Intercommunity Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 12627 Studebaker Road, Norwalk, California 90650
- CMS Provider Number
- 055457
- Inspections on file
- 26
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Intercommunity Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents alleged abuse by staff, and in both cases the facility failed to immediately remove the accused staff from resident contact as required by its abuse policy. A cognitively intact resident with HTN, PVD, and hypothyroidism reported that a CNA roughly grabbed and twisted her arm; the CNA informed an LVN, who only changed the CNA’s assignment, allowing her to continue working in the same room with the resident’s roommates. In a separate incident, a severely cognitively impaired, aphasic resident’s family member observed an LVN place her hand under the resident’s sheet and later the resident, using a letter board, identified that LVN as having touched him inappropriately; the RN, after being informed of this allegation, reassigned the LVN to other residents instead of suspending her and sending her home, contrary to facility policy and statements by the DON and administrator that accused staff should be suspended with no resident contact pending investigation.
Two residents made separate abuse allegations against direct care staff that were not immediately reported to the facility’s abuse coordinator as required by policy. In one case, a cognitively intact resident with HTN, PVD, and hypothyroidism reported that a CNA was rough, grabbed her wrist, and twisted her arm during incontinence care; the CNA reported the accusation to an LVN, but the Administrator was not informed until the following day. In the other case, a severely cognitively impaired, aphasic resident who was fully dependent for ADLs was reported by a family member to have been inappropriately touched under the sheet by an LVN during the night; the family member relayed this to an LVN and then an RN, but the RN did not successfully notify the DON and the Administrator did not learn of the allegation until the next day during an IDT meeting.
Surveyors found that the facility did not post required signs at the entrance to notify about the presence of COVID-19 cases, even though two residents had recently tested positive. The Infection Preventionist confirmed that no public notifications were made, and the DON acknowledged that outbreak postings were necessary. Review of facility policy showed that such postings were required but were not implemented.
Surveyors identified multiple deficiencies in food storage and preparation, including undated and unlabeled tea bags and frozen sherbet, improper storage of disinfecting wipes with food items, and a dietary aide working without a required hair covering. These actions were inconsistent with facility policies on food safety, chemical storage, and sanitation.
The facility did not follow its own infection control policies by failing to consistently monitor and document laundry washer and dryer temperatures. Staff were unclear about the correct temperature ranges and the type of equipment in use, and multiple conflicting policies existed. This resulted in improper temperature monitoring and documentation, compromising infection control in the laundry process.
The facility did not complete and transmit MDS assessments within required timeframes for two residents. One resident's assessment was delayed due to an incorrect entry date, while another's discharge assessment was completed and submitted late, both in violation of regulatory requirements for timely MDS submission.
Two residents did not have accurate MDS assessments completed, resulting in incorrect information about the frequency of RNA services, splint use, and current tobacco use. One resident was documented and observed to receive daily RNA services and splint assistance, but the MDS reflected only five days of RNA and no splint use. Another resident's MDS failed to indicate ongoing tobacco use despite documentation and risk assessment showing otherwise. These inaccuracies were confirmed by staff interviews and record reviews.
A resident with complex medical needs and total dependence on staff repeatedly refused or was unable to cooperate with dental assessments, but the care plan was not updated to address this non-compliance. Despite documentation of the refusals and facility policy requiring individualized care planning, no interventions or strategies were included in the care plan to manage the resident's lack of cooperation with dental care.
Surveyors found that a disaster box in the medication room contained expired medications, syringes, hand sanitizers, and wound cleanser, with some items expired for several years. An LVN acknowledged that these expired items should not be present and could be given to a resident by mistake. The DON stated that expired medications are not administered, and facility policy requires outdated drugs to be returned to the pharmacy for destruction.
A resident with cognitive capacity and multiple medical conditions was not informed of a dentist's recommendation for tooth extraction. Although the dental evaluation and recommendation were documented, there was no record or evidence that the resident was notified, and staff interviews confirmed the lack of communication and documentation regarding the treatment plan.
A resident with multiple medical conditions was administered Carvedilol despite physician orders to hold the medication if systolic blood pressure was below 110 or heart rate was below 60. Documentation showed the medication was given on several occasions when these parameters were not met, and staff confirmed the medication should have been withheld according to the order and facility policy.
A resident with a gastrostomy tube and severe cognitive impairment was observed receiving tube feeding while lying nearly flat, despite orders and facility policy requiring the head of the bed to be elevated 30–45 degrees to prevent aspiration. The nurse confirmed the bed was only at 10 degrees during the feeding.
An unlocked cabinet was found containing 24 opened and unlabeled discontinued medications stored in a plastic cup, with no pharmaceutical waste bin nearby. Licensed staff and leadership confirmed that medications should be labeled, documented, and disposed of according to policy, but the medications were not documented in the Medication Disposition Record Log and were not stored securely or disposed of properly.
A resident with diabetes and atrial fibrillation, who was receiving Xarelto, did not receive the required daily monitoring for signs and symptoms of bleeding as outlined in facility policy. Nursing staff confirmed that monitoring for adverse consequences was not initiated when the medication was started.
A resident with malnutrition and dysphagia, who was cognitively intact and had ill-fitting dentures, was not provided with follow-up dental care after requesting new dentures. Despite an order for dental consultation and treatment, there was no evidence of further dental visits or action taken to address the resident's needs, and responsible staff were unaware of the outstanding dental recommendations.
A resident with a Spanish language background and mental health diagnoses was not provided with adequate Latino food options, resulting in meal refusals and dissatisfaction. Menu reviews showed minimal Latino offerings despite a large Latino resident population, and the Dietary Services Supervisor confirmed resident requests for more culturally appropriate meals.
A resident with chronic respiratory failure, ventilator dependence, and severe cognitive impairment had documented preferences for activities such as soft music and reading tapes. Although these activities were provided, the resident's care plan did not reflect these preferences, contrary to facility policy requiring individualized, person-centered care plans.
A resident was not re-admitted to the facility after hospitalization, despite being cleared for return. The resident, with a history of respiratory failure and multi-drug resistant infections, was unable to return due to the facility's lack of available isolation beds. The facility's policy required re-admission to the first available semi-private room, but this was not followed, resulting in a deficiency.
A resident in a long-term care facility experienced a decline in range of motion and developed contractures in both hands and wrists due to the facility's failure to conduct required quarterly joint mobility assessments and provide passive range of motion exercises as ordered. The Restorative Nursing Assistant did not report the decline in ROM to the charge nurse and modified the resident's splints without notifying Occupational Therapy, contributing to the resident's condition.
The facility failed to adhere to infection control protocols for nine residents, including improper disposal of soiled tracheostomy supplies, inadequate PPE use by staff, and inappropriate cleaning of equipment. These actions led to potential cross-contamination and infection spread, violating the facility's policies.
The facility failed to conduct necessary PASARR evaluations for three residents with mental disorders and cognitive impairments, leading to potential inappropriate placement and lack of specialized services. Despite having severe conditions such as schizophrenia and dementia, the residents did not receive the required Level I or II evaluations upon admission. Interviews with staff revealed lapses in oversight and responsibility for ensuring these evaluations were completed.
The facility failed to create comprehensive care plans for two residents, one on anticoagulant therapy and another on anti-anxiety medication, leading to potential delays in care. Interviews with staff highlighted the importance of care plans for monitoring and managing medication effects, which were not implemented according to the facility's policy.
The facility failed to measure and document the compatibility of siderails with bedframes and mattresses before installation for four residents, posing a risk of entrapment. Observations revealed gaps between siderails and mattresses, and staff interviews confirmed the lack of necessary checks. Residents involved had significant medical conditions, increasing their vulnerability to potential harm.
The facility failed to provide non-pharmacological interventions for three residents prescribed psychotropic medications. A resident with chronic respiratory failure and anxiety disorder was given Ativan without documented interventions. Another resident with cancer and a tracheostomy received Lorazepam without interventions. A third resident with similar diagnoses was also administered Ativan without interventions. Staff confirmed the lack of non-pharmacological measures, contrary to facility policy.
A dietary aide at the facility was found to be unaware of the correct chlorine levels for the dishwashing machine, incorrectly stating it should be 200 ppm instead of the required 50-100 ppm. The dishwashing machine was not consistently checked for proper temperature and chlorine levels, as indicated by the kitchen's log and staff interviews. This failure to adhere to proper sanitation procedures could potentially place residents at risk for food-borne illnesses.
A resident with chronic respiratory failure and traumatic brain injury experienced a significant decline in range of motion (ROM) in both wrists and hands, leading to contractures. Despite the resident's pain and ROM issues, the facility's Restorative Nursing Assistant (RNA) failed to report these changes to the charge nurse or Director of Rehabilitation (DOR). Consequently, the physician was not notified, and appropriate interventions were not provided, resulting in the development of contractures.
A resident with epilepsy and intellectual disabilities was observed using full side rails, but the MDS assessment inaccurately reported no use of side rails. The MDS nurse admitted to miscoding, and the DON confirmed the error, highlighting potential risks to patient safety. Facility policy requires accurate certification of MDS assessments.
A resident with cognitive impairments and thick, overgrown toenails did not receive necessary podiatry care due to communication failures among staff. Despite a physician's order for regular podiatry services, the resident's toenails were not managed appropriately, leading to potential discomfort and risk of injury. Staff interviews revealed that the CNA did not report the condition to the LVN, preventing timely intervention.
A facility failed to accurately document the administration of Tramadol, a controlled substance, for a resident. A discrepancy was found between the Controlled Drug Record (CDR) and the medication card, with one tablet unaccounted for. An LVN admitted to not recording the morning dose in the CDR, although it was documented in the electronic medical record. The DON emphasized the importance of CDR documentation to prevent drug diversion and medication errors, as per the facility's policy.
A resident with Type 2 Diabetes Mellitus received expired Insulin Lispro due to the facility's failure to remove it from the medication cart. The insulin, which expired on 8/5/2024, was administered on three occasions in August. The LVN and DON acknowledged the oversight, which was against the facility's policies requiring the removal of expired medications.
The facility failed to maintain proper food storage and hygiene practices, including storing personal items in food areas, improper labeling and storage of frozen foods, inadequate hand hygiene by kitchen staff, and unclean conditions around the ice machine, potentially exposing residents to food-borne illnesses.
Failure to Remove Accused Staff From Resident Contact After Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policies by not immediately removing from resident contact two staff members who were accused of abuse. For one cognitively intact resident with HTN, PVD, and hypothyroidism, the care plan and facility policy required immediate suspension and removal from the facility of any employee identified as an aggressor, with prompt notification of the abuse coordinator. On one date, this resident reported that a CNA had been rough, grabbed her wrist, twisted her arm, and pressed fingers into her ankle. The CNA reported to an LVN that the resident had accused her of abuse, and the LVN changed the CNA’s assignment so she no longer directly cared for the resident. However, the CNA remained in the facility and was assigned to care for the resident’s two roommates, requiring her to enter the same room, during which the resident cursed at her and attempted to block the doorway. Nursing staff did not further question the CNA or the resident about the allegation at the time of the assignment change. A second deficiency involved a severely cognitively impaired resident with aphasia and total dependence for ADLs, whose care plan also required immediate suspension and removal of any staff member accused of abuse. The resident’s family member reported that during a night shift, an LVN entered the room in the dark, put her hand under the resident’s sheet, touched the resident’s diaper area, bent over and whispered something in his ear, and then left the room, apparently unaware the family member was present. Later that night, using a letter board, the resident told the family member that a nurse had touched him inappropriately and identified the same LVN when she returned to the room. The family member reported this allegation to another LVN, who stated he would report it to the RN. In response to the family member’s concerns, the LVN accused of inappropriate touching reported that the family member had yelled at her to get out of the room, and the RN reassigned the LVN to care for other residents. The RN later acknowledged she was aware of the facility’s abuse policy and that, after being informed of the allegation that the LVN had inappropriately touched the resident’s private area, she only changed the LVN’s assignment instead of sending her home. The DON and Administrator both stated that when there is an allegation of abuse against staff, the staff member should be suspended and removed from resident contact until the investigation is completed, and the written policy specified that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete. Despite this, both the CNA and LVN remained on the premises with potential access to other residents after abuse allegations were made.
Failure to Immediately Report Allegations of Abuse to Facility Abuse Coordinator
Penalty
Summary
The deficiency involves the facility’s failure to immediately report allegations of abuse to the Administrator (the facility’s abuse coordinator) as required by policy. For one resident with intact cognition and medical conditions including HTN, PVD, and hypothyroidism, documentation on a change of condition/SBAR form dated 3/2/2026 showed the resident reported that a CNA was rough, grabbed her wrist, and twisted her arm, prompting the resident to try to kick the CNA to get away. In an interview, the resident, via translation by the same CNA, stated that on 3/1/2026 she was in bed when the CNA came in, grabbed her left arm tightly, and pressed her fingers into the resident’s left ankle hard, but the resident did not initially report this to anyone. CNA 1 stated that on 3/1/2026 she went to the resident’s room to change an adult brief, rolled the resident from left to right, and the resident became upset and accused her of grabbing the resident’s left arm and abusing her. CNA 1 reported this accusation to LVN 3, and CNA 2 corroborated that she was present when CNA 1 reported the allegation of abuse to LVN 3. LVN 3 stated that CNA 1 told her the resident had called her a derogatory name and was being aggressive, and that she relayed this to an RN and was instructed to change the CNA’s assignment. LVN 3 further stated that on 3/2/2026 the resident told her that the CNA had twisted her left arm on 3/1/2026, and that she reported this allegation to the Administrator on 3/2/2026, meaning the Administrator was not informed immediately when the initial allegation was made on 3/1/2026. A second deficiency involved another resident with severe cognitive impairment, aphasia following a cerebral infarction, and total dependence on staff for ADLs. A change of condition/SBAR form dated 3/5/2026 documented that during an IDT meeting, the resident’s family member reported that an LVN had lifted the resident’s sheet, touched the resident’s diaper, then replaced the sheet and left the room during the night shift. The family member stated she had been in the darkened room when the LVN entered, put a hand under the sheet, bent over and whispered something to the resident, and that later the resident communicated via letter board that a nurse had touched him inappropriately and identified the LVN when asked. The family member reported this allegation to an LVN, who said he would report it to an RN. RN 1 stated that the family member told her she did not want the LVN caring for the resident and later reported that the LVN had touched the resident’s private area inappropriately; RN 1 attempted to call the DON the next day but did not reach her and did not report the allegation to the DON. The Administrator stated he was not notified of this abuse allegation until the following day during an IDT meeting, and also confirmed he did not learn of the first resident’s allegation from 3/1/2026 until 3/2/2026, despite facility policy requiring immediate reporting of suspected abuse to the Administrator and other officials.
Failure to Post COVID-19 Outbreak Notification at Facility Entrance
Penalty
Summary
The facility failed to post signs at the entrance indicating the presence of COVID-19 cases, despite having two residents who tested positive for the virus. Observations on 9/26/2025 confirmed that there were no postings at the facility entrance to inform staff, visitors, or family members about the presence of COVID-19. Review of the facility's COVID-19 Line List showed that one resident tested positive on 9/23/2025 and another on 9/25/2025. Interviews with the Infection Preventionist confirmed that no public notifications or postings were made after these positive cases were identified. The Director of Nursing acknowledged that the facility should provide outbreak postings to safeguard the public, staff, and visitors. Review of the facility's own COVID-19 policy indicated that visual alerts and notifications should be posted at entrances and strategic locations, and that the facility would follow CDC and CDPH guidelines for notification. Despite these policies, the required postings were not present at the time of the survey.
Deficient Food Storage and Preparation Practices Identified
Penalty
Summary
Surveyors observed several deficiencies in the facility's kitchen related to food storage and preparation practices. Five boxes of tea bags were found in the dry storage area without any date or label, contrary to facility policy requiring all food items to be labeled with received and use-by dates. An opened container of Clorox disinfecting wipes was also found stored in the dry storage area, which the Dietary Service Supervisor acknowledged should have been kept in a designated chemical storage room to prevent possible cross contamination with food items. Additionally, three gallons of rainbow sherbet were found in a freezer without any label or open date, which the supervisor stated was necessary to track expiration and reduce the risk of cross contamination. Further, a dietary aide was observed in the food preparation area without wearing a hair covering while dispensing hot water, despite facility policy requiring all kitchen staff to wear hair nets or head coverings to prevent hair from contaminating food. The facility's policies and procedures reviewed by surveyors confirmed the requirements for proper dating and labeling of food, separation of chemicals from food storage, and use of hair coverings in food preparation areas. These observations were made during interviews and concurrent walkthroughs with the Dietary Service Supervisor and dietary staff.
Failure to Monitor and Document Laundry Equipment Temperatures for Infection Control
Penalty
Summary
The facility failed to implement effective infection control measures in its laundry operations by not adhering to its own policies regarding the monitoring and documentation of laundry equipment temperatures. Observations and interviews revealed that laundry staff were unsure of the correct water and dryer temperature ranges, did not consistently document temperatures, and were unclear about the type of laundry machines in use. The Water Temperature Log showed uniform entries of 140°F, but staff could not confirm the source of this figure, and the thermometer above the washers indicated 120°F. Additionally, dryer temperatures were measured at 120°F and 122°F, which staff believed to be below the required range. There was also confusion among staff and supervisors regarding the correct temperature standards, with multiple, conflicting policies in place for both washer and dryer temperatures. Record reviews confirmed that the facility had several different policies outlining acceptable temperature ranges for washers and dryers, but these were not uniformly communicated or followed by staff. The Infection Preventionist Nurse acknowledged the existence of three different policies and the lack of a clear, unified procedure. The contracted laundry machine service representative clarified that the washers were designed for low-temperature operation with chlorine, but emphasized the need for the facility to follow its own policy. The Director of Nursing also stated the importance of clear policies and proper monitoring. This lack of consistent monitoring and documentation of laundry equipment temperatures compromised the facility's infection control practices.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments within the required regulatory timeframes for two residents. For one resident with diagnoses including squamous cell carcinoma, dysphagia, and malignant neoplasm of the glottis, the MDS 5-day assessment was submitted more than 13 days after the entry date due to an incorrect entry date being recorded by the MDS nurse. This error resulted in the assessment being completed and transmitted late to CMS. For another resident with metabolic encephalopathy, respiratory failure, and sepsis, the discharge MDS assessment was completed and transmitted late, with the assessment being finalized and sent to CMS more than 14 days after the Assessment Reference Date (ARD). The MDS nurse confirmed that the discharge assessment was not completed within the required 14-day period, which is necessary for timely notification to CMS regarding the resident's discharge. The facility's policy requires adherence to federal and state submission timeframes for MDS completion and submission.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect data being transmitted to CMS. For one resident with chronic respiratory failure, anoxic brain damage, tracheostomy, and gastrostomy, the MDS assessment did not accurately reflect the resident's receipt of Restorative Nursing Assistant (RNA) services and splint assistance. Although the resident was documented and observed to be receiving RNA services seven days a week, including passive range of motion exercises and splint application, the MDS indicated only five days of RNA services and no splint assistance. This discrepancy was confirmed during interviews with the MDS nurse and Director of Nursing, who acknowledged the importance of accurate MDS coding for care planning. Another resident with a history of nicotine use, anemia, and abnormal posture was also affected by inaccurate MDS documentation. The resident's Smoker Risk Assessment indicated ongoing tobacco use requiring staff supervision, but the MDS assessment incorrectly coded the resident as not currently using tobacco. The MDS nurse confirmed this error during a record review and interview, noting that the MDS should have reflected the resident's current tobacco use to ensure appropriate care interventions. Facility policies require that all portions of the MDS assessment be completed and certified for accuracy by the responsible staff. Both the MDS nurse and Director of Nursing emphasized the necessity of accurate MDS assessments to ensure that resident needs are properly identified and addressed in the plan of care. The deficiencies were identified through interviews, record reviews, and direct observation, demonstrating a failure to follow established procedures for accurate resident assessment documentation.
Failure to Care Plan for Non-Compliance with Dental Assessments
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's non-compliance with dental assessments. The resident, who was dependent on staff for all self-care and mobility needs and had significant medical conditions including a tracheostomy, ventilator dependence, and a gastrostomy tube, repeatedly refused or was unable to cooperate with dental staff during multiple visits. Dental consult notes documented the resident's inability to follow instructions and refusal to open his mouth, making dental assessments impossible. Despite these documented refusals and the resident's lack of decision-making capacity, the care plan did not include interventions or strategies to address the non-compliance with dental care. Interviews with facility leadership confirmed that refusals or non-compliance with care should be included in the care plan to alert staff and allow for appropriate interventions. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, developed and revised as resident conditions changed, but this was not followed in the case of this resident.
Expired Medications and Supplies Found in Disaster Box
Penalty
Summary
Surveyors observed that the facility failed to ensure that medications, syringes, hand sanitizers, and wound cleanser stored in a disaster box in the Station 1 medication room were not kept beyond their expiration dates. During the inspection, expired items found included a bottle of acetaminophen, a bottle of ibuprofen, wound cleanser, insulin syringes, and hand sanitizers, with expiration dates ranging from 2019 to 2024. An LVN confirmed during an interview that expired items should not be present in the disaster box, acknowledging the risk of accidental administration. The DON also stated that expired medications are not given to residents. Review of the facility's policy indicated that outdated drugs or biologicals are to be returned to the dispensing pharmacy and destroyed as indicated.
Failure to Inform Resident of Dental Treatment Recommendation
Penalty
Summary
The facility failed to inform a resident with a history of epilepsy, hypertension, and congestive heart failure about a dental treatment recommendation for tooth extraction. The resident was cognitively intact and able to make decisions, as documented in both the History and Physical and the Minimum Data Set. Dental notes indicated that the resident was evaluated for molar pain and a tooth extraction was recommended. However, there was no documentation in the Interdisciplinary Team notes that the resident was notified of this recommendation. During interviews, the resident confirmed being seen by the dentist for tooth pain but stated that no staff had communicated the dentist's plan. The Social Service Director acknowledged awareness of the dental recommendation and admitted to not documenting any notification to the resident, stating that if it was not documented, it was not done. The Director of Nursing also confirmed that residents have the right to be involved in their care planning and that such changes should be discussed in care conferences. The facility's policy supports the resident's right to be informed and participate in care planning, but this was not followed in this instance.
Failure to Withhold Antihypertensive Medication per Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus and atrial fibrillation did not receive medication administration in accordance with physician orders and professional standards. The resident, who was moderately cognitively impaired and required substantial assistance with activities of daily living, had a physician order for Carvedilol to be administered twice daily via G-tube for hypertension, with specific instructions to hold the medication if the systolic blood pressure was less than 110 or if the heart rate was less than 60 beats per minute. Despite these clear parameters, the medication administration record showed that Carvedilol was given on multiple occasions when the resident's heart rate was below 60 and when the systolic blood pressure was below 110. Interviews and record reviews confirmed that the licensed nurse did not follow the physician's hold parameters for Carvedilol. The facility's policy on administering medications required that vital signs be obtained prior to administration when necessary, which was not adhered to in this case. The failure to withhold the medication as ordered was acknowledged by facility staff during interviews.
Failure to Maintain Head-of-Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency was identified when a resident receiving gastrostomy tube (GT) feeding was observed lying flat in bed while the tube feeding was running. The resident's medical record indicated orders for aspiration precautions, specifically requiring the head of the bed to be elevated at 30 to 45 degrees during GT feeding. During the observation, the head of the bed was only elevated to 10 degrees, contrary to both the physician's order and the facility's policy. The nurse present confirmed that the standard of practice is to maintain the head of the bed at 30 to 45 degrees during tube feeding. The resident involved had a history of GT placement, chronic obstructive pulmonary disease (COPD), and epilepsy, and was assessed as having severely impaired cognitive skills, being totally dependent on staff for care, and unable to make decisions. Facility policy and the resident's orders both required head-of-bed elevation to prevent aspiration during tube feeding, but this was not followed at the time of the surveyor's observation.
Failure to Properly Label and Dispose of Discontinued Medications
Penalty
Summary
The facility failed to properly label and dispose of discontinued medications according to its own policies and procedures. During an observation in the medication storage room, an unlocked cabinet was found containing 24 opened and unlabeled medications in a plastic cup, with no pharmaceutical waste bin nearby. Licensed staff confirmed that discontinued medications should be labeled and disposed of in designated pharmaceutical waste bins, and that documentation with two witnesses is required when medications are disposed of. However, staff were unable to identify the medications present in the discontinued medication cabinet, and the medications were not documented in the Medication Disposition Record Log. Interviews with the Director of Staff Development and the Director of Nursing confirmed that all medications should be labeled, documented, and stored securely until proper disposal. Facility policy requires that drugs and biologicals be stored in locked compartments, that improperly labeled medications be returned to the pharmacy, and that discontinued medications be documented and disposed of with appropriate witness signatures. The observed practice of storing unlabeled, discontinued medications in an unlocked cabinet and failing to document their disposition was not in compliance with these policies.
Failure to Monitor for Anticoagulant Complications
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed pharmacist performed appropriate monitoring for complications related to Xarelto, an anticoagulant medication, for one resident. The resident, who had a history of diabetes mellitus and atrial fibrillation, was admitted and readmitted to the facility and was assessed as having moderately impaired cognition and requiring substantial to maximal assistance with activities of daily living. The resident began receiving Xarelto 20 mg, but there was no evidence in the medical record that monitoring for adverse consequences, such as bleeding or bruising, was conducted as required by facility policy. During a review of the medication administration record and interviews with nursing staff, it was confirmed that monitoring for signs and symptoms of bleeding had not been initiated when the medication was started. The facility's policy specifically required daily monitoring for such complications with the administration of Xarelto, but this was not followed, as acknowledged by the licensed vocational nurse involved in the resident's care.
Failure to Follow Up on Dental Services for Resident
Penalty
Summary
The facility failed to follow up on dental services for a resident who was admitted with diagnoses of moderate protein-calorie malnutrition and dysphagia. The resident was cognitively intact and had been evaluated by a dentist, who noted the resident was edentulous and had old dentures with an inadequate fit. The dental note indicated the resident requested new dentures with smaller teeth. An order for a dental consultation and treatment as needed was placed, but there was no evidence in the record that the facility followed up on the request for new dentures or arranged additional dental consultations. During interviews and record reviews, it was confirmed that the resident had not seen the dentist again after the initial evaluation, and the Social Services Director, who was responsible for following up on dental recommendations, was unaware of the outstanding dental needs. The Director of Nursing also acknowledged the importance of following up on dental recommendations. The facility's policy required routine dental care and consultation as needed, but this was not carried out for the resident in question.
Failure to Provide Ethnic Food Options for Resident
Penalty
Summary
The facility failed to provide food options that accommodated the ethnic preferences of a resident whose primary language was Spanish and who had a history of major depressive disorder and anxiety disorder. The resident was cognitively intact and had documented meal refusals, with nutritional assessments indicating that these refusals were likely due to disliking the food provided by the facility. The facility's menu review showed that out of 21 meals in a week, only one meal was a Latino food option, and the only alternative considered Latino was a cheese quesadilla. Interviews with the resident confirmed dissatisfaction with the lack of Latino food options, leading to meal refusals and emotional distress. The Dietary Services Supervisor acknowledged that there was a significant Latino resident population and that requests for more Latino food options had been made. The facility's policy required offering a variety of foods at each scheduled mealtime, but the current menu did not reflect the ethnic preferences of the resident. The deficiency was identified through interviews, record reviews, and menu analysis, all indicating that the facility did not adequately honor the resident's cultural food preferences.
Failure to Include Resident Activity Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address a resident's preferred activities. The resident, who was dependent on a ventilator due to chronic respiratory failure and had severely impaired cognition, required total assistance with activities of daily living. The resident's activity assessment documented preferences for soft music, western, and reading tapes, and the Activity Director confirmed that these activities were provided during room visits. However, a review of the resident's care plan revealed that it did not include the resident's stated activity preferences. The Activity Director acknowledged during an interview that the care plan should have been updated to reflect these preferences. The facility's policy requires that each resident have a comprehensive care plan that includes goals and measurable objectives to meet their medical, nursing, mental, and psychosocial needs, as identified during assessment, but this was not followed in this case.
Failure to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after hospitalization, despite the resident being cleared for return by the General Acute Care Hospital (GACH). The resident, who was initially transferred to the GACH for evaluation of a possible small bowel obstruction, was unable to return to the skilled nursing facility (SNF) for approximately 12 months. This resulted in an unnecessarily prolonged stay of 14 days at the GACH, placing the resident at risk for unmet care needs and other complications. The resident had a history of respiratory failure requiring a tracheostomy and ventilator, and was unable to make decisions independently, having a designated responsible party. After being transferred to the GACH, the resident was found to have multi-drug resistant infections, which required isolation. The facility stated they could not re-admit the resident due to a lack of available isolation beds, despite having a bed available in a shared room. The facility's policy indicated that residents exceeding the bed-hold period should be re-admitted to the first available semi-private room. However, the facility did not comply with this policy, citing the inability to cohort residents with different infections. The California Department of Public Health's guidance states that facilities may not refuse care for residents with multi-drug resistant organisms, and inability to cohort is not a valid reason for refusal. Despite this, the facility did not re-admit the resident, leading to the deficiency noted in the report.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide appropriate care to a resident, resulting in a decline in range of motion (ROM) and the development of contractures in both hands and wrists. The resident was initially admitted with no ROM limitations and was at risk for contracture development. However, the facility did not conduct the required quarterly joint mobility assessments (JMS) to monitor changes in ROM, as per their policy. This lack of monitoring meant that the resident's decline in ROM went unnoticed and unaddressed for an extended period. Additionally, the Restorative Nursing Assistant (RNA) did not report the resident's decline in ROM during restorative program sessions to the charge nurse, as required by the facility's job description. The RNA also modified the resident's splints without notifying the Occupational Therapy (OT) department, which is against the facility's protocol. The RNA's actions, combined with the facility's failure to conduct regular assessments, contributed to the resident's decline in ROM and the development of contractures. The facility also failed to provide the resident with passive range of motion (PROM) exercises as ordered by the physician and recommended by OT. The resident missed numerous scheduled RNA services from March to October 2023, which were crucial for maintaining ROM and preventing contractures. The Director of Nursing (DON) and other staff members were not informed of the resident's decline in ROM, and the facility did not follow its policy to ensure residents received the necessary treatment and services to prevent a decline in ROM.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to observe infection control measures for nine residents, leading to multiple deficiencies. For Resident 68, soiled tracheostomy supplies were improperly disposed of in an open trash can, posing a risk of exposure to microorganisms. The facility's policy required double bagging and disposal in a biohazard container, which was not followed. Additionally, CNA 3 did not wear the required PPE while feeding Resident 33, who was on Enhanced Barrier Precautions due to a history of multidrug-resistant organisms. The Infection Preventionist Nurse had incorrectly advised that PPE was not necessary during feeding, leading to potential cross-contamination. Several residents, including Residents 3, 17, 37, and 76, were on Contact Isolation Precautions due to infections with multidrug-resistant organisms. However, a physician entered their rooms without wearing the appropriate PPE, such as gowns, which was against the facility's policy. This oversight increased the risk of cross-contamination and infection spread. Furthermore, RNA 1 used inappropriate cleaning agents on a cloth gait belt after assisting Resident 20, contrary to the manufacturer's instructions and facility policy, which required laundering for porous materials. Additional deficiencies included RNA 1 not wearing an isolation gown while providing care to Resident 60, who was on Enhanced Barrier Precautions, and RNA 2 failing to perform hand hygiene after removing splints from Resident 22. These actions were against the facility's infection control protocols, which emphasized the importance of PPE and hand hygiene to prevent infection spread. The facility's policies were not adhered to, resulting in multiple infection control breaches.
Failure to Conduct PASARR Evaluations for Residents
Penalty
Summary
The facility failed to adhere to the Preadmission Screening and Resident Review (PASARR) requirements for three residents, leading to a deficiency in ensuring appropriate placement and identification of specialized services. Resident 54 was admitted with multiple diagnoses, including dementia and major depressive disorder, and was found to have moderate cognitive impairment and dependency on self-care abilities. Despite these conditions, the facility did not obtain a PASARR Level II evaluation for Resident 54, which is necessary for residents with mental disorders or intellectual disabilities. Similarly, Resident 36, who was diagnosed with schizophrenia and bipolar disorder, was admitted without a completed PASARR Level II evaluation, despite the initial PASARR indicating the need for such an evaluation. Resident 36 was unable to complete the interview due to cognitive impairments and was on multiple medications for mood disorders and schizophrenia. The absence of a PASARR Level II evaluation for Resident 36 highlights the facility's failure to follow through with necessary assessments for residents with severe mental health conditions. Resident 4, diagnosed with paranoid schizophrenia, dementia, and other conditions, also did not receive a PASARR Level I evaluation upon admission. The resident had severe cognitive impairment and was dependent on self-care abilities. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nurses, revealed that the responsibility for overseeing PASARR evaluations was not adequately fulfilled, leading to the potential for improper placement and a lack of necessary services for these residents.
Failure to Formulate Comprehensive Care Plans for Residents on Specific Medications
Penalty
Summary
The facility failed to formulate a comprehensive care plan for two residents, leading to potential delays in care and services. Resident 50, who was prescribed Eliquis for anticoagulant therapy, did not have a specific care plan addressing the management and monitoring of this medication. This oversight could result in undetected complications such as bleeding, which would delay necessary care. Similarly, Resident 68, who was prescribed Lorazepam for anxiety, lacked a care plan that included interventions for behavior management, monitoring of medication effectiveness, and potential adjustments to the treatment plan. Interviews with facility staff, including an LVN and the DON, highlighted the importance of having a care plan for residents on specific medications to ensure collaborative interventions and timely detection of adverse reactions. The facility's policy on comprehensive, person-centered care plans emphasizes measurable objectives, professional services, and ongoing assessments, which were not adhered to in these cases. The absence of these care plans for Residents 50 and 68 indicates a failure to meet the facility's own standards and procedures for resident care management.
Failure to Ensure Safe Installation of Bed Rails
Penalty
Summary
The facility failed to ensure proper measurement and documentation of siderails to the bedframe and mattress before installing full side rails for four residents. This oversight was observed in the cases of residents with significant medical conditions such as chronic respiratory failure, traumatic brain injury, epilepsy, and intellectual disabilities. The lack of measurement and documentation posed a risk of physical harm due to potential entrapment, as gaps between the siderails and mattresses were noted. For Resident 55, the physician's orders required bilateral full siderails for safety due to involuntary movements and the use of a low air loss mattress. However, an observation revealed a volleyball-sized gap between the siderail and the mattress, which could lead to entrapment. Similar issues were noted for Resident 69, who also had orders for full siderails due to involuntary movements. The facility's failure to measure and document the compatibility of the siderails with the bedframe and mattress was confirmed by the Maintenance Director, who admitted to not performing these checks. Residents 14 and 80, both with severe cognitive impairments, also had orders for full siderails. Observations and interviews with staff highlighted the risks associated with these installations, particularly the potential for entrapment if the mattresses deflated. The facility's policy required that bed systems meet safety specifications to prevent entrapment, but this was not adhered to, as evidenced by the gaps observed and the lack of compatibility checks performed by the maintenance staff.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were ordered for three residents who were prescribed psychotropic medications. Resident 50, diagnosed with chronic respiratory failure and anxiety disorder, was prescribed Ativan for anxiety without any documented non-pharmacological interventions. Similarly, Resident 68, with a diagnosis of malignant neoplasm of the tongue and tracheostomy, was given Lorazepam for anxiety without non-pharmacological interventions being ordered or documented. Resident 75, also diagnosed with chronic respiratory failure and anxiety disorder, was administered Ativan without any non-pharmacological interventions documented. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing Services, confirmed that non-pharmacological interventions were not provided to these residents prior to administering psychotropic medications. The facility's policy on psychotropic medication use, revised in March 2023, mandates that non-pharmacological approaches must be used to minimize the need for medications. The failure to implement these interventions had the potential to result in the use of unnecessary psychotropic drugs, which could lead to side effects and adverse drug reactions.
Deficiency in Monitoring Chlorine Levels in Dishwashing Machine
Penalty
Summary
The facility failed to ensure that a dietary aide was knowledgeable about the correct chlorine levels required for the dishwashing machine, which could potentially place residents at risk for food-borne illnesses. During an observation, a dietary aide incorrectly stated that the chlorine level should be 200 ppm, while the facility's policy and manufacturer's guidelines indicated it should be between 50 to 100 ppm. The dietary aide attempted to adjust the chlorine solution to reach 200 ppm, demonstrating a lack of understanding of the correct procedures. Additionally, there was inconsistency among staff regarding the correct chlorine levels, as another dietary aide mentioned following 100 ppm. The facility also failed to ensure that the dishwashing machine was checked and monitored for the correct temperature and chlorine levels before use. The kitchen's Dish Machine Temperature Log showed that the machine was not checked on the day of the observation, and previous records indicated incorrect temperature and chlorine levels. Interviews with staff revealed that the machine should be checked at the beginning of each shift to ensure it is operating correctly, with the temperature between 120-135 degrees Fahrenheit and chlorine levels between 50-100 ppm. The facility's policy and job description for dietary aides emphasized the importance of following proper sanitation procedures, which were not adhered to in this instance.
Failure to Report Change of Condition in Resident with Declining ROM
Penalty
Summary
The facility failed to report a change of condition for a resident, identified as Resident 60, who experienced a decline in range of motion (ROM) in both wrists and hands. This deficiency was identified through observation, interviews, and record reviews. Resident 60 was initially admitted with no ROM limitations and was later found to have severe ROM limitations and contractures in both hands and wrists. Despite these changes, the facility did not report the decline to the physician or initiate a change of condition (COC) evaluation as required by their policy. Resident 60's medical history included chronic respiratory failure and traumatic brain injury. The resident was dependent on staff for daily activities and had moderately impaired cognitive skills. Over time, the resident's ROM in both arms declined significantly, leading to contractures. The facility's Restorative Nursing Assistant (RNA) was aware of the resident's pain and ROM issues but failed to report these changes to the charge nurse or the Director of Rehabilitation (DOR), as required by the facility's procedures. Interviews with facility staff, including the RNA, DOR, and Director of Nursing (DON), revealed that the decline in Resident 60's ROM was not communicated during monthly meetings or through proper channels. The RNA admitted to modifying the resident's splints due to pain but did not document or report the changes. Consequently, the physician was not notified, and appropriate interventions were not provided to address the resident's condition, resulting in the development of contractures.
Inaccurate MDS Assessment for Resident Using Restraints
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident using full side rails, which is considered a restraint. The resident, who has a history of epilepsy, intellectual disabilities, and convulsions, was observed on multiple occasions with bilateral full side rails in the up position while in bed. However, the MDS assessment inaccurately indicated that the resident was not using side rails. This discrepancy was confirmed during interviews with the MDS nurse and the Director of Nurses (DON), both acknowledging the miscoding of the MDS section related to restraints. The MDS nurse admitted to the error, stating that the resident does indeed use bilateral full side rails, and the inaccurate assessment could potentially lead to the resident not receiving appropriate care. The DON also confirmed that the MDS should have been coded to reflect the use of side rails, emphasizing that such inaccuracies could result in negative outcomes for patient safety. The facility's policy requires all personnel completing any portion of the MDS to sign and certify the accuracy of their assessments, which was not adhered to in this case.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as Resident 38, who had thick and overgrown toenails. Despite having a physician's order for podiatry care every two months and as needed, the resident's toenails were observed to be long, thick, and ragged. The resident had previously refused podiatry services on two occasions, and there was no follow-up to ensure the resident's toenails were managed appropriately. The Certified Nursing Assistant (CNA2) who observed the resident's toenails did not report the condition to the Licensed Vocational Nurse (LVN4), which was necessary to arrange for podiatry services. Interviews with staff revealed a breakdown in communication and procedure adherence. CNA3 had noticed the long toenails and informed LVN4, but CNA2 failed to do so. LVN4 acknowledged that CNA2 should have reported the issue, allowing her to arrange for a podiatry consult. The Social Service Director (SSD) confirmed that no referral for podiatry consult was received, and the Director of Nursing (DON) recognized the potential for discomfort or infection due to the long toenails. The facility's policy indicated that staff should identify underlying causes when residents with cognitive impairments resist care, but this approach was not effectively implemented in this case.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to accurately account for the use of a controlled substance, Tramadol, for a resident, which was identified during a review of the Middle Medication Cart Sub-Acute. The Controlled Drug Record (CDR) indicated a discrepancy in the number of Tramadol tablets remaining, with 25 tablets recorded, while the medication card showed 24 tablets. Licensed Vocational Nurse (LVN) 1 admitted to not documenting the administration of a morning dose of Tramadol in the CDR, although it was recorded in the electronic medical record. This oversight in documentation was acknowledged by LVN 1, who stated the importance of recording controlled substances in both the CDR and electronic medical record to prevent drug diversion and misuse. The Director of Nursing (DON) confirmed the necessity of documenting controlled substances in the CDR to prevent risks such as drug diversion and medication errors. The facility's policy on controlled substances mandates reconciliation upon receipt, administration, and at the end of each shift, with the nurse responsible for recording the administration details. The failure to document the administration of Tramadol in the CDR placed the facility and the resident at risk for medication errors, drug loss, and diversion, as the documentation serves to ensure medication security and patient safety.
Expired Insulin Not Removed from Medication Cart
Penalty
Summary
The facility failed to remove an expired insulin medication from a medication cart, which was not in accordance with the manufacturer's requirements and the facility's policy and procedure. This incident involved a resident with Type 2 Diabetes Mellitus, who was dependent on facility staff for daily living activities and required insulin administration as per a sliding scale. The expired insulin, Insulin Lispro, was found in Medication Cart 3 Back Cart, labeled with an opened date of 7/8/2024, and had expired on 8/5/2024. During an inspection, it was observed that the expired insulin was still present in the medication cart, and the Licensed Vocational Nurse (LVN) acknowledged that it should have been removed. The LVN stated that the expired insulin would not be effective in controlling blood sugar levels, potentially leading to health complications for the resident. The Medication Administration Record indicated that the expired insulin was administered on three occasions in August 2024. The Director of Nursing (DON) confirmed that medications should be removed immediately once expired and that licensed nurses are responsible for ensuring no expired medications are administered. The facility's policies and procedures outlined the importance of checking expiration dates and labeling medications with the necessary information, including expiration dates. However, these procedures were not followed, resulting in the administration of expired insulin to the resident.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, which could potentially expose residents to food-borne illnesses. During an initial kitchen tour, personal items such as a tumbler, lunch bags, a purse, and a cup of coffee were found stored in the refrigerator and dry storage area, which is against the facility's policy due to infection control concerns. Additionally, frozen food items like corn, hotdogs, and sliced ham were improperly stored, with some showing signs of freezer burn and lacking proper labeling, which could lead to serving expired food to residents. The facility also failed to ensure proper hand hygiene and glove use among kitchen staff. An observation revealed that a cook did not wash hands or change gloves between tasks, such as chopping tomatoes and handling turkey for residents on a mechanical diet, which could lead to cross-contamination. The facility's policy requires handwashing and glove changes between tasks to prevent the spread of infection. Furthermore, the cleanliness of the kitchen was compromised, particularly around the ice machine. The area was observed to have grime and dirt, and it was noted that the responsibility for cleaning this area was unclear among staff. The facility's policy mandates that food service employees maintain sanitary conditions to prevent cross-contamination and infection, but this was not adhered to, as evidenced by the unclean state of the ice machine area.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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