromise residents' health and safety.
The facility failed to offer, administer, and track influenza, pneumococcal, and COVID-19 vaccines for three residents. Documentation was missing for the administration and offers of these vaccines, contrary to the facility's policy.
Several multi-resident rooms in the facility provided less than the required 80 square feet per resident, with square footage per bed ranging from 72 to 75 square feet. Despite this, staff and residents reported no issues with movement or care within the rooms, and the report recommends the continuance of the room waiver.
Failure to Develop and Implement Elopement Prevention Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent elopement for a resident who had been identified as at risk for elopement. The resident was admitted with diagnoses including paranoid schizophrenia, schizoaffective disorder bipolar type, and a history of stimulant abuse, and was receiving multiple antipsychotic and mood-stabilizing medications. The resident’s BIMS score indicated moderately impaired cognition, and the primary care physician documented that the resident did not have capacity to understand and make healthcare decisions. An elopement evaluation completed on admission produced a score indicating the resident was at risk for elopement. Despite this identified risk, review of the resident’s records showed no evidence that the facility developed or implemented a person-centered care plan addressing elopement risk, nor any documented interventions or strategies to maintain safety and prevent elopement. Review of all documented care plans revealed no person-centered care plan for elopement risk, and review of nursing notes, physician orders, and the EMAR from admission through the date of elopement showed no documented interventions for monitoring or supervision related to wandering or elopement prevention. Staff interviews, including with the LVN, CNAs, and the DON, confirmed that the resident was known to wander and was considered at risk for elopement, and also confirmed that there were no documented interventions, no continuous or scheduled supervision, and no regular monitoring of the resident’s whereabouts to address this risk. On the day of the elopement, nursing staff observed the resident walking in the courtyard outside the building in the late afternoon. When a nurse went to administer scheduled medications later that afternoon, the resident was not in the room and could not be located in the facility despite a search. Subsequent nursing alert notes documented that the facility contacted local hospitals and searched surrounding community areas but was unable to locate the resident. Staff interviews indicated that the only likely way the resident could have left the premises was by jumping over a six-foot metal fence in the dark, and staff acknowledged that the lack of supervision and monitoring contributed to the inability to prevent the resident from leaving. The DON confirmed that the resident had been identified as at risk for elopement on admission, that no person-centered care plan or interventions for elopement prevention had been developed or implemented, and that the facility was unable to determine how the resident eloped and had been unable to locate the resident as of the latest interview. The facility’s physical layout included three separate buildings surrounding a central courtyard, with six-foot metal fences and an eight-foot brick wall with a locked gate, and the maintenance director stated that the front gate was always locked and that only staff with keys could access it. However, staff interviews indicated that the resident, described as tall and thin, was physically capable of jumping the fence, and that it was dark at the time the resident likely left, which staff believed contributed to the elopement going unnoticed. The facility’s own policies on wandering and elopement and on comprehensive person-centered care plans required identification of residents at risk for unsafe wandering or elopement and inclusion of strategies and interventions in the care plan to maintain safety. Despite these policies and the resident’s documented risk factors and behaviors, the facility did not create or implement a person-centered care plan or effective monitoring and supervision interventions to prevent the resident’s elopement.
Failure to Attempt Non-Pharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to ensure that unnecessary antipsychotic medications were not administered to residents without first attempting non-pharmacological interventions. For two sampled residents, both with significant neurological and psychiatric diagnoses, there was no documented evidence that non-drug approaches were tried prior to the administration of quetiapine, an antipsychotic medication. Review of clinical documentation, medication orders, and electronic medication administration records confirmed that both residents received quetiapine nightly over several months without any record of alternative interventions being attempted beforehand. Interviews with the facility's DON confirmed the absence of documentation for non-pharmacological interventions prior to administering the antipsychotic medication to both residents. The facility's own policy requires that non-pharmacological interventions be attempted before resorting to antipsychotic medications, except in cases where behavioral symptoms are not sufficiently relieved by such interventions. The lack of adherence to this policy was verified through record review and staff interview.
Failure to Implement Discharge Planning and Documentation for Safe Resident Transitions
Penalty
Summary
The facility failed to implement its discharge planning process for two residents, resulting in unsafe discharges and placing the residents at health and safety risks. For both residents, records lacked discharge care plans, interdisciplinary team (IDT) meeting notes addressing discharge planning, and documentation of referrals to or acceptance from shelters and home health agencies. Interviews with facility staff confirmed that required documentation and resident participation in discharge planning were missing, and that much of the discharge process was conducted verbally without written records. One resident had severe cognitive impairment, dementia with agitation, and no family or income. Despite expressing a desire to return to his hometown and a lower level of care, his record did not contain an active discharge plan, IDT notes, or evidence of referrals to community resources. He was discharged to a shelter without documented preparation or coordination, and was later readmitted to the facility due to inability to care for himself. Shelter staff reported rarely receiving referrals for elderly skilled nursing residents and noted that such residents are considered a red flag for admission. The second resident, with alcohol-induced dementia and moderate cognitive impairment, was also discharged to a shelter without documentation of an active discharge plan, IDT notes, or evidence that he was informed about his destination or provided with community resource information. There was no assessment of his ability to manage in the community without income or support. After discharge, he was found sleeping outside a liquor store, was hospitalized, and was described as gravely disabled and homeless. Facility policy required a post-discharge plan and resident preparation, but these steps were not documented or followed for either resident.
Failure to Timely Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of two residents. For the first resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3, the discharge notice was faxed to the ombudsman's office on the same day the resident was picked up and discharged. Documentation showed that the resident had expressed a desire to return to his hometown community prior to discharge. For the second resident, who had moderate cognitive impairment with a BIMS score of 8, the discharge notice was also sent to the ombudsman's office on the day of discharge. The resident had previously communicated to the social services director a wish to transfer to a lower level of care. Facility policy required that discharge notices be sent to the ombudsman's office at the same time as they are provided to the resident and their representative, but this was not followed in these cases.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a female resident with multiple cognitive and psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, dementia, and moderately impaired cognition, from sexual abuse. The incident occurred when a certified nursing assistant (CNA) discovered the female resident in a male resident's bed, with no clothing from the waist down, while the male resident was standing nearby with his belt buckle undone. Both residents had documented moderate cognitive impairment, and the female resident was only oriented to person, not to place or time. Upon discovering the situation, the CNA attempted to separate the residents but was threatened by the male resident, who became aggressive and told the CNA to leave. The CNA left the room without separating the residents or ensuring the female resident's safety, and went to report the incident to the charge nurse in another unit. During this time, no staff remained in the room to supervise or protect the residents. When the licensed vocational nurse (LVN) arrived a few minutes later, the female resident was still exposed and the male resident was present, with no staff having intervened in the interim. Interviews with facility staff, including the CNA, LVN, director of staff development, assistant director of nursing, and director of nursing, confirmed that the CNA should not have left the two residents alone together and that the situation could have been prevented if the residents had been separated or supervised. The facility's abuse prevention policy states that residents have the right to be free from abuse, but this policy was not followed in this instance, resulting in the female resident's exposure and lack of protection from potential sexual abuse.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident, resulting in multiple falls. The resident, who was admitted with a fracture of the left femur, unspecified dementia, and adult failure to thrive, was not given appropriate assistance with activities of daily living (ADL) to prevent accidents. Despite being identified as high risk for falls, the resident was observed walking independently with a front wheel walker and limping, which led to several falls and injuries, including a fracture, contusion, and skin tear. The resident's fall risk assessment indicated a high risk for falls due to balance problems and decreased muscular coordination. The care plan required the use of a wheelchair with supervision and substantial assistance for transfers and mobility. However, the resident was not consistently provided with the necessary supervision or assistance, as evidenced by the falls on multiple occasions. The facility's interdisciplinary team had recommended frequent monitoring to anticipate the resident's needs, but this was not effectively implemented. Interviews with facility staff, including the minimum data set coordinators and the director of staff development, confirmed the resident's falls and the lack of adequate supervision and assistance. The facility's policy on fall risk assessment emphasized the need for a resident-centered falls prevention plan, but this was not adequately followed, leading to the resident's compromised safety and multiple falls.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in a physical altercation between two residents. Resident 1 was physically abused by Resident 2 during an argument over a chair, leading to Resident 1 being pushed to the floor and sustaining a minor injury, specifically bruising to the back of the head. This incident was reported to the California Department of Public Health as an abuse allegation, with Resident 1 identified as the victim and Resident 2 as the abuser. The facility's investigation confirmed the occurrence of the incident, as documented in the 5-day investigative report. The report detailed that Resident 2 hit and pushed Resident 1, causing the latter to fall and sustain a small induration to the posterior head. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse, was not adhered to in this instance, as confirmed by the administrator during an interview.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the medical doctor for a resident, which had the potential to adversely affect the resident's health and well-being. The resident was admitted with diagnoses including dementia, alcohol abuse, cognitive communication deficit, and encephalopathy. The physician's medication orders included divalproex, trazodone, and melatonin, with specific dosages and administration times. However, the electronic medication administration record (EMAR) for June 2024 showed blank documentation on multiple dates for these medications, indicating they were not administered as ordered. During a review of the EMAR and interviews with the registered nurse supervisor and the director of nursing, it was confirmed that the medications were not administered to the resident on the specified dates. The registered nurse supervisor stated that if the EMAR was left blank without a licensed nurse's initials, it meant the medications were not given. The director of nursing confirmed this and stated that licensed nurses should have administered the medications as ordered and completed the EMAR documentation. The facility's policy and procedure for administering medications required that medications be administered according to orders and documented appropriately, which was not followed in this case.
Failure to Follow Psychiatric and Medication Recommendations
Penalty
Summary
The facility failed to adhere to the psychiatric nurse practitioner's (PNP) recommendations and medication regimen review (MRR) for two residents. For Resident 1, the facility did not follow up on the PNP's recommendations for medication adjustments and necessary blood tests, including TSH, CBC, CMP, valproic acid, and ammonia levels. Additionally, the facility did not follow up on a medication regimen review request sent to the consulting pharmacy regarding behavioral changes in Resident 1. There was no documented evidence that the PNP's recommendations were ordered or that the MRR response was received or pursued by the facility. For Resident 2, the facility failed to act on the psychologist's recommendation for a psychiatric follow-up. The lack of documented evidence for the follow-up indicates that the facility did not ensure the necessary psychiatric consultation was arranged. Interviews with the registered nurse supervisor and the director of nursing confirmed these oversights, acknowledging that the nursing staff did not carry out the required follow-ups for both residents as per the PNP's and psychologist's recommendations.
Failure to Submit 5-Day Investigative Reports for Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Policy & Procedure titled 'Abuse Reporting and Investigation' for three residents who reported abuse allegations. Specifically, the facility did not complete the required 5-day investigative reports for the abuse allegations made by three residents. These reports were supposed to be sent to the California Department of Public Health (CDPH) within five working days of the reported allegations. The absence of these reports meant that the CDPH was not informed of the outcomes of the investigations conducted by the facility. Interviews with the Director of Nursing (DON) and the Administrator revealed that they were unable to locate or provide the 5-day reports for the abuse allegations made by the residents. The facility's policy, dated 2021, clearly stated that the Abuse Prevention Coordinator was responsible for providing a written report of the results of all abuse investigations to the CDPH and other required agencies within the specified timeframe. The failure to complete and submit these reports for the three residents' allegations indicates a lapse in following the established procedures for abuse reporting and investigation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the medical doctor for two residents. This deficiency was identified through a review of the electronic medication administration records (EMAR) and interviews with the medical record director (MRD) and the director of nursing (DON). The EMARs for both residents showed multiple instances of blank documentation, indicating that medications were not administered as prescribed. The MRD and DON confirmed that if the EMARs were left blank, it meant the medications were not given to the residents. Resident 1 had a range of medications prescribed, including Oxybutynin, Benztropine, Fish Oil, and others, which were not documented as administered on several occasions throughout February 2024. Similarly, Resident 2's EMAR showed blank documentation for medications such as Ticagrelor, Metoprolol Tartrate, and others. Additionally, blood glucose monitoring for Resident 2 was not consistently documented, with several instances of blank entries and missed checks. Interviews with Resident 2 revealed that the resident was aware of missed medication administrations, particularly when the facility used nurses from outside agencies. The DON confirmed that the facility had used registry nurses who did not administer or document the administration of medications for both residents. The facility's policy and procedure for administering medications, which requires medications to be administered in a safe and timely manner as prescribed, was not followed, leading to this deficiency.
Failure to Provide Scheduled Showers and Document Care
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) for a resident who was dependent on staff for bathing due to a chronic medical condition. The resident, who was cognitively intact with a BIMS score of 15, reported not being showered regularly according to her scheduled days (Mondays, Wednesdays, and Fridays) over a one-month period. This was confirmed by a review of the shower sheet binder, which showed no documentation of showers, bed baths, or refusals for the resident from 3/4/24 to 4/4/24. The Certified Nursing Assistant (CNA) acknowledged the lack of documentation, stating that shower sheets should be filled out each time a resident is showered, given a bed bath, or refuses care. The Director of Nursing (DON) confirmed the absence of documented shower sheets for the specified period. The facility's policy and procedure for bathing, dated 2018, requires documentation of the date and time of the shower, the name and title of the assisting individual, assessment data, how the resident tolerated the shower, and any refusals. The failure to document and provide regular showers as per the resident's schedule had the potential to negatively affect the resident's physical and mental health.
Failure to Timely Order Medications
Penalty
Summary
The facility failed to provide care according to professional standards of practice for two residents when nursing staff did not order two medications in a timely manner. For Resident 1, the Physician Orders indicated Hydroxyzine 25MG tablet to be given every 12 hours for anxiety. However, the Medication Administration Record (MAR) showed that Resident 1 did not receive the medication on multiple occasions because the medication ran out and was not reordered in time. Licensed Vocational Nurse (LVN) A confirmed that the medication was not available and had to be ordered after it was already depleted, resulting in missed doses on 3/18/24 and 3/19/24. The facility's policy required medications to be reordered five days in advance, which was not followed in this case. Similarly, Resident 2's Physician Orders indicated Clozapine 50MG tablet to be given daily at bedtime for schizoaffective disorder, bipolar type. The MAR showed that Resident 2 did not receive the medication on 3/11/24 because it was not reordered in time. LVN A confirmed that the medication ran out and had to be ordered after it was already depleted. The Director of Nursing (DON) stated that nurses are responsible for ordering medications when they run low, and the pharmacy does not automatically refill any medications. The facility's policy and procedure for medication ordering and receiving from the pharmacy, dated 2008, was not adhered to, leading to these deficiencies.
Failure to Ensure Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed rails for 40 residents, as evidenced by the lack of documentation for routine maintenance, informed consents, and attempts at alternatives before bed rail use. The Maintenance Director confirmed that there were no daily or annual checks of the bed rails unless a complaint was made, which contradicts the facility's policy requiring routine inspections to identify risks, including potential entrapment hazards. Observations revealed that multiple residents had bed rails in the upright position without the necessary documentation or assessments in place. Informed consents for bed rail use were not found in the medical records of any of the 40 sampled residents. The Medical Record Director confirmed that no side rail consents had been filed in the past 14 months. Additionally, there was no evidence that alternatives to bed rails were offered or attempted for 38 of the 40 residents before resorting to bed rail use. This lack of documentation and adherence to protocol was confirmed through interviews with various staff members, including licensed vocational nurses and the minimum data set coordinator. Furthermore, bed rail assessments were not completed for 16 of the 40 residents, and there were no care plans in place for 29 of the 40 residents who used bed rails. The minimum data set coordinator confirmed that bed rail assessments should be done prior to use to determine appropriateness, and registered nurses emphasized the importance of care plans for proper implementation and intervention. The facility's policy clearly states that bed rails should not be used unless criteria, including attempts at alternatives and informed consent, are met, which was not adhered to in these cases.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety. The kitchen refrigerator had ice buildup in the rubber gasket, which was confirmed by the Dietary Staff and Maintenance Director. Despite daily cleaning and recent maintenance, the issue persisted, and the Maintenance Director was unable to provide a receipt for the repair. Additionally, three colored chopping boards were found stained and with cuts, and two blender containers were cloudy while one was cracked. These observations were confirmed by the Dietary Manager, who acknowledged that the equipment should have been discarded or replaced. Furthermore, the unit refrigerator contained outdated snacks and nourishment, including yogurts and sandwiches beyond their use-by dates. This was verified by multiple staff members, including Certified Nurse Assistants, Licensed Vocational Nurses, and a Registered Nurse. The facility's policy indicated that food items must be labeled with the resident's name and use-by date, and outdated items should be discarded. The failure to adhere to these standards had the potential to cause food contamination and spread food-borne illness to residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain respect and dignity for seven residents in various ways. Staff provided feeding assistance to two residents while standing, which was against the facility's policy that required staff to sit while feeding residents to show respect. Additionally, two residents with indwelling urinary catheters did not have their urine collection bags covered, exposing the contents and violating their privacy. Staff confirmed that the urine collection bags should have been covered, as per the facility's policy on dignity. Another resident's privacy was compromised when a Licensed Vocational Nurse administered medication through a gastrostomy tube without closing the privacy curtain or the door, exposing the resident's abdomen and waist to other residents and visitors. Furthermore, a Certified Nursing Assistant referred to a resident in a disrespectful manner, which was against the facility's policy that required staff to speak respectfully to residents at all times. Lastly, a resident's room lacked a privacy curtain, resulting in the resident being visible from the hallway while undressed. Staff confirmed the absence of the privacy curtain and acknowledged that it should have been replaced or alternatives provided to ensure the resident's privacy. The facility's policy emphasized the importance of maintaining and protecting residents' privacy during personal care and treatment procedures.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained or verified prior to the administration of psychotropic medications for three residents. Resident 58, who was admitted with bipolar disorder, major depressive disorder, and vascular dementia, had been receiving trazodone and Cymbalta since admission without documented informed consent. The Director of Nursing (DON) confirmed that the informed consent forms were missing from both electronic and paper medical records after a thorough search. Resident 75, diagnosed with unspecified dementia and cognitive communication deficit, had been receiving Depakote and escitalopram without verified informed consent. Similarly, Resident 370, admitted with bipolar disorder, was administered aripiprazole and trazodone without documented informed consent. The DON acknowledged the absence of informed consent forms for these medications and confirmed that the facility's staff should have ensured these forms were in place before administering the medications. The facility's Informed Consent Nursing Manual mandates that informed consent be verified and documented for each new psychotropic drug order.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that residents' call light buttons were within reach, affecting five of the 24 sampled residents. Resident 11's call light button was found inside her bedside's top drawer, making it inaccessible while she was asleep. Similarly, Resident 2's call light button was on the floor under her bed, and Resident 18's call light button was on the floor slightly under the bed, despite her right-sided weakness. Certified Nurse Assistant O confirmed these observations, and Licensed Vocational Nurse F acknowledged that Resident 18's call light should have been placed near her functioning hand. Resident 41's call light button was tied to the right side of the side rail, making it unreachable while she was lying in bed. Certified Nurse Assistant Z confirmed that Resident 41 was unable to use the call device and stated there was no need to place it within her reach. The Minimum Data Set Coordinator acknowledged that residents should have a call device and that the facility should provide an alternative means of communication if the resident cannot use the call device. Resident 52's call light was broken and not within reach. During an observation, no call device was found in her room. Certified Nurse Assistant M and Registered Nurse N confirmed the absence of the call device, and RN N stated it was removed due to Resident 52's self-harming behavior. However, no alternative means of communication was provided. Licensed Vocational Nurse F found the call device behind the resident's closet, but it was not working. The facility's policy indicated that residents should have a functional call system or an alternative means of communication documented in the care plan, which was not adhered to in this case.
Failure to Transmit MDS Assessments and Death Tracking Records Timely
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) discharge assessment and death tracking record in a timely manner for three residents. Resident 47 was admitted to the facility and later discharged to home, but the MDS discharge assessment was not signed by a Registered Nurse Coordinator (RNC) and was not transmitted to the Center for Medicare and Medicaid System (CMS) within the required timeframe. Similarly, Resident 82 was discharged to another skilled nursing facility, but their MDS discharge assessment was also not signed by an RNC and not transmitted to CMS as required. Both assessments should have been completed within 7 days of discharge and transmitted within 14 days, but these requirements were not met. Additionally, Resident 15, who expired at the facility, had their death tracking MDS completed but not transmitted to CMS within the required timeframe. The Minimum Data Set Coordinator (MDSC) confirmed that the death tracking MDS should have been completed within 7 days of the resident's death and transmitted within 14 days. The failure to transmit these assessments and records in a timely manner resulted in non-compliance with federal regulations, as outlined in the CMS's Long-Term Care Facility Resident Assessment Instrument (LTCF RAI) guidelines.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for five residents. For Resident 22, the staff did not follow the care plan for wandering and elopement, as there were no documented visual checks every two hours as required. Observations showed Resident 22 repeatedly attempting to leave the facility without supervision, and staff confirmed the lack of documentation for the required checks in December 2023 and January 2024. Resident 28, who had a diagnosis of COPD and was on oxygen, did not have a care plan addressing these needs. Observations confirmed the resident was on oxygen, but staff acknowledged that no care plan had been developed for COPD or oxygen use. Similarly, Resident 52, who had a mood disorder and multiple bruises, did not have care plans addressing these conditions. Staff confirmed the absence of care plans for both the mood disorder and skin discoloration. Residents 369 and 79, both diagnosed with COPD and using oxygen, also lacked care plans for these conditions. Observations and staff interviews confirmed the absence of care plans for COPD and oxygen use for both residents. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not done for these five residents.
Failure to Provide Ongoing Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program that met the needs, interests, and preferences of five residents. Resident 22, diagnosed with dementia, schizoaffective disorder, and bipolar disorder, had a care plan that included activities such as reading, listening to music, and going outside. However, observations revealed that Resident 22 was often found at the facility's exit door, asking staff to open it, and no activities were provided according to her care plan. The activities assistant confirmed that there were no documented activities for Resident 22 in February 2024 and only minimal activities in January 2024. Resident 61, with diagnoses including cerebrovascular disease, paranoid schizophrenia, and dementia, had a care plan that included watching TV, joining others in the dining room, and receiving nail care grooming. However, multiple observations showed that Resident 61 was often in bed, experiencing loud screaming and anger outbursts, with no activities provided. The activities assistant confirmed that there were no activity documentations for Resident 61 from March 2023 to February 2024, indicating that the care plan was not implemented. Resident 75, diagnosed with type 2 diabetes, dementia with agitation, and hypertensive heart disease, had a care plan that included 1:1 stimulation, religious visits, and outdoor activities. Observations showed that Resident 75 was often in bed, and the activities assistant confirmed that there were no documented activities for January 2024 and only a few in February 2024. Similarly, Resident 70, with diagnoses including epilepsy, type 2 diabetes, and bipolar disorder, had a care plan that included daily activities and providing books and magazines. However, observations revealed that Resident 70 did not receive any activities or room visits, and the activities assistant confirmed the lack of documentation. Resident 41, diagnosed with psychosis, dementia, and hypertension, had a care plan for 1:1 room visits, but the activities assistant confirmed that there were no documented activities from July 2023 to December 2023.
Multiple Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure that Resident 56 received the prescribed antibiotic treatment for a urinary tract infection (UTI) after returning from the hospital. Despite the hospital's discharge summary indicating the need for Macrobid 100 mg twice daily for five days, the nursing staff did not carry out this order. This oversight was confirmed by the interim Director of Staff Development and the Director of Nursing, who acknowledged that the failure to administer the antibiotic constituted a medication error. The resident continued to experience UTI symptoms, including burning on urination, for a week after returning to the facility. Resident 58 experienced significant sleep disturbances, with multiple nights of zero hours of sleep documented over several months. Despite the physician's order to monitor sleep and the resident's report of difficulty sleeping to social services, the facility staff failed to notify the physician or follow up on the issue. The Director of Nursing confirmed the lack of documentation and communication regarding the resident's sleep problems, which were not addressed despite being reported by the resident and documented in the medical record. The facility also failed to follow physician orders and policies for several other residents. Resident 28 was administered oxygen without a physician's order and did not have Prevalon Boots applied to both feet as prescribed. Resident 369 received oxygen without a physician's order, and Resident 370 did not have the PICC line dressing changed as required, nor were the arm circumference and catheter length measured and documented. These failures were confirmed through observations, interviews, and record reviews with nursing staff and the Director of Nursing, highlighting a pattern of non-compliance with physician orders and facility policies.
Inadequate Training on Charting System for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were competent in using the facility's charting system before their first shift. This deficiency was identified through interviews and record reviews, revealing that the Interim Director of Staffing Development (IDSD) could not locate the onboarding binder used to orient new staff to the charting system. The IDSD admitted that the facility's charting system was uncommon compared to other long-term care facilities, and there was no documentation showing that registry staff were oriented or competent in using the system before starting work. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and Certified Nurse Assistants (CNAs), confirmed that they did not receive adequate training on the charting system and had to rely on other staff for assistance, leading to potential issues in documentation of patient care, assessments, and medication administration. The facility's Policy & Procedure (P&P) on Staffing, Sufficient and Competent Nursing, dated 2022, indicated that the facility should provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents. However, the lack of proper training and documentation for the charting system contradicted this policy. Staff members reported that the charting system was difficult to use, and some were trained by other registry staff who were also not proficient in the system. This situation highlighted a significant gap in ensuring that all nursing staff were adequately prepared to use the charting system effectively, potentially compromising the quality of care provided to residents.
Failure to Post Direct Care Staffing Information
Penalty
Summary
The facility failed to post direct care staffing numbers and nursing staff responsible for direct care to residents for two consecutive days in each of the three halls of the facility. Observations on multiple occasions over these two days revealed that no staff schedule or direct patient care hours were posted in Halls BB, CC, and AA. During an interview, the Director of Nursing (DON) was unaware of the missing staffing information and acknowledged that it should have been posted. The facility's policy, dated 2022, mandates that direct care daily staffing numbers be posted for every shift, which was not adhered to in this instance.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three out of 24 sampled residents. Resident 56's Depakote was not available for administration, leading to missed doses over several days. Additionally, morning medication administration in Hall CC was consistently late, affecting timely delivery of medications to residents, including Resident 56 and Resident 95. This resulted in missed doses and potential discomfort for the residents. Furthermore, there was no documentation of routine medication administration for two days for Residents 56 and 95, leading to inaccuracies and omissions in medication records. Controlled medication audits revealed discrepancies for four residents, with medications not being fully accounted for. Specifically, the audit for Residents 17, 20, 56, and 65 showed that several doses of controlled medications were signed out but not documented as administered. This raised concerns about the potential misuse or diversion of these medications. Additionally, the Narcotic Count Sheet Release logs were incomplete for two out of three inspected medication carts, further indicating lapses in controlled substance management. One of the three opened emergency kits was not replaced timely, compromising the availability of medications for emergencies. Resident 76's routine Risperdal was not administered for four days, which could have led to untreated behavioral conditions. The facility's policies and procedures were not followed, as evidenced by the delayed replacement of the emergency kit and the failure to ensure a sufficient supply of medications. These deficiencies highlight significant lapses in the facility's pharmaceutical services and medication management practices.
Failure to Conduct Proper Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) and conducted an interim or immediate MRR (iMRR) for three residents. For Resident 58, the facility did not request an iMRR to evaluate whether her multiple falls were caused or contributed by medications. Despite the resident receiving medications that could contribute to falls, there was no evidence of an iMRR being conducted after the falls occurred. Both the CP and the Director of Nursing (DON) acknowledged that an iMRR should have been requested in such cases. For Resident 75, the CP failed to make recommendations regarding the management of her diabetes medications. The resident was receiving four medications to control blood sugar without a hold order for low blood sugar, a hypoglycemia protocol, or staff monitoring for signs and symptoms of hypo/hyperglycemia. The DON confirmed these omissions and stated that the CP should have identified and reported these issues during the monthly MRR. The CP admitted that he should have made these recommendations. For Resident 370, the CP did not make recommendations for monitoring signs and symptoms related to the use of Lovenox and aspirin, which increases the risk of bleeding. Additionally, there were no orders for monitoring signs and symptoms of hypo/hyperglycemia or a written hypoglycemia protocol. The DON confirmed the lack of monitoring and protocols, and the CP acknowledged that he should have made the necessary recommendations. The facility's policy and procedure indicated that the CP should review the medication regimen for each resident at least monthly and report any irregularities, which was not done in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a medication error rate of 14.29% when five medication errors occurred out of 35 opportunities during the medication administration for one resident. Licensed Vocational Nurse C (LVN C) administered Gericare Artificial Tears eye drops instead of the prescribed Refresh Tears eye drops to the resident. Additionally, LVN C did not administer Depakote (divalproex) as it was not available, and the resident's medication administration record indicated it was not given as required. Furthermore, LVN C did not administer levothyroxine because it was supposed to be given before breakfast, which the resident had already eaten. During the medication pass, LVN C also failed to administer polyethylene glycol (Miralax) and fluticasone nasal spray as prescribed. The Director of Nursing (DON) confirmed that medications should be given within one hour of the ordered time. The facility's policy and procedure for administering medications indicated that medications should be administered in accordance with prescriber orders and within the specified time frame.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled appropriately. During a visit to the Medication Room in Hall AA, a medication refrigerator was found unlocked and its temperature was not being monitored and maintained twice daily as per professional standards. The refrigerator contained numerous medications, including flu and pneumococcal vaccines. The temperature log was incomplete, with temperatures documented only once a day and missing entries on specific dates. The Director of Nursing (DON) acknowledged that the refrigerator should be locked when not in use and that temperature monitoring should occur twice daily, as per the Centers for Disease Control and Prevention's guidelines and the facility's policies and procedures. Additionally, an inspection of Medication Cart 2 in Hall AA revealed several issues. An opened multi-dose eye drop was not labeled with a resident's name, an expired package of blood sugar test strips was found, a bottle of Lorazepam Intensol was stored at room temperature instead of being refrigerated, and an opened insulin lispro pen was incorrectly dated with a 54-day expiration instead of the correct 28-day expiration. The Licensed Vocational Nurse (LVN) confirmed these findings, and the DON acknowledged that eye drops should be labeled with the resident's name and that medications should be stored and labeled according to the facility's policies and professional standards.
Improper Garbage Containment
Penalty
Summary
The facility failed to ensure garbage was properly contained when one of the receptacles' lids was not tight-fitting and could not close. During an observation and interview with the maintenance director (MD), it was noted that the garbage receptacle lid was defective and could not close, which the MD confirmed. The MD acknowledged that the defective lid could attract pests. The United States Food and Drug Administration's 2022 Food Code requires that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The facility's policy, revised in 10/2017, also indicated that all garbage and refuse containers must have tight-fitting lids and be kept covered when not in continuous use to prevent pest access. The failure to comply with these standards was observed and confirmed by the MD.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. A dietary staff member was observed picking up a name plate from the floor and touching his hair and bare skin while wearing gloves, without changing them between tasks. This was confirmed by the Dietary Manager, who stated that gloves should be changed for every task and hands should be washed. The facility's policy also indicated that gloves need to be changed before beginning a different task and after touching bare skin or hair. Additionally, a licensed vocational nurse did not clean a resident's nasal cannula before placing it back on the resident's nostrils, despite the resident's oxygen concentrator being on the floor. The nurse acknowledged that the nasal cannula should have been cleaned or changed to prevent respiratory infection, in line with CDC guidelines for preventing healthcare-associated pneumonia. Further deficiencies were observed during medication administration. The same licensed vocational nurse used bare hands to open a medication capsule for one resident and did not clean or sanitize a pill cutter before returning it to the medication cart after use. The nurse also touched a bed remote control with bare hands and then administered eye drops to another resident without performing hand hygiene or wearing gloves between tasks. The Director of Nursing confirmed that wearing gloves when opening medication capsules and administering eye drops is standard nursing practice. The facility's policy on administering medications indicated that staff should follow established infection control procedures, including handwashing and wearing gloves.
Failure to Document Resident Transfer Details
Penalty
Summary
The facility failed to document essential information regarding the transfer of a resident (Resident 56) to the hospital. Specifically, the medical record lacked details such as the date and time of transfer, the destination, the mode of transportation, and a summary of the resident's condition at the time of transfer. This deficiency was identified during a review of Resident 56's medical record, which indicated she was admitted to the facility with a urinary tract infection (UTI) and had a BIMS score of 15, indicating she was cognitively intact. The resident reported being transferred to the hospital a few days prior and not receiving the prescribed antibiotic upon return to the facility. The nursing progress notes only documented the resident's return to the facility but omitted critical transfer details. Interviews with the interim Director of Staff Development, the Medical Record Director, and the Director of Nursing revealed that the necessary transfer documentation was missing and could not be retrieved. The Medical Record Director suggested that registry nurses might have forgotten to document the transfer. A review of the acute care hospital's discharge summary confirmed the resident's hospital admission and discharge dates and times. The facility's policy on transfers and discharges mandates detailed documentation, which was not adhered to in this case.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess and complete the Minimum Data Set (MDS) for two residents, which compromised the ability to develop and implement resident-centered care plans. For Resident 12, the MDS did not indicate that the resident was on hospice care, despite the resident being admitted to hospice with a diagnosis of heart failure. This error was confirmed by the Minimum Data Set Coordinator (MDSC) during a record review and interview, where it was acknowledged that hospice care should have been checked on the MDS for the specified dates. For Resident 46, the MDS inaccurately coded the resident's weight loss status. The 5-day assessment indicated a weight of 146 pounds and incorrectly coded weight loss, while the Quarterly assessment showed a weight of 147 pounds and also incorrectly coded weight loss. The MDSC confirmed that the Quarterly assessment should have been coded as '0. No or unknown' for weight loss, as there was no significant weight loss during the assessment period. These inaccuracies were identified during a concurrent interview and record review with the MDSC.
Failure to Complete Annual PASRR Screening
Penalty
Summary
The facility failed to follow their Policy and Procedure for the Preadmission Screening and Resident Review (PASRR) for one of the sampled residents. The resident, who was readmitted with diagnoses including cognitive communication deficit, seizure, paranoid schizophrenia, and idiopathic peripheral autonomic neuropathy, had a positive result on the Level I PASRR Screening. However, there was no documented evidence that the required annual PASRR Screening was completed for the following year. The State Agency (SA) had previously closed the case due to the resident being isolated as a health or safety precaution and had instructed the facility to submit a new Level I Screening to reopen the case, which was not done. The Administrator incorrectly believed that a new PASRR Level I was not needed if the resident was readmitted without a significant change in condition, contrary to the facility's policy that requires annual screenings for all residents. During the review of the facility's policy and procedure, it was confirmed that all residents should be screened on admission and annually thereafter. The failure to complete the annual PASRR Screening for the resident had the potential to result in inaccurate care and services for residents with mental disorders, intellectual disabilities, or related conditions. This oversight was identified during an interview and record review with the Administrator, who acknowledged the lapse in following the required procedures.
Failure to Maintain a Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. For Resident 81, broken pieces of glass from a wall clock that fell off the wall were not cleaned up in a timely manner. The glass was observed on the floor near the resident's bed and wheelchair during a medication administration observation. The incident occurred around 4 a.m., and the glass remained on the floor for approximately five hours. The resident has a history of cognitive impairment and traumatic brain injury, which increases the risk of injury from such hazards. Both nursing staff and the Director of Nursing acknowledged that the broken glass should have been cleaned up immediately to ensure safety for residents and staff. For Resident 40, a wet shower sheet blanket was placed on the floor near the bed, presenting a fall risk. The sheet was observed during a room inspection and was noted to be wet in the middle. The CNA responsible for placing the sheet on the floor stated that it was a common practice to soak up urine, as instructed by other CNAs. However, this practice contradicts the resident's Fall Risk Care Plan, which emphasizes maintaining a safe environment free of clutter. The resident has a diagnosis of dementia and is at high risk for falls. The facility's policy on safety and supervision of residents indicates that the environment should be as free from accident hazards as possible, which was not adhered to in this case.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for Resident 370, who had diagnoses including acute osteomyelitis, type 2 diabetes with diabetic neuropathy, and bipolar disorder. Despite having physician orders for Norco and Hydromorphone to manage moderate to severe pain, the resident did not receive Norco from 2/02/2024 to 2/13/2024. During this period, the resident reported severe pain, with pain levels recorded as high as 7/10. The resident stated that he was given Tylenol instead, which was insufficient to alleviate his pain. The Licensed Vocational Nurse confirmed that the Norco was unavailable because the physician needed to sign for the prescription, and the Director of Nursing acknowledged that the medication should have been available and administered as ordered. The facility's policy on pain assessment and management emphasizes the importance of appropriate assessment and treatment of pain based on professional standards of practice and the resident's choices. However, the facility did not adhere to this policy, resulting in Resident 370 experiencing unmanaged pain for an extended period. The Director of Nursing confirmed that the resident's pain assessments indicated moderate to severe pain on multiple occasions, and the prescribed Norco was not administered as required.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 75 received two routine insulin medications and two other medications to control blood sugar without a hold order for low blood sugar, without a hypoglycemia protocol, without staff monitoring for signs and symptoms of hypo/hyperglycemia, and without a written care plan for diabetes. The Director of Nursing confirmed these deficiencies during a record review and interview, noting that there should have been a hold order and a hypoglycemia protocol in place, as well as monitoring for symptoms of hypo/hyperglycemia. Resident 370 received Lovenox and aspirin without staff monitoring for signs and symptoms related to anticoagulant use, and also had two insulin orders without a written hypoglycemia protocol and staff monitoring for signs and symptoms of hypo/hyperglycemia. The Registered Nurse confirmed the lack of monitoring for adverse effects of Lovenox and aspirin and was unaware of how to locate the hypoglycemia protocol. The Director of Nursing also confirmed that there should have been orders for monitoring signs and symptoms related to anticoagulation and aspirin use, as well as a written hypoglycemia protocol. The facility's clinical protocols for diabetes and anticoagulation were not followed, as evidenced by the lack of physician orders for monitoring and reporting information related to blood sugar management and adverse drug reactions. The staff failed to incorporate these parameters into the Medication Administration Record and care plan, and did not identify and report issues related to diabetes management and anticoagulation, leading to the potential for side effects of these medications to go undetected or unrecognized for timely intervention.
Failure to Update Bed Safety Policy
Penalty
Summary
The facility failed to update and revise their bed safety policy and procedure in compliance with Federal regulations and accepted professional standards. The policy, last revised in December 2007, was not updated upon completion of the facility's recertification survey's plan of correction (POC). During interviews, the Director of Nursing (DON) acknowledged that the policy should have been reviewed quarterly due to changing regulations, while the Administrator (ADM) confirmed that the policy was reviewed but not updated, and it should have been revised. This failure had the potential to compromise residents' health and safety.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to offer, administer, and track influenza, pneumococcal, and COVID-19 vaccines for three residents. Resident 12's clinical record showed consent for the influenza vaccine, but there was no documentation that the vaccine was administered. The Director of Staff Development Consultant (DSDC) confirmed the absence of documentation for both the influenza and pneumococcal vaccines for Resident 12. Similarly, Resident 52's record lacked documentation for all three vaccines, and the Minimum Data Set Coordinator (MDSC) confirmed that there was no evidence the vaccines were offered or declined, despite the MDS indicating they were offered and declined. Resident 370's record also lacked documentation for the influenza, pneumococcal, and COVID-19 vaccines, and the DSDC acknowledged the facility's failure to track these immunizations. The facility's policy and procedure on vaccination, revised in October 2019, stated that all residents should be offered vaccines unless medically contraindicated or already vaccinated, and refusals should be documented. However, the facility did not adhere to this policy, as evidenced by the missing documentation and lack of vaccine administration for the three residents. The MDSC confirmed the discrepancies in the MDS sections for Resident 52 and Resident 370, indicating that the facility did not properly track or document the vaccination status and offers for these residents.
Deficiency in Room Size Requirements
Penalty
Summary
The report identifies that several multi-resident rooms in the facility provided less than the required 80 square feet per resident. Specifically, rooms in [NAME] Hall and [NAME] Hall were found to have square footage per bed ranging from 72 to 75 square feet, which is below the regulatory requirement. Despite this deficiency, it was observed that the staff and residents were able to move freely within the rooms, and both parties stated that the room sizes were not a concern. The report recommends the continuance of the room waiver based on these observations.
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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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