Infinity Care Of East Los Angeles

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not addressing visible water damage, peeling paint, and damaged surfaces in multiple resident care areas. On the second floor, surveyors observed a ceiling panel near a window across from the second dining/TV room with dark brown discoloration and adjacent wall areas with cracked wood and peeling paint. Along the second-floor resident hallway, ceilings showed scattered dark brown discoloration and dried brown water leak marks on the walls. In Room A, there were multiple scratches on the wall, peeling paint, and a cracked baseboard protruding from the wall. In Rooms C, D, and E, surveyors observed cracked and peeling paint on walls and ceilings, including the bathroom ceiling in Room D, despite the Maintenance Supervisor stating these areas had been repainted after a roof leak in early January. In Room B, surveyors and the Maintenance Supervisor observed a framed painting on the wall that appeared damp inside the frame, with an unidentified green substance on the top left corner and a black substance on the bottom middle area extending to the right corner. A dried dark brown water mark extended from the ceiling to the wall above the painting, continued beneath it, and ran down to the baseboards; the Maintenance Supervisor confirmed this was from a water leak after heavy rains in early January and stated no staff or residents had reported it. The Housekeeping Supervisor stated that rooms, hallways, and other areas are cleaned daily and that housekeeping staff should clean walls and floors, but she did not know why the dried water leak marks and the dirty painting with greenish and blackish substances in Room B had not been addressed, and acknowledged that the painting looked very dirty and that whatever substance was in it could potentially make residents sick. The DON stated staff are expected to report dirty rooms, cracked walls, and peeling paint to maintenance so issues can be addressed immediately, and the Administrator confirmed that the facility’s “Homelike Environment” policy, which requires a safe, clean, comfortable, and homelike setting, was not followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by a roommate. One resident with dementia and Alzheimer’s disease, documented as severely impaired in cognitive skills for daily decision-making and dependent or needing assistance with most ADLs, was lying in bed when another resident entered his space. The cognitively impaired resident required assistance with transfers, dressing, personal hygiene, and eating, and was not able to provide meaningful information during post-incident interviews, only being able to state his name. The Director of Nursing later stated that this resident did not have the ability to consent to sexual activity. A second resident, also diagnosed with dementia and polyneuropathies and severely impaired in cognitive skills for daily decision-making, was identified as the perpetrator of the sexual contact. This resident required varying levels of assistance with transfers, dressing, personal hygiene, and eating, and was unable to recall the incident when interviewed. On the date of the incident, a CNA entered the shared room while passing dinner trays and observed the second resident on his knees at the side of the first resident’s bed, with the first resident’s diaper open, and using both hands to touch the first resident’s private parts. The CNA estimated that the touching continued for approximately 10 seconds from the time she first observed it until she intervened. Another cognitively intact resident reported having previously witnessed the same perpetrating resident lowering the first resident’s diaper and touching his buttocks in the shared room. This witness stated he reported what he saw to an unidentified staff member, but the facility was unable to identify who received that report and was unable to substantiate that earlier allegation. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including sexual abuse, and that the administration will protect residents from abuse by anyone, identify and assess all possible incidents of abuse, and investigate and report any allegations of abuse within required timeframes. Despite these policies, the observed non-consensual sexual contact occurred between the two residents, constituting a failure to protect the first resident’s right to be free from sexual abuse. The facility’s documentation following the incident reflected that the first resident experienced unwanted touching behavior and was at risk for emotional/psychological distress due to possible unwanted touching behavior by another resident. The second resident’s documentation reflected possible unwanted touching behavior as well. The survey findings concluded that the facility failed to protect the first resident from sexual abuse by the second resident when the second resident was observed playing with the first resident’s private part, and that this failure resulted in sexual abuse and had the potential to result in negative psychosocial effects based on the reasonable person concept, given the first resident’s severely impaired cognitive status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to report an allegation of sexual abuse to the state survey agency (CDPH) within the required federal time frame and to submit the results of the investigation within five working days. One resident with dementia and Alzheimer’s disease, who was assessed as severely cognitively impaired and dependent or needing assistance with most ADLs, was the alleged victim. According to the SBAR documentation, a CNA observed the cognitively impaired roommate kneeling by the resident’s bed and touching the resident’s genital area while the resident was lying in bed. The CNA intervened, separated the residents, and reported the incident to an RN, who then notified the physician, DON, and Administrator. The roommate alleged to have committed the touching also had dementia and polyneuropathies and was documented as severely cognitively impaired, requiring assistance with transfers, dressing, hygiene, and other ADLs. SBAR documentation for this resident indicated that when interviewed by the RN after the incident, the resident did not remember what had occurred. Another cognitively intact resident later reported that, on a separate occasion, he had witnessed the same roommate lowering the alleged victim’s brief and touching the victim’s buttock in their shared room and that he had reported this to an unidentified staff member. The report does not identify any injuries but characterizes the incident as inappropriate sexual touching of a resident who lacked capacity to consent. Interviews with facility leadership and staff showed that the incident was reported to local law enforcement and the ombudsman, but not to CDPH. The DON stated she was informed of the incident and confirmed that it was reported to the police and ombudsman only. The RN reported that the Administrator instructed her not to call CDPH because both residents had dementia. The Administrator stated that, based on his interpretation of AFL 24-09 and the absence of injury, he believed the incident did not need to be reported to CDPH. Review of the facility’s Abuse Investigation and Reporting policy showed it required reporting all alleged violations of abuse to the state licensing/certification agency and also referenced AFL 24-09 for resident-on-resident abuse involving residents with dementia. Both the Administrator and DON later acknowledged, after reviewing the CMS SOM, that the allegation of sexual abuse involving a resident without capacity to consent should have been reported to CDPH within two hours and that a five-day written investigation report was also required, but this did not occur.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a resident’s right to return to their reserved bed following a hospitalization within the state-defined bed-hold period. The resident, who had dementia with severe cognitive impairment and polyneuropathy, required assistance with transfers, dressing, hygiene, and bed mobility. The resident had been initially admitted and later readmitted to the facility and was residing in a specific room and bed (Bed AA), which was placed on a seven-day bed hold when the resident was transferred to a general acute care hospital (GACH) for escalating dementia. The DON confirmed that the resident’s discharge date from GACH fell within this seven-day bed-hold period and that it was the resident’s right to return to the same room and bed. Instead of readmitting the resident to the facility, the Administrator requested that the resident be placed at another SNF (SNF 2), citing an isolated incident of sexual abuse involving the resident and stating that SNF 2 was more appropriate to care for the resident. The Admissions Director at SNF 2 reported that the referral came from the facility’s marketer (MK) and that no reason for the transfer was provided other than a request to take the resident “for now.” The GACH case manager stated that the transfer request to SNF 2 did not come from the resident or the resident’s family representative, but from the facility’s MK, who reported that the building was undergoing remodeling due to water damage and that the resident’s room needed remodeling, necessitating a temporary transfer. GACH documentation reflected that, according to the facility, there was a problem at the facility and that the resident would be sent temporarily to a sister facility due to building construction from rain damage, with the family allegedly made aware. Subsequent observations and interviews did not support the stated reason of remodeling for denying the resident’s return. Surveyors observed no remodeling or maintenance in the resident’s former room, and the Maintenance Supervisor confirmed that only other specified rooms were undergoing drywall replacement due to leaks, with no work needed in the resident’s room. The DON stated that the resident was on a seven-day bed hold and had the right to return to the facility and to the same room and bed, and that she was not notified on the day the resident was transferred to SNF 2, so she could not verify bed availability. The DON also stated she was unaware that SNF 2 was not a locked facility and that SNF 2 should have been informed of the resident’s behavior before accepting the transfer. The facility’s bed-hold policy stated that residents returning within the bed-hold period are allowed to return to their previous room if available and that post-hospitalization evaluations should be based on the resident’s current condition. Despite this, the resident was not readmitted to the reserved bed and was instead discharged from GACH to another SNF within the bed-hold period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement care plans for two residents who were using bed alarms as fall prevention interventions, as required by facility policy. For one resident with diagnoses including generalized muscle weakness, anxiety disorder, and urinary tract infection, the care plan did not include the use of a bed alarm, despite the resident being observed with one in use and staff confirming its purpose for fall prevention. The resident's care plan only addressed other safety measures such as adequate lighting, bed positioning, and call light accessibility, omitting the bed alarm intervention. Similarly, another resident with depression, hypothyroidism, and generalized muscle weakness was observed with a bed alarm in place, and staff confirmed its use for fall prevention. However, this intervention was not documented in the resident's care plan. Facility staff, including a CNA, LVN, and RN, acknowledged that the care plans should have reflected the use of bed alarms, in accordance with the facility's policy, which requires interdisciplinary team involvement and documentation of such interventions in the care plan for residents at risk for falls.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its policy and procedure regarding the management of a resident's personal funds, resulting in an overcharge. A review of the resident's financial records showed that the resident, who had diagnoses including dementia, glaucoma, and bilateral hearing loss, was severely cognitively impaired and dependent on staff for daily activities. The resident's eligibility response indicated a share of cost of $1,133.00, but the facility ledger showed the resident was charged $1,867.00 for one month, resulting in an overcharge of $734.00. There was no documentation explaining the reason for this overcharge. Further review of the facility's policies revealed that any overcharge to a resident's funds should be returned to the resident or their representative. Additionally, the facility's policy required residents to be informed in advance of any changes to their bills. The finance manager confirmed the overcharge and the lack of documentation to support it during interviews and record reviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of Parkinson's Disease, muscle weakness, dementia, and previous falls was not provided with adequate care and services to prevent accidents. The resident's fall risk assessment was found to be incomplete and inaccurate, as it only marked the age category and failed to account for significant risk factors such as vision impairment, cognitive deficits, use of antihypertensive medication, unsteady gait, and altered awareness. The Director of Nursing (DON) acknowledged that these omissions placed the resident at a high risk for falls. Additionally, the resident's Minimum Data Set (MDS) did not accurately reflect the level of assistance required for activities of daily living (ADLs), as therapy certifications indicated the need for moderate to contact guard assistance, while the MDS documented independence in these activities. The facility also failed to conduct a thorough investigation following the resident's fall. The investigation did not include an interview with the resident's roommate, who had witnessed the fall and could provide critical details about the incident. The DON admitted to forgetting to interview the roommate, which was contrary to facility policy requiring clarification of fall circumstances and evaluation of events leading up to the fall. Furthermore, the resident's care plan was not resident-centered and lacked specific, individualized interventions to address the resident's risk for decline in ADLs and falls, as required by facility policy. There were additional lapses in monitoring and documentation after the suspected fall. The responsible party reported the fall to both the LVN and the DON, but the LVN did not initiate further assessment or monitoring because the resident denied the fall. Progress notes revealed gaps in monitoring and documentation across several shifts following the incident, despite facility policies mandating ongoing monitoring and documentation of residents after a fall. These deficiencies in assessment, investigation, care planning, and post-fall monitoring contributed to the failure to ensure a safe environment and adequate supervision to prevent accidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made to their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit complete and accurate Payroll Based Journal (PBJ) staffing data for the first quarter of 2025 within the required timeframe. According to the CMS PBJ Staffing Data Report, the facility did not submit staffing data for the period from January 1, 2025, to March 31, 2025, by the designated deadline. The Payroll Coordinator reported that there were three errors in the staffing data report for this quarter. Additionally, the Payroll Coordinator stated that the facility's previous payroll processing company had closed for an unknown reason, and a new payroll company was not engaged until the end of May 2025. As a result, the required staffing data was not submitted on time and was only accepted by CMS after the deadline. The facility's policy and procedure required that staffing and census information be reported electronically to CMS through the PBJ system no later than 45 days after the end of each reporting quarter. The policy also specified that the Payroll Coordinator was responsible for preparing, verifying, and submitting the quarterly PBJ. The Administrator, who began working at the facility in June 2025, was not aware of the failure to submit the staffing data report for the first quarter and indicated that the Payroll Coordinator should have informed the previous Administrator about the payroll company closure to prevent the delay.

Plan Of Correction

Immediate Corrective Action: On 6/16/25, the Payroll Coordinator sought help with the new payroll software in familiarizing themselves with the system in preparation for future submissions. Corrective Action for Others Affected: On 6/16/25, the Payroll Coordinator reviewed all reports from the quarterly Payroll Base Journal reports for the past year and did not find any other quarter affected by the deficient practice. Measures Taken to Prevent Recurrence: The Administrator in-serviced the Payroll Coordinator on 06/16/25 regarding the significance of regularly and promptly submitting the quarterly Payroll Base Journal, as it affects reporting of the facility’s direct care staffing compliance. Performance Monitoring to Ensure that Solutions are Sustained: Starting 7/01/25, the administrator will review with the Payroll Coordinator the preparation of the monthly labor reports that will comprise the quarterly Payroll Base Journal submission. Starting 7/01/25, the administrator will review with the Payroll Coordinator on a quarterly basis the submission of the Payroll Base Survey to ensure prompt submission. Starting 7/01/25, the administrator will discuss during the QAPI meeting issues encountered during the monthly and quarterly Payroll Base Journal reviews for the next 3 months. Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents, as evidenced by multiple observations and interviews. One resident's closet handle was found to be replaced with a plastic trash bag loop, which the resident used to make it easier to open the door. The Director of Staff Development acknowledged that this posed a safety risk, as residents could get caught in the loop and injure themselves. Another resident's bed sheet was observed to be worn out, thin, discolored, and old, with confirmation from a Licensed Vocational Nurse that the sheet needed replacement. In a shared restroom used by two residents, towels were found hanging on various fixtures such as the soap dispenser, toilet paper holder, and shower hose, rather than on a proper towel rack. The ceiling paint in the restroom was also peeling. One resident expressed concern about the lack of a towel rack and the unsanitary conditions, while the other resident noted the safety risk of reaching for towels in unsafe locations. The Director of Staff Development agreed that the situation was unsafe, unsanitary, and not homelike. Another resident's room wall near the head of the bed was observed to have discolorations and multiple scratches, which the resident found unpleasant. The Maintenance Director stated that the damage was likely caused by the bed hitting the wall and agreed that it did not create a homelike environment. Additional deficiencies included a rollator walker with a chipped seat cushion exposing foam for one resident, and a wheelchair in poor condition for another resident, with a cracked armrest held together by tape, a sagging and cracked backrest, and missing vinyl. The affected resident reported discomfort and had previously requested a new wheelchair. The Maintenance Supervisor and DON confirmed the importance of maintaining assistive devices in good repair and acknowledged the poor condition of the wheelchair. Facility policies reviewed indicated requirements for maintaining a clean, safe, and homelike environment, as well as regular maintenance of equipment, which were not met in these instances.

Plan Of Correction

b. The Housekeeping Supervisor replaced the worn-out bedsheet of resident 55 on 6/9/25. c. The Maintenance Supervisor installed a towel rack on 6/17/25 in the shared restroom for Residents 37 and 57. On 6/17/25, the Maintenance Supervisor patched the ceiling of the restroom for Residents 37 and 57. d. On 6/18/25, the Maintenance Supervisor painted the wall for resident 64, near to the head of the resident bed. e. The Maintenance Supervisor replaced on 6/9/25 Resident 7's rollator with a newer one. f. The Maintenance Supervisor replaced on 6/9/25 Resident 66's wheelchair with a newer one. Corrective Action for Others Affected a. On 6/16/25, the Maintenance Supervisor began daily rounds and found no other residents affected by the deficient practice related to paint and wheelchairs and rollators. Measures Taken to Prevent Reoccurrence a. The Administrator in-serviced the Housekeeping Director on 6/16/2025 regarding quality control in the distribution of linens. b. The DSD in-serviced the CNA staff on 6/16/2025 regarding safe, clean, comfortable home-like environment. c. The Administrator in-serviced the Maintenance Supervisor on 6/17/25 regarding proper maintenance of wheelchairs, walkers, and rollators. Performance Monitoring to Ensure that Solutions are Sustained a. Beginning 6/16/25, the DSD shall make random rounds monthly, for the next 3 months, and check 5 random rooms to make sure that residents are using good quality linens. b. Beginning 7/01/25, the Maintenance Supervisor will report monthly to the Administrator on the status of painting and patching for the next 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Two residents were found to be placed in Geri chairs, which are considered physical restraints, without the required assessments or physician's orders. Both residents had significant cognitive impairments and required varying levels of assistance with daily activities. Observations confirmed that each resident was seated in a Geri chair in the hallway or their room, and staff interviews revealed that the chairs were used to prevent the residents from getting up unassisted, as it was more difficult for them to rise from a Geri chair compared to a wheelchair. Record reviews for both residents showed no documentation of a restraint assessment prior to the use of the Geri chair, nor was there a physician's order authorizing its use. Staff, including a CNA and Registered Nurse Supervisors, acknowledged that the Geri chair limited the residents' movement and that proper procedures, such as assessment and obtaining a physician's order, had not been followed. The facility's own policy also identified Geri chairs as potential restraints and required a pre-restraining assessment and a written physician's order before use. The failure to conduct assessments and obtain physician's orders for the use of Geri chairs resulted in the use of physical restraints without proper justification or documentation. This practice limited the residents' mobility and did not comply with regulatory requirements or the facility's policy regarding the use of restraints.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice; DON added on EHR Restraint-Physical assessment and attained consents and orders for residents 81, 86, 85, 77. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Admission assessment will include 19. Physical Restraint Initial/Quarterly/Annual. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON and or designee will add to her Chart Review to include Restraint Physical assessment which is done initially and Quarterly, annually with IDT members. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy for two residents by not reporting an allegation of abuse to the appropriate authorities within the required timeframe. An incident occurred involving a verbal altercation between two residents, one of whom attempted to hit the other with a pillow. The altercation was witnessed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who intervened by moving one resident to a new room. However, the incident was not reported to the California Department of Public Health (CDPH), the state ombudsman, or local law enforcement within two hours as required by federal and facility policy. Resident 15, who was involved in the incident, had a history of severe cognitive impairment and required substantial assistance with daily activities. The resident's care plan was updated to reflect the risk for emotional and psychosocial distress following the altercation. Resident 241, the other party in the incident, also had severe cognitive impairment and a history of encephalopathy and psychosis. Documentation showed that the altercation was only recorded as a room change in the communication book, and no formal incident report was made at the time. Interviews with facility staff, including the DON, LVN, CNA, and Administrator, confirmed that the incident was not reported as required. The DON and Administrator both acknowledged that the event should have been reported within two hours, but the delay occurred because the incident was not brought to their attention until several days later during a meeting. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this procedure was not followed in this case.

Plan Of Correction

Immediate Corrective Action a. The new administrator faxed over the SOC-341 to the CDPH and Long-Term Care (LTC) Ombudsman, and reported to the local police district on 6/5/25, after being informed by the MDS Coordinator about the alleged altercation between residents 15 and 241. b. The final investigation report was faxed over to the ombudsman on 6/11/25 within 15 days from submitting the SOC-341. On 6/11/25, within 5 working days from submitting the Corrective Action for Others Affected, the progress notes for the residents contained in the residents' files were reviewed by the MAS, Coordinator, and analyzed. No other residents were found to be affected by the incident. Preventive Measures to Recurrence a. The previous DON resigned on 6/2/25 with immediate effect. b. LVN 3 was in-serviced over the phone by the new administrator in 2025 regarding the incident and documentation of allegations of abuse. c. The administrator in-serviced all staff on 6/6/25 regarding the prevention of abuse. Performance Monitoring and Solutions a. The MDS Coordinator will review, twice a month for the next 3 months starting 6/6/2025, 5 random progress notes of residents to verify documentation and allegations of abuse. The MDS Coordinator will report findings during the monthly QAPI meeting. b. The RN/DS Coordinator will report during the resident stand-up meeting at around 9:50 a.m., with progress notes of date achieved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers by not following physician orders for heel offloading for two residents. Both residents had documented orders and care plans requiring their heels to be offloaded, either with heel protectors or pillows, to prevent skin breakdown due to their high risk for pressure injuries. Despite these orders, multiple observations over several days showed that neither resident had their heels offloaded as required. For one resident with a history of cerebral infarction, contractures, and high risk for pressure injury, the care plan and physician order specified bilateral heel offloading every shift. Observations revealed the resident lying in bed without heel protectors or pillows under the heels, and the resident confirmed that staff had not been applying the heel protectors or using pillows. Interviews with CNAs and the Restorative Nursing Assistant indicated a lack of awareness of the order and inconsistent application of the intervention, with staff stating that heel offloading had not been performed during their shifts. The second resident, who had a diagnosis including an unstageable pressure ulcer on the right heel and diabetes, also had a physician order and care plan intervention for continuous right heel offloading. Observations found the resident's right foot wrapped but not offloaded, with no heel protector or pillow in use. Staff interviews confirmed that the required offloading was not being performed, and the importance of following the order to prevent further injury was acknowledged by nursing staff. Facility policy required structured assessment and intervention for residents at risk of pressure injuries, but these were not implemented as ordered for these residents.

Plan Of Correction

Immediate Corrective Actions for resident affected by this deficient practice. On 6/12/25, DON and DSD immediately placed bilateral heel protectors for both residents 42 and 54. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; All other Residents with orders for Off-Loading heels were checked and verified by Treatment Nurse and DON on 6/12/25 and found no other deficient practices. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur. On 07/02/25, DSD and DON in-serviced all licensed Nurses regarding proper implementation of heel protectors as ordered by the physician. Starting 7/01/25, Medical Records Director will Audit daily EHR orders for heel protectors and report to the DON any deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DON or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance starting 7/01/25. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the administration of medications for two residents, as medications were not given within the required time frame according to facility policy and physician orders. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered scheduled 9 AM medications to two residents after the permitted 60-minute window. The LVN confirmed that the delay occurred because they became occupied with another resident, resulting in late administration of all prescribed medications for both individuals. The first resident involved had diagnoses including neuralgia and right knee osteoarthritis, and required varying levels of assistance with daily activities. This resident was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all of which were administered late during the observed medication pass. The second resident had a medical history of hypertension, dementia, anemia, and encephalopathy, and was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix. All of these medications were also administered outside the required time frame. Interviews with facility staff, including another LVN, the Registered Nurse Supervisor, and the Director of Nursing, confirmed that medications are to be administered within one hour before or after the scheduled time, and that deviations from this protocol constitute a medication error. The Director of Nursing further stated that the LVN should have requested assistance if unable to complete the medication pass on time. Review of the facility's policy corroborated that medications must be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: Resident 55 and Resident 84 were reassessed by the DON on 06/11/25 and the DON also called MD for a one-time late med pass order. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON found two residents affected by the same deficient practice. Physician was notified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1:1 in-service with LVN 4 on 6/16/2025 with DON and Pharmacy Consultant with importance of timely Medication Pass emphasis to ask for assistance by another licensed nurse and call Physicians for an order to pass medications late to reduce complications. All licensed Nurses are in-serviced on 6/16/25 regarding 60 minutes Pharmaceutical/Facility Policy and Physician orders to include, "Medications must be administered within 60 minutes of scheduled time". Pharmacy Consultant to continue random twice monthly med pass observation / Medication Cart Audit per Regulation and provide DON results. Any discrepancies will be addressed immediately. See Med pass Observation form. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its medication error rate remained below five percent, as required by federal regulations. During a survey, it was observed that a Licensed Vocational Nurse (LVN 4) administered medications late to two residents, resulting in eight medication errors out of 25 opportunities, yielding a 32% medication error rate. The late administration occurred because LVN 4 became busy with another resident and did not administer the 9 AM medications within the required one-hour window. Resident 84, who had diagnoses including neuralgia and right knee osteoarthritis, was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all scheduled for administration at 9 AM. During observation, these medications were given at 10:18 AM, outside the permitted time frame. Resident 55, with a history of hypertension, dementia, anemia, and encephalopathy, was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix, also scheduled for 9 AM. These medications were administered at 10:30 AM, again exceeding the one-hour window. Interviews with nursing staff and the Director of Nursing confirmed that medications must be administered within one hour of the scheduled time, and that failure to do so constitutes a medication error. The facility's policy also requires medications to be given in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. The deficiency was attributed to the nurse not seeking assistance when unable to complete medication administration on time.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice; DON Followed as a 1:1 Medication Pass with LVN 4 and gave instruction with return Demonstration. See 6/12/2025 at 6 pm form. 1:1 in-service 6/12/2025 with DON Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Laminated Medication Pass reminders and given to all Medication Pass Nurses. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON will do Competency Medication Pass with LVN 4 every Month times 3 months to ensure efficiency and any discrepancies will be addressed immediately by DON. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed multiple instances where food items stored in the facility's kitchen refrigerator and freezer were not labeled with required open or use-by dates. Items such as cooked chicken, sliced ham, turkey, ground beef, chicken salad, diced pears, cut honey dew, salsa sauce, peeled garlic, tomato sauce, and margarine were found in the walk-in refrigerator without use-by dates. Additionally, three bags of corn tortillas were found with a use-by date that had already passed. In the freezer, several packages of frozen fish, chicken thighs, chicken strips, mixed vegetables, and peas were missing open or use-by dates, or only had delivery dates. These observations were made during a walkthrough with the Dietary Supervisor, who confirmed that facility policy requires all food removed from original packaging to be labeled with open and use-by dates, and that expired food should be discarded. Interviews with the Dietary Supervisor and the Administrator confirmed the importance of proper food labeling and discarding expired foods to prevent foodborne illness. A review of the facility's policy and procedure on food receiving and storage indicated that all food stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The failure to follow these procedures was directly observed and acknowledged by facility staff during the survey.

Plan Of Correction

Immediate Corrective Action Undated food items were immediately discarded by Kitchen Supervisor 06/09/25. Corrective Actions for Others Affected On 6/09/25, the kitchen supervisor conducted a thorough inspection and all food items were labeled properly and found no other residents affected by the deficient practice. Measures Taken to Prevent Reoccurrence On 7/01/25, the Dietary Supervisor implemented a strict policy requiring all food items to be clearly labeled with a use-by date. Starting 7/01/25, the Dietary Supervisor will conduct regular audits of food inventory to ensure compliance with labeling requirements. Dietician Consultant conducted an in-service on food storage practices on 06/18/25 with all kitchen staff to reiterate the importance of checking use-by dates when restocking the storages; notify all staff the importance of labeling and checking food for spoilages. Beginning 7/01/25, the Dietary Supervisor implemented a log for regularly checking and updating use-by dates. Performance Monitoring to Sustain Solutions 1. Beginning 7/01/25, the Dietary Supervisor will conduct random spot checks weekly to ensure standards are maintained continuously (to be submitted and documented for monthly QAPI meetings) for 3 months. F 812

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to adhere to infection prevention and control protocols for two residents on Enhanced Barrier Precautions (EBP) and in the facility's laundry area. For one resident with dementia and multiple pressure ulcers, a certified nurse assistant provided care while only wearing gloves and removed her isolation gown before completing all care activities, despite an active EBP order. Interviews with nursing staff confirmed that the EBP protocol required the use of both gown and gloves for all high-contact care activities, and that the gown should not have been removed until care was finished and before leaving the room. For another resident with end stage renal disease and a central venous catheter, there was no EBP signage or PPE cart outside the room, despite an active EBP order. A nurse confirmed that staff should have access to and use appropriate PPE, including gown, gloves, and mask, during direct care for this resident. Facility policy required that EBP signage and PPE be readily available and that staff, residents, and visitors be educated on EBP requirements. In the laundry area, a cart of clean linen was placed in the dirty area next to a sink clogged with dark brown water, and there was no signage to distinguish clean and dirty areas. The housekeeping supervisor and infection preventionist nurse both stated that clean linen should be stored in the clean area to prevent cross-contamination, and that the sink should remain unclogged to prevent the spread of bacteria. Facility policy required that soiled and clean linens not be stored together and that laundry equipment problems be reported and addressed promptly.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: On 6/13/25, DSD applied Enhance Barrier Precautions signage and isolation cart to outside of room 119. On 6/13/25, Housekeeping Supervisor placed signs to indicate clean and dirty areas in Laundry Room. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurse aides received the required in-service training, specifically dementia management training, as mandated by federal regulations. A review of employee records for two certified nursing assistants (CNAs) revealed that one CNA had not received dementia management training since 2022, and the other since 2024. Additionally, one CNA reported never receiving dementia management training from the facility, only from her school. The Director of Staff Development (DSD) confirmed there was no tracking system in place to ensure CNAs completed at least 12 hours of in-service education per year, nor was there an updated in-service calendar or timely updates to employee files. The DSD acknowledged the lack of upcoming dementia management training and was unable to provide documentation of recent training for CNAs and other staff. The facility's policy and procedure for the DSD role outlined responsibilities for planning, developing, and coordinating the nursing assistant training program, including maintaining appropriate records and ensuring compliance with federal and state guidelines. However, these duties were not fulfilled, resulting in the deficiency related to insufficient in-service training for nurse aides.

Plan Of Correction

Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. DSD rounded on 6/12/25 and found no other resident affected by the deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 6/12/25, DSD will maintain a calendar of what in-services will be given every month to include Dementia Management. DSD initiated a log on 6/19/2025. Continue Education to oversee CNAs have enough CEUs that include Dementia Management with Competency to ensure residents are properly cared for. DSD on 06/17/25 and 06/19/25 conducted required in-service training with CNAs and Licensed Nurses with emphasis given on Dementia Management that all Nurse Aides to be in-serviced quarterly and for at least 2 hours. Dementia-specific Training as part of facility orientation program. Administrator conducted 1:1 in-service training with the DSD on Dementia on 6/19/2025. Performance Monitoring: Starting 7/01/25, the DON will review the DSD's training calendar to ensure inclusion of Dementia Training and the DON will report in the monthly QAPI meeting for discussion and review. Monthly discussion and review will occur for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DSD will report any deficient practices, review Performance, and report to Administrator and report to QAPI monthly meetings for compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a certified nurse assistant (CNA) assisted a resident with dementia, sacral pressure ulcer, and heel pressure ulcers during mealtime while standing above the resident's eye level. The resident was dependent on staff for all activities of daily living, including eating, and had moderately impaired cognitive skills, requiring cues and supervision. The care plan for the resident specified that staff should assist at mealtime and with all food and fluid offerings. During the observed incident, the CNA stood on the right side of the bed and fed the resident from above, rather than sitting at eye level. This action was confirmed by a licensed vocational nurse (LVN) who verified that the CNA and the resident were not at the same eye level. The CNA explained that she did not sit because she was short and found it difficult to reach the resident from a seated position. Interviews with other nursing staff, including an LVN and a registered nurse (RN), confirmed that staff are expected to maintain eye level with residents during feeding to establish rapport and show respect. A review of the facility's policies indicated that residents should be cared for in a manner that promotes their sense of well-being, self-worth, and dignity, and that staff should not stand over residents while assisting them with meals. The observed practice did not align with these policies, resulting in a failure to promote dignity and respect for the resident during mealtime.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: On 6/12/25, Administrator ordered 4 Height Adjustable Stools to provide to Staff to better assist them with providing meals to the residents in a dignified manner. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 6/13/25, DON did rounds with DSD and found 9 other residents who are assisted with meals by CNAs, all were observed sitting down at eye level and exchanging rapport and socializing in a dignified manner. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. F 550 Immediate Corrective Action: a. The plastic bag tying resident 33's closet was removed by the Maintenance Supervisor on 6/9/25.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents were free from unnecessary psychotropic drug use, specifically regarding PRN Lorazepam orders that were not discontinued after 14 days as required by federal regulations and the facility's own policy. For one resident, the Lorazepam PRN order was initiated for anxiety and restlessness, with the order specifying an 'indefinite' stop date. Upon review, the Registered Nurse Supervisor confirmed that the order should have been discontinued after 14 days, but it remained active beyond this period without appropriate physician documentation or review. Another resident had a similar issue, with a PRN Lorazepam order for anxiety that also had an 'indefinite' stop date. The order was not discontinued after 14 days and was only changed months later when the frequency was increased, but the new order again lacked a stop date. The Registered Nurse Supervisor and the Director of Nursing both verified that the PRN Lorazepam order should have been limited to 14 days, and there was no written documentation from the physician to justify extending the order beyond this period. Both residents had significant cognitive impairments and required extensive assistance with activities of daily living. Their medical records indicated diagnoses such as dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder. The facility's policy on psychotropic medication use, revised in February 2025, clearly stated that PRN orders for psychotropic medications are limited to 14 days, yet this policy was not followed in these cases.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: Resident 85 Hospice Physician was alerted and new order placed for Lorazepam 2mg/ml q 4 hrs as needed for anxiety on 6/12/2025 to include a 14 day stop date. See Written Education with Compliance Cue to support 1:1 with DON. Immediate Corrective Action for resident affected by this deficient practice: Resident 86 Lorazepam was discontinued on 2/17/2025. Renewed on 6/24/2025 by Hospice Physician. Give Lorazepam 1 mg q 2 hours PRN x 14 days for anxiety. See Written Education with Compliance Cue to support 1:1 with DON. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: Resident 86 Hospice N/P and Resident 85 Hospice Physician have received a 1:1 in-service by DON on 7/4/2025 regarding Compliance Cue (New Regulation) to provide written documentation extending a PRN psychotropic drug if deemed necessary or need to limit to 14 days. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when staff failed to follow proper procedures for the care and management of a gastrostomy tube (G-tube) for a resident with significant medical needs, including dysphagia, type 2 diabetes mellitus, and heart failure. The resident was totally dependent on staff for daily care and was receiving nutrition via a feeding tube. Physician orders and the resident's care plan required staff to check tube placement and patency every shift, as well as to check gastric residual volume (GRV) before administering feedings. During an observation, a Licensed Vocational Nurse (LVN) was seen preparing to administer a tube feeding to the resident. The LVN did not disinfect the tip of the G-tube or the extension feeding port prior to connecting the feeding, and also failed to check the GRV or the patency of the tube before starting the feeding. The LVN acknowledged that not performing these checks could result in feeding being administered incorrectly, potentially leading to complications for the resident. Interviews with nursing staff confirmed the importance of disinfecting the G-tube and checking placement and GRV for infection control and to prevent complications. Review of the facility's policy on enteral nutrition also indicated that staff should confirm tube placement and check GRV as part of standard care. The failure to follow these procedures constituted a deficiency in the care and treatment of the resident's G-tube.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: On 6/11/25, LVN 4 disinfected the G-Tube tubing tip. DSD checked resident 28 was checked for residual prior to connecting the G-Tube Feeding on 06/11/25. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD rounded on 06/11/25 for all other gastric tube residual and found no other resident affected by same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 7/01/25, LVN 4 will be observed q monthly by Pharmacy Consultant and random medication pass with medication review and cart check twice a month per regulation. On 6/16/25, LVN 4 was given a 1:1 in-service to properly disinfect extension tubing at enteral feeding port also showed proficiency with checking Gastric Volume Residual with DON and Pharmacy Nurse Consultant. Medication Administration Clinical Competency Skills check for all licensed nurses done by DON from 6/19/25 to 7/04/25 and found no other residents affected by same deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a history of respiratory failure, COPD, and dementia, who was dependent on staff for all activities of daily living and receiving oxygen therapy, was found with the head of bed positioned almost flat. The resident's medical orders included oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observation, the resident was noted to be on oxygen with the bed nearly flat, contrary to the facility's policy requiring the head of bed to be elevated to at least 30 degrees when oxygen is applied. Staff interviews confirmed that the resident had been left in this position by a CNA, and a nurse acknowledged the head of bed was only at 15-20 degrees, which was not appropriate for a resident with shortness of breath. The facility's policy and procedure for oxygen therapy specifically stated that the head of bed should be elevated 30 degrees or higher for residents receiving oxygen. The failure to maintain the required bed elevation was directly observed and confirmed by staff, constituting a failure to follow established protocols for respiratory care.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: Resident 34 head of bed was immediately raised to 30 degrees by CN on 6/12/2025. DON and DSD rounded and found two other residents on continuous low dose oxygen with head of bed at 30 degrees or greater without discomfort. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON rounded and found no other residents were affected by deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: All licensed nurses in-serviced on 06/14/25 and 06/15/25 regarding head of bed to be greater than 30 degrees while on oxygen for comfort. Licensed nurses' daily check list and duties as soon as you step in, to include number 4: head of bed greater than 30-45 degrees. DON added to batch order set on electronic health template details to include "While on oxygen, keep head of bed at least 30 degrees or greater." Facility plan to monitor corrective action(s) and sustain compliance: Starting 7/01/25, DON or designee will review performance and report to the administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident receiving hemodialysis was provided appropriate dialysis care and services in accordance with facility policy and physician orders. Specifically, staff did not properly assess the resident's right femoral dialysis access site on multiple occasions, as required. Documentation and assessments were inaccurate, with staff incorrectly recording findings such as bruits and thrills, which are not applicable to a femoral central venous catheter but rather to an arteriovenous fistula. Additionally, the assessment forms indicated the wrong access site location, listing a right thigh access instead of the correct right femoral site. The resident involved had a history of end stage renal disease and a right femoral central venous catheter for dialysis. The care plan and physician orders required regular monitoring of the access site for signs of infection or leakage, as well as pre- and post-dialysis assessments. However, record reviews and staff interviews confirmed that these assessments were not performed accurately or consistently, leading to incomplete and potentially misleading documentation regarding the resident's dialysis access care.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice. DON re-assessed the right femoral hemodialysis site and found the site intact and covered. 06/13/25 Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. No other residents were affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1. 1:1 in-serviced to 5 CN for proper placement of Hemo Dialysis catheter. On 05/24/25, 05/25/25, 05/27/25, 05/29/25, 05/31/25, 06/03/25. 2. Medical Records to Audit this form daily and any deficient practices will be brought to DON to adhere to standards of practice. 3. Hemo dialysis Nursing pre and post communication record will also accompany new form "Dialysis Alert" to double down on precise location and description of access to receive proper care. 4. All licensed nurses were in-serviced on 6/13/2025 on accurate dialysis site assessment pre and post hemodialysis. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours on a specific day, as required by federal regulations. Review of the Nursing Staffing Assignment and Sign-In Sheet for that day showed that no RN Supervisor was present for either the morning or evening shifts. The Director of Staff Development confirmed that the RNs scheduled for those shifts did not report to work—one did not show up and the other called in sick. The Director of Nursing was not scheduled and was also not present, and no replacement RN was arranged for either shift. The facility's own Facility Assessment and staffing plan indicated that an RN Supervisor is needed every day of the week. The RN Supervisor job description outlined responsibilities such as supervising nursing staff, handling personnel issues, reporting to the DON or medical staff, and monitoring incident reports. The absence of an RN on the specified day meant that there was no qualified individual to oversee resident care, supervise staff, or respond to clinical needs as required by the facility's policies and federal regulations.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: On 6/03/25, DSD reviewed the rest of the R.N. schedule for June 2025 and found 8 hrs consecutively 7 days a week were covered. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 7/01/25, DSD reviewed the schedule for June 2025, and no other deficient practice was identified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 7/10/25, an RN Supervisor was hired 7:00am-3:30pm Monday through Friday. Starting 6/02/25, DSD and/or DON will utilize Contracted Agency for RN as needed. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure that a medication irregularity identified during the monthly Medication Regimen Review (MRR) was reported to the resident's primary physician in accordance with facility policy. The irregularity involved a psychotropic medication, lorazepam, prescribed as needed (PRN) for a resident with diagnoses including dementia, major depressive disorder, and anxiety disorder. The facility's policy and federal regulations require that PRN orders for psychotropic medications be limited to 14 days unless the physician documents the rationale for extending the order in the clinical record. The MRR conducted in February identified that the PRN lorazepam order should be limited to 14 days, and this recommendation was documented by the pharmacy consultant. However, the order for lorazepam, initiated in February, was not discontinued after 14 days and remained active without a stop date until June, when the frequency of administration was changed. There was no written documentation from the physician to justify extending the PRN order beyond 14 days, and the new order also lacked a stop date. The pharmacy consultant stated that the recommendation was made only once and not repeated in subsequent monthly reviews, while the DON confirmed that the recommendation was not followed and the physician was not made aware of it. The failure to act on the pharmacist's recommendation and to communicate the irregularity to the physician resulted in the continued administration of lorazepam without proper review or documentation. This was contrary to both facility policy and federal requirements, which mandate that such irregularities be reported and acted upon to ensure appropriate medication management for residents.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: 1:1 Inservice given to DON on 07/01/25 by Pharmacist Physician regarding regulation and policy of Psychotropic Drugs to include end date for PRN medications of 14 days. Also, pharmacist to review Drug Regimen Review Report monthly. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON evaluated all Residents and educated 2 Separate Hospice Physician/Resident N/P regarding regulations and policy on PRN Psychotropic Drugs to include 14 day end dates or to justify necessity to continue psychotropes or discontinue. No other residents were found for the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: All licensed Nurses were inserviced on 06/16/25 with DON and DSD with Pharmacist Consultant new audit tool to include PRN Psychotropic Drugs to have a 14 day end date. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Starting 7/01/25, the DON and or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with end stage renal disease, anemia, and diabetes mellitus did not receive their prescribed calcium acetate medication as ordered. The physician's order specified that calcium acetate, a phosphate binder, should be administered with meals to treat hyperphosphatemia. On the day in question, the resident's medication was given before lunch was delivered, and the resident did not eat the lunch meal. This was confirmed through interviews with the resident, a CNA, and the nurse who administered the medication. The resident stated she received her medication before food arrived and subsequently refused to eat lunch, which was verified by the CNA who removed the untouched tray. The nurse acknowledged administering the medication before the meal and not ensuring the resident was eating at the time, contrary to the physician's order and facility policy. The facility's policy requires medications to be administered according to prescriber orders and at times that optimize therapeutic effect, not for staff convenience. The failure to administer the medication with food, as ordered, was also confirmed by the RN, who stated that the medication should have been given with the meal to ensure effectiveness.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice: Resident 29 was assessed by DON and graham crackers were given on 06/12/25. Dietary Supervisor provided a quesadilla. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON found no other resident affected by this deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 06/16/25 a 1:1 Inservice with LVN 4 by DON and Pharmacy consultant regarding the use of Calcium Acetate and Phosphate binders and the importance of medications being given with food. Observation with Pharmacy Consultant will randomly observe Medication Pass twice a month per Facility Policy. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON and or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of expired and discontinued medications in medication storage room 1 (MSR 1), as observed when the incineration bin was found overflowing and its lid not properly closed. A Licensed Vocational Nurse (LVN) confirmed that the bin should not be overflowing, as this defeats the purpose of preventing access to disposed medications. Additionally, the facility's policy requires non-controlled substances to be disposed of in accordance with state and federal guidelines, and for medication storage areas to be maintained in a clean, safe, and sanitary manner by nursing staff. In a separate incident, a non-licensed staff member, the Central Supply Manager (CSM), was left alone inside medication storage room 2 (MSR 2) after being asked to clean up the incineration bin. The Director of Nursing (DON) acknowledged that the CSM, not being a licensed nurse, should not have been left alone in the medication room, as this allowed unauthorized access to medications. The CSM also stated she should not be handling medications without a licensed nurse present. These actions were not in accordance with the facility's policies and federal regulations regarding medication storage and access.

Plan Of Correction

Immediate Corrective Action for resident affected by this deficient practice. On 6/11/25, DON immediately emptied Station 1 incineration bin to biohazard container in locked area in the back next to laundry. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. On 6/12/25, DON inspected all incineration bins to ensure all bin lids were properly closed and no other deficient practice was identified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; On 06/12/25 an in-service was done to all Licensed Nurses regarding properly disposing of expired and/or discontinued medications to incineration burn bin. New form added: Task list labeled "Attention All Licensed Nurses: 8 states," 7-3 Licensed Nurses check medication room and empty incineration bin daily to biohazard bin next to laundry room. DON to check Q daily for compliance. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its policy regarding the labeling and storage of food brought in by family or visitors for a resident. During an observation in the resident's room, a shopping bag containing three unlabelled zipped bags with food items, including crackers, a ham sandwich, and tortillas, was found on the floor. Additionally, unopened cups of applesauce and yogurt were observed on the nightstand, and more food items were found in the side drawer. None of these items were labeled with the resident's name, date, or expiration information, and perishable items were not stored in the refrigerator as required by facility policy. Certified Nursing Assistant 1 confirmed that all the food in the resident's room had been brought by the family and lacked proper labeling. The CNA stated that it was not possible to determine if the food was still safe to consume and acknowledged that perishable items like yogurt and applesauce should have been refrigerated. The CNA also noted the risk of illness if expired or improperly stored food was consumed. The Registered Nurse Supervisor stated that dietary staff are responsible for checking outside food to ensure it is appropriate for the resident's prescribed diet and to prevent choking hazards. The supervisor also confirmed that outside food should be labeled with the date it was made, the resident's name, and room number. A review of the facility's policy indicated that food brought in by family or visitors must be labeled and stored in resealable containers in a refrigerator, with clear identification and a "use by" date, especially for perishable items and residents with cognitive or swallowing difficulties.

Plan Of Correction

On 6/11/25, CNA threw open food away with resident 54's permission. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; On 6/11/25, DSD conducted rounds and found no other deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; On 6/11/25, the DON sign placed in Staff Lounge in English and Spanish to include "Any Food brought into facility must have a name, opened date and expiration date." In-service done for CNAs on 6/15/2025 regarding Personal Food Policy. CNA1 had a 1:1 on 6/15/2025 in-service with DSD and educated on any food which is brought into facility and opened must have a name, opened date and expiration date of 3 days and will be thrown out. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 6/30/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings for compliance for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident's call light system was found to be non-functional. During an observation, the call light was seen on the resident's bed, and the resident reported that it was broken. A Licensed Vocational Nurse confirmed that activating the call light did not produce any audible or visible signal above the resident's door, indicating the system was not working. The facility's policy requires that each resident have a functional call light system at all times, both for audible and visual alerts. The affected resident had a history of encephalopathy, cerebral infarction, and lack of coordination, and was assessed as moderately impaired in cognitive skills. The resident required supervision or assistance with bathing and setup or clean-up assistance with toilet hygiene, personal hygiene, and eating. The failure to provide a functioning call light system was confirmed by both nursing staff and a review of facility policy, which mandates that residents must have a means to call for staff assistance from their bed and bathroom areas.

Plan Of Correction

Immediate Plan of Correction a. The call light in room 117B for resident 55 was immediately fixed by the Maintenance Supervisor on 6/9/25. Corrective Action for Others Affected On 6/09/25, the Maintenance Supervisor checked all rooms and did not find any other residents affected by the deficient practice. Measures Taken to Prevent Reoccurrence a. The administrator in-serviced the Maintenance Supervisor on 06/17/25 regarding the importance of regularly checking the call system to be able to promptly assist residents as may be needed. b. On 06/17/25, the DSD in-serviced the direct care staff to report issues with the call system. c. On 06/17/25, the administrator in-serviced the department heads to make sure that they check the call light system for its functionality to be able to promptly assist residents as may be needed. Performance Monitoring Starting 7/01/25, the Maintenance Supervisor will make weekly rounds in 5 rooms, for the next 3 months, to check the functionality of the call systems. The Maintenance Supervisor will report any findings during the monthly QAPI meeting for the next 3 months. Immediate Corrective Action for resident affected by this deficient practice DSD in-serviced CNA 6 on 6/16/2025 on Dementia Management. DSD in-serviced CNA 7 on 6/16/2025 on Dementia Management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that 11 out of 41 resident rooms met the required minimum square footage of 80 square feet per resident in multiple resident bedrooms, as specified by federal regulations. During an initial observation, it was found that rooms 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222 did not meet this requirement. The measured square footage for these rooms ranged from 143 to 234 square feet, with several rooms housing two or three residents, resulting in less than the required space per resident. The facility's room waiver documentation indicated that these rooms were considered adequate for resident needs and did not adversely affect health and safety, but the actual measurements did not comply with the regulatory standards. Interviews with nursing staff, including a CNA, RNA, and LVN, revealed that they believed there was sufficient space in the rooms to provide care and for residents to move around safely, including those using wheelchairs. Additionally, residents interviewed did not express concerns about the size of their rooms. Despite these observations and staff and resident feedback, the deficiency was cited based on the objective measurements of room size not meeting the federal requirements.

Plan Of Correction

Immediate Corrective Action A request for room waiver was submitted to the CDPH Surveyor Team on 6/9/25 for the following rooms which have less than 80 square feet for multiple residents in a room: 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222. Corrective Action for Others Affected The granting of waiver request will not adversely affect the resident's health and safety and is in accordance with the special needs of the residents. A completed Facility Client Accommodations Analysis indicates all other rooms met the required measurement. Measures Taken to Prevent Reoccurrence Starting 7/01/25, the department heads will conduct Angel Rounds on a daily basis to ensure that the space available for the residents in the affected rooms is sufficient to provide care, provide privacy, and provide adequate space for patient care equipment and personal items. Performance Monitoring Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months to ensure total compliance is achieved.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.

Removal Plan

• Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
• Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
• The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
• Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
• Received orders from physician to apply a wander guard to Resident.
• Obtained informed consent from Resident's Responsible Party (RP).
• Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
• Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
• Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
• Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
• Resident's care plan was updated with interventions implemented to prevent a repeat event.
• Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
• Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
• All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
• Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
• Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
• The facility has identified only one resident at high risk for elopement which is Resident.
• The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
• The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
• The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
• The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
• The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
• The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
• The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.

Penalty

Fine: $54,194

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its policies and procedures for abuse prevention, reporting, and investigation, resulting in unreported and uninvestigated incidents of physical and sexual abuse involving three residents. On one occasion, a staff member witnessed a resident physically assault another resident by punching them in the chest while in the elevator. Despite multiple staff being aware of the incident, there was no documented evidence that the event was reported to the State Survey Agency, Ombudsman, or law enforcement within the required timeframe, nor was there any documentation of an investigation into the incident. In a separate incident, several staff members observed a resident inappropriately touch another resident's inner thigh and upper back while waiting in the hallway. The staff who witnessed the event reported it internally, but the abuse was not reported to the appropriate authorities, and no investigation was documented. The resident who experienced the inappropriate touching expressed feeling scared and unsafe in the facility following the incident. Interviews with staff revealed a lack of knowledge and follow-through regarding mandated reporting requirements and the completion of necessary forms, such as the SOC 341. The residents involved had significant medical and psychological histories, including cognitive impairment, depression, schizophrenia, and histories of trauma. The failure to report and investigate these incidents, as well as to protect residents from further abuse, was confirmed through interviews, record reviews, and observations. The administrator admitted to not reporting or investigating the incidents, and staff interviews highlighted gaps in training and understanding of abuse reporting protocols.

Penalty

Fine: $54,194

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from sexual abuse by another resident. On the day of the incident, a resident with a history of depressive disorder, schizophrenia, and cognitive decline was sitting in her wheelchair in the hallway when another resident touched her inner thigh and later placed his hands inside her shirt to touch her upper back. Multiple staff members witnessed the inappropriate touching, but the residents were not immediately separated, and both were subsequently taken to the same group activity in the Activities Room. The affected resident expressed feeling scared and unsafe following the incident, especially given her history of sexual trauma prior to admission. Staff interviews and record reviews revealed that there was no documentation of the incident in either resident's chart, including the absence of an SBAR, progress notes, care plan, or 72-hour monitoring. The physicians and responsible parties for both residents were not notified, and there was no evidence of assessment or intervention for emotional distress immediately following the event. Staff members acknowledged that the residents should have been separated and that the incident should have been reported and documented according to facility policy, but these actions were not taken. Further investigation uncovered that the resident who committed the abuse had a known history of inappropriate sexual behavior, including touching himself and making female residents uncomfortable during group activities. Despite this, there was no care plan or documentation addressing his behavior, and staff responses to his actions were inconsistent and inadequately communicated to leadership. The facility's policies for abuse prevention, reporting, and resident protection were not followed, resulting in the resident experiencing sexual abuse and ongoing emotional distress.

Penalty

Fine: $54,194

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide treatment and care in accordance with professional standards for three residents following incidents involving inappropriate touching and physical aggression. In the first case, a resident with a history of depressive disorder, schizophrenia, and cognitive decline was inappropriately touched by another resident. The charge nurse observed the incident and confirmed that the resident expressed discomfort and fear, yet there was no documentation of the event, no assessment or monitoring of the resident's physical, emotional, or mental status, no care plan developed to address the incident, and the physician was not notified. The resident reported feeling unsafe and scared, and only one staff member spoke to her about the incident. In the second case, another resident with diabetes, osteoarthritis, and polyneuropathies was punched in the chest multiple times by the same aggressor in an elevator. Despite staff being aware of the incident, there was no documentation in the medical record, no assessment for injuries, no monitoring for 72 hours post-incident, no care plan addressing the event, and the physician was not notified. The resident confirmed the physical altercation, and staff interviews revealed that required documentation and follow-up were not completed. The third resident, who was the perpetrator in both incidents, had diagnoses of dementia, depressive disorder, and anxiety disorder. There was no documentation of his involvement in the incidents, no assessment or monitoring of his behavior, no care plan to address his inappropriate and aggressive actions, and no physician notification. Interviews with facility leadership and review of policies confirmed that the facility's procedures for change of condition, abuse prevention, and documentation were not followed for any of the three residents involved.

Penalty

Fine: $54,194

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to maintain accurate and complete medical records for two residents when documentation regarding an incident of inappropriate touching was falsified. Specifically, a charge nurse was instructed by the administrator to document that a resident had inappropriate behavior toward staff, rather than accurately recording that the behavior was directed toward another resident. The charge nurse initially disagreed with this directive but ultimately completed the SBAR form as instructed, misrepresenting the facts of the incident. The MDS nurse subsequently developed a care plan based on this inaccurate information, indicating that the resident had inappropriate behavior with staff instead of the actual victim. The incident involved two residents, both with cognitive impairments and requiring varying levels of assistance with daily activities. One resident, with a history of depressive disorder, schizophrenia, and psychosis, reported feeling unsafe after being touched inappropriately by another resident with dementia and anxiety disorder. The affected resident expressed discomfort and a lack of safety due to the incident, which was only discussed with the charge nurse and not properly documented in the medical record as required. Multiple staff interviews confirmed that the administrator directed the documentation to be falsified to avoid reporting the incident to the state health department and to justify a psychiatric evaluation for the resident who exhibited the inappropriate behavior. As a result, the social services director was unable to assess the affected resident, and the care plan did not reflect the true nature of the incident. Facility policy requires that documentation be objective, complete, and accurate, and that the administrator is responsible for ensuring compliance with these standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident 1, who was admitted with diagnoses including psychosis, encephalopathy, and acute kidney failure, allegedly grabbed and shook Resident 2, resulting in a scratch on Resident 2's neck. Resident 1's cognitive skills for daily decision-making were moderately impaired, requiring supervision or assistance with various activities of daily living. The incident was documented in an SBAR by LVN 1, who heard loud voices from the room shared by the two residents and observed Resident 1 standing next to his bed while Resident 2 was sitting on his bed. Resident 1 admitted to grabbing and shaking Resident 2. Resident 2, who was also moderately impaired in cognitive skills and required assistance with daily activities, confirmed that Resident 1 grabbed him, resulting in a scratch on his neck. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from abuse, including physical abuse by other residents. Despite this policy, the altercation between Resident 1 and Resident 2 occurred, leading to physical harm to Resident 2. The facility's failure to prevent this incident constitutes a deficiency in ensuring the safety and well-being of its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the functionality and expiration of a wander guard for a cognitively impaired resident who displayed wandering behaviors. The resident was admitted with diagnoses including psychosis, encephalopathy, and acute kidney failure, and required various levels of assistance for daily activities. The resident's care plan included the use of a wander guard to mitigate the risk of elopement, but the facility did not adhere to its policy and procedure regarding the device's maintenance. During observations and interviews, it was revealed that the wander guard was not checked for expiration before being applied to the resident. The device was initially placed on the resident's right wrist but was later moved to the left ankle without proper inspection for functionality. Staff members, including a Licensed Vocational Nurse and a Registered Nurse, were unaware of the expiration date printed on the device and did not test its functionality as required by the facility's policy and the manufacturer's guidelines. Interviews with facility staff, including the Director of Staff Development, the Administrator, and the Director of Nursing, highlighted a lack of awareness and adherence to the facility's procedures for wander guard use. The Director of Nursing acknowledged that expired medical supplies, such as wander guards, should not be used and that their use could compromise resident safety. The facility's policy emphasized the importance of using wander guards as a primary measure to prevent elopement, but the failure to follow these procedures placed the resident at risk of elopement and potential harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the building in good repair and free from hazards, as evidenced by the presence of water damage and moldy discoloration on the ceiling of the second-floor dining room. Observations and interviews with staff, including a CNA, LVN, and RN, confirmed the presence of peeling, brown discoloration, and a hole in the ceiling, which appeared to be moldy and indicative of water damage. The maintenance supervisor acknowledged noticing the damage on 2/18/2025 and documented it in the maintenance log, but no repairs had been made by the time of the survey on 2/22/2025. The facility's policy and procedure for maintenance service require that the building be kept in good repair and free of hazards, which was not adhered to in this instance. The maintenance supervisor admitted that the room should have been closed off to residents due to the potential health hazard posed by the mold and debris. The administrator confirmed that the maintenance supervisor had identified the issue on 2/18/2025, but the room was only closed off on the day of the survey, 2/22/2025, indicating a delay in addressing the hazard and protecting residents from potential exposure to mold and debris.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe and comfortable environment for its 52 residents on the second floor by not addressing a leakage issue in the ceiling above the shower room and hallway. The Maintenance Supervisor observed a water stain on the ceiling outside the shower room, indicating a leak, but was unable to determine when the leak or water stain began. The Administrator explained that the leak was due to micro cracks and fissures from the mounting of a commercial air conditioner unit on the roof, which allowed water to seep through and affect the second-floor ceiling. The Maintenance Supervisor measured the water stain to be 22.5 inches by 17 inches and suggested it could have resulted from recent rain. The facility's policy, revised in March 2024, states that repairs such as painting, patching, and leak repairs should be done in coordination with the resident and in a timely manner. However, the failure to address the leak promptly had the potential to cause the ceiling tile to swell and collapse, posing a risk of injury to residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy and procedure regarding advance directives, which are written statements of a resident's wishes concerning medical treatment. This deficiency was identified during interviews and record reviews, where it was found that three residents were not provided with written information about the option to formulate an advance directive. This failure violated the residents' rights to be fully informed about their healthcare options. Resident 47, who was admitted with leukemia and cellulitis, had the capacity to understand and make decisions, as indicated by their medical records. However, a review of their medical chart revealed that neither an advance directive nor an acknowledgment form was present. The Social Services Director confirmed the absence of these documents, which should have been available in the resident's chart. Similarly, Resident 2, with diagnoses of atrial fibrillation and cerebral infarction, also had intact cognitive skills for decision-making. Yet, their medical chart lacked a fully completed and signed advance directive acknowledgment form. The Social Services Director acknowledged this oversight. Resident 10, who had schizophrenia and dementia, did not have the capacity to make decisions, but their chart also lacked documentation of advance directive discussions. Interviews with staff confirmed the importance of having these documents readily available in case of emergencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate oxygen therapy and respiratory care services for two residents, leading to deficiencies in their care. Resident 92, who was admitted with pulmonary hypertension and COPD, had a physician's order for continuous oxygen at 2 liters per minute (lpm) via nasal cannula. However, observations revealed that the oxygen was set between 2.5-3 lpm, contrary to the physician's order. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the care plan needed revision to reflect continuous oxygen administration rather than as needed. Resident 22, diagnosed with Parkinson's disease and epilepsy, had a physician's order for oxygen at 2 lpm via nasal cannula as needed for shortness of breath. During an observation, the resident's oxygen tubing was found on the floor, which was confirmed by a Certified Nursing Assistant (CNA) and the Infection Preventionist (IP) as inappropriate. The facility's policy indicated that tubing should not touch the floor to prevent infection, and if it does, it should be changed by a licensed nurse. The facility's policy on oxygen administration, dated March 2024, outlined the need for verifying physician's orders and ensuring proper oxygen flow. However, the facility failed to adhere to these guidelines, resulting in incorrect oxygen settings for Resident 92 and improper handling of oxygen tubing for Resident 22. These deficiencies had the potential to cause respiratory distress and infection, respectively, for the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the lids of their outside garbage dumpsters were fully closed, as required by their policy and procedure. This was observed on multiple occasions, with one dumpster lid wide open on June 4, 2024, and both lids open and overflowing with trash bags on June 5, 2024. On June 6, 2024, one dumpster lid was again observed to be wide open. During an interview with the Dietary Supervisor, it was confirmed that the lids are supposed to be closed to prevent infection control issues, such as the attraction of flies. The facility's policy, revised in March 2024, mandates that all infectious and regulated waste be disposed of in closable, leak-proof containers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease, a serious form of pneumonia caused by the bacteria Legionella. During interviews, the Maintenance Supervisor (MS) admitted that there was no specific treatment for Legionella or other water pathogens, and the facility did not treat the water coming from outside. The MS also revealed that a company was supposed to handle water management, but no testing or monitoring had been conducted since 2018. Furthermore, the MS confirmed that there had been no water treatment in 2024, highlighting the importance of water management for resident health and infection prevention. The Administrator (ADM) and Director of Nursing (DON) also acknowledged the lack of a comprehensive water management program. The ADM stated that the last Legionella program review occurred in 2019, and since then, only hot water temperature logs from the kitchen and laundry were maintained. There was no monitoring, testing, or analysis of water samples conducted in the facility. The DON emphasized the significance of water management in preventing bacterial infections that could affect both residents and staff. The facility's policy and procedure for a Legionella Water Management Program, revised in 2024, was based on CDC and ASHRAE recommendations. It included elements such as identifying situations that could lead to Legionella growth, specific control measures, and a system for monitoring control limits. However, the facility failed to implement these measures effectively, as evidenced by the lack of documentation, monitoring, and testing. The CDC's toolkit and ASHRAE standards further outlined the need for regular verification and validation of the program, which the facility did not adhere to, placing residents at risk for severe respiratory infections.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the call light system was accessible and functional for five residents, leading to a deficiency in meeting their needs and preferences. For three residents, the call lights were not within reach, contrary to the facility's policy. Resident 74, who has severely impaired cognitive skills and requires assistance with activities of daily living, had a call light hanging on the overhead lights, out of reach. This was observed on multiple occasions, and both the Registered Nurse Supervisor and the Director of Nursing acknowledged the importance of having the call light within reach. Similarly, Resident 26, who is severely impaired in cognitive skills and needs total assistance, had a call light hanging from the top of the side rail, not within reach. Resident 46, also severely impaired and needing total assistance, had a call light wrapped around the side rail, making it inaccessible. In addition to accessibility issues, the facility also failed to ensure the proper functioning of the call light system for two residents. Resident 79, who requires moderate physical assistance, had a call light that did not remain on after being pressed, indicating a malfunction. The Maintenance Supervisor confirmed the issue, stating that the call light should have stayed on after being pressed. Similarly, Resident 55, who has moderately impaired cognition and requires substantial assistance, had a call light that lit up and turned off immediately when pressed. The call light panel on the second floor was not working properly, making it difficult to identify which resident needed assistance. The facility's policy and procedure require that call lights be accessible and functional to ensure timely responses to residents' requests and needs. However, the observations and interviews revealed that the call light system was not maintained according to these standards. The Maintenance Supervisor noted that old wall outlets might be causing the malfunction, indicating a need for repairs. The deficiency in the call light system had the potential to prevent the facility from meeting the residents' needs and preferences, as stated in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a homelike environment for three residents, as observed during a survey. Resident 79's room had multiple unfinished patching, watermarks, and holes between the wall and ceiling, which were attributed to a leak from rain in March 2024. Despite the resident's ability to understand and make decisions, the room remained in disrepair for an extended period. The Maintenance Supervisor acknowledged the issue but had not addressed it, and the Director of Nursing emphasized the importance of a presentable and personalized environment for residents. Resident 76's room also had unfinished patching on the ceiling above the bed. The resident was independent and required minimal assistance with daily activities. The Maintenance Supervisor admitted responsibility for the repairs but had not completed them, while the Director of Nursing reiterated the need for a homelike environment, stating that the current state of the rooms did not meet this standard. Resident 55's room was found with white towels and a sheet on the floor, which were not supposed to be there. The CNA stated that housekeeping was responsible for cleaning, but the Director of Nursing clarified that CNAs should remove such items to prevent infection and maintain a homelike environment. Additionally, the facility's hallways on the first and second floors had water leak marks and brownish discoloration, which the Maintenance Supervisor attributed to leaks from rain and air conditioning vents. The Director of Nursing expressed dissatisfaction with the old environment, noting that it did not feel homelike.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program, resulting in a gnat infestation that affected three residents. Observations revealed multiple small black flies in the rooms of Residents 2, 70, and 89. Resident 2, who was admitted with paroxysmal atrial fibrillation and cerebral infarction, reported that despite not keeping food out, the flies were always present. Similarly, Resident 70, admitted with malignant neoplasm of the endometrium and spinal stenosis, expressed that the flies were bothersome and had to purchase her own bug spray. Resident 89, admitted with weakness and low back pain, also had flies observed around their bedside. Interviews with staff, including a Certified Nursing Assistant and the Maintenance Supervisor, confirmed the presence of the flies and the importance of keeping the facility free from insects to prevent contamination, infection, and disease. The facility's policy and procedure on pest control, dated March 2024, stated that the facility should maintain an ongoing pest control program to ensure the building is free of insects and rodents. However, the observations and interviews indicated that the facility's pest control measures were ineffective in preventing the gnat infestation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the dignity and respect of a resident, identified as Resident 30, by not ensuring that the resident's indwelling catheter collection bag was covered with a dignity bag. This oversight was observed during a survey when Resident 30 was found awake in bed with the catheter collection bag exposed, revealing the urine inside. Certified Nursing Assistant 1 confirmed that the dignity bag, which should have been used to cover the collection bag, was hanging on the resident's wheelchair instead. This failure to cover the catheter bag violated the resident's right to privacy and dignity. Resident 30 was admitted to the facility with several medical conditions, including hemiplegia following a cerebral infarct, a chronic subdural hemorrhage, and complications related to a urinary catheter. The resident had intact memory and cognition, and required substantial assistance with daily activities. The Director of Nursing acknowledged that catheter bags should always be covered to prevent embarrassment and protect the resident's dignity, as outlined in the facility's policies on dignity and resident rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise and update the care plan for Resident 2 to reflect her preference for activities of daily living (ADL) while in the shower, as required by the facility's policy and procedure. Resident 2, who was admitted with diagnoses of paroxysmal atrial fibrillation and cerebral infarction, had intact cognitive skills for daily decision-making and required supervision or touching assistance with showering and other ADLs. Despite this, Resident 2 expressed a preference to shower independently without assistance or supervision from facility staff, which was not documented in her care plan. Interviews and observations revealed that Resident 2 was allowed to shower by herself, with a CNA waiting outside the shower room to monitor her needs. The MDS Nurse confirmed that Resident 2's care plan should have been updated to reflect her refusal to be supervised in the shower, and the Director of Nursing acknowledged that the care plan should have been revised to ensure staff were aware of Resident 2's preferences. The facility's policy indicated that care plans should be updated within 48 hours based on observed changes, but this was not done for Resident 2, leading to a deficiency in her care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care to prevent the worsening of pressure ulcers for a resident who was admitted with an unstageable pressure ulcer. The resident, who was severely impaired in cognitive skills and required total assistance for daily activities, was placed on a low air loss mattress (LALM) set to the maximum weight setting of 400 lbs, despite the resident's actual weight being 121 lbs. This discrepancy in the mattress setting was not addressed by the facility staff, as they did not adjust the settings according to the resident's weight, which is a critical factor in the prevention and treatment of pressure ulcers. Interviews with various staff members, including a Certified Nurse Assistant (CNA), Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), revealed a lack of clarity and responsibility regarding the adjustment of the LALM settings. The CNA and LVN indicated that they did not alter the settings and relied on the company that provided the bed to set it up. The DON confirmed that the settings should be based on the resident's weight, but this was not done. The Medical Director and Treatment Nurse also did not ensure that the LALM settings were correctly adjusted, and there was no order specifying the appropriate settings for the mattress. The deficiency was further highlighted by the DME Vendor Trainer Tech, who stated that the mattress should be set according to the resident's weight, but it was instead set to the maximum firmness. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on the resident's risk factors, yet this was not followed. The failure to adjust the LALM settings according to the resident's weight placed the resident at risk of poor wound healing and deterioration of existing pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate services to prevent complications for a resident with a G-tube (GT). The resident, who was severely impaired in cognitive skills and required total assistance for daily activities, had a GT feeding system that was not properly maintained. Observations revealed that the resident's [NAME] valve was not covered and was dirty, with an accumulation of dried brown stains. This was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the valve should have been capped and clean to prevent infection. Additionally, the GT feeding bag was not labeled with the name, date, or time when the formula was prepared or hung, contrary to the facility's policies and procedures. The facility's policies indicated that the formula label should document initials, date, and time of administration, and that infection prevention measures should be adhered to. These deficiencies had the potential to transmit infectious microorganisms and increase the risk of infection for the resident.